111TH CONGRESS 

1ST SESSION H. R. 3962 

AN ACT 

To provide affordable, quality health care for all Americans 

and reduce the growth in health care spending, 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, 
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1 SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, 

2 AND SUBTITLES. 

3 (a) SHORT TITLE.—This Act may be cited as the 

4 ‘‘Affordable Health Care for America Act’’. 

5 (b) TABLE OF DIVISIONS, TITLES, AND SUB6 TITLES.—This Act is divided into divisions, titles, and 

7 subtitles as follows: 

DIVISION A—AFFORDABLE HEALTH CARE CHOICES 

TITLE I—IMMEDIATE REFORMS 

TITLE II—PROTECTIONS AND STANDARDS FOR QUALIFIED 

HEALTH BENEFITS PLANS 

Subtitle A—General Standards 

Subtitle B—Standards Guaranteeing Access to Affordable Coverage 

Subtitle C—Standards Guaranteeing Access to Essential Benefits 

Subtitle D—Additional Consumer Protections 

Subtitle E—Governance 

Subtitle F—Relation to Other Requirements; Miscellaneous 

TITLE III—HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS 

Subtitle A—Health Insurance Exchange 

Subtitle B—Public Health Insurance Option 

Subtitle C—Individual Affordability Credits 

TITLE IV—SHARED RESPONSIBILITY 

Subtitle A—Individual Responsibility 

Subtitle B—Employer Responsibility 

TITLE V—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 

Subtitle A—Shared Responsibility 

Subtitle B—Credit for Small Business Employee Health Coverage Expenses 

Subtitle C—Disclosures To Carry Out Health Insurance Exchange Subsidies 

Subtitle D—Other Revenue Provisions 

DIVISION B—MEDICARE AND MEDICAID IMPROVEMENTS 

TITLE I—IMPROVING HEALTH CARE VALUE 

Subtitle A—Provisions related to Medicare part A 

Subtitle B—Provisions Related to Part B 

Subtitle C—Provisions Related to Medicare Parts A and B 

Subtitle D—Medicare Advantage Reforms 

Subtitle E—Improvements to Medicare Part D 

Subtitle F—Medicare Rural Access Protections 

TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS 

Subtitle A—Improving and Simplifying Financial Assistance for Low Income 

Medicare Beneficiaries 

Subtitle B—Reducing Health Disparities 

Subtitle C—Miscellaneous Improvements 

TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND COORDINATED CARE 
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TITLE IV—QUALITY 

Subtitle A—Comparative Effectiveness Research 

Subtitle B—Nursing Home Transparency 

Subtitle C—Quality Measurements 

Subtitle D—Physician Payments Sunshine Provision 

Subtitle E—Public Reporting on Health Care-Associated Infections 

TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION 

TITLE VI—PROGRAM INTEGRITY 

Subtitle A—Increased funding to fight waste, fraud, and abuse 

Subtitle B—Enhanced penalties for fraud and abuse 

Subtitle C—Enhanced Program and Provider Protections 

Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and Abuse 

TITLE VII—MEDICAID AND CHIP 

Subtitle A—Medicaid and Health Reform 

Subtitle B—Prevention 

Subtitle C—Access 

Subtitle D—Coverage 

Subtitle E—Financing 

Subtitle F—Waste, Fraud, and Abuse 

Subtitle G—Puerto Rico and the Territories 

Subtitle H—Miscellaneous 

TITLE VIII—REVENUE-RELATED PROVISIONS 

TITLE IX—MISCELLANEOUS PROVISIONS 

DIVISION C—PUBLIC HEALTH AND WORKFORCE DEVELOPMENT 

TITLE I—COMMUNITY HEALTH CENTERS 

TITLE II—WORKFORCE 

Subtitle A—Primary Care Workforce 

Subtitle B—Nursing Workforce 

Subtitle C—Public Health Workforce 

Subtitle D—Adapting Workforce to Evolving Health System Needs 

TITLE III—PREVENTION AND WELLNESS 

TITLE IV—QUALITY AND SURVEILLANCE 

TITLE V—OTHER PROVISIONS 

Subtitle A—Drug Discount for Rural and Other Hospitals; 340B Program Integrity 

Subtitle B—Programs 

Subtitle C—Food and Drug Administration 

Subtitle D—Community Living Assistance Services and Supports 

Subtitle E—Miscellaneous 

DIVISION D—INDIAN HEALTH CARE IMPROVEMENT 

TITLE I—AMENDMENTS TO INDIAN LAWS 

TITLE II—IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED 

UNDER THE SOCIAL SECURITY ACT 
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1 DIVISION A—AFFORDABLE 

2 HEALTH CARE CHOICES 

3 SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; 

4 GENERAL DEFINITIONS. 

5 (a) PURPOSE.— 

6 (1) IN GENERAL.—The purpose of this division 

7 is to provide affordable, quality health care for all 

8 Americans and reduce the growth in health care 

9 spending. 

10 (2) BUILDING ON CURRENT SYSTEM.—This di11 vision achieves this purpose by building on what 

12 works in today’s health care system, while repairing 

13 the aspects that are broken. 

14 (3) INSURANCE REFORMS.—This division— 

15 (A) enacts strong insurance market re16 forms; 

17 (B) creates a new Health Insurance Ex18 change, with a public health insurance option 

19 alongside private plans; 

20 (C) includes sliding scale affordability 

21 credits; and 

22 (D) initiates shared responsibility among 

23 workers, employers, and the Government; 

24 so that all Americans have coverage of essential 

25 health benefits. 
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1 (4) HEALTH DELIVERY REFORM.—This division 

2 institutes health delivery system reforms both to in3 crease quality and to reduce growth in health spend4 ing so that health care becomes more affordable for 

5 businesses, families, and Government. 

6 (b) TABLE OF CONTENTS OF DIVISION.—The table 

7 of contents of this division is as follows: 

Sec. 100. Purpose; table of contents of division; general definitions. 

TITLE I—IMMEDIATE REFORMS 

Sec. 101. National high-risk pool program. 

Sec. 102. Ensuring value and lower premiums. 

Sec. 103. Ending health insurance rescission abuse. 

Sec. 104. Sunshine on price gouging by health insurance issuers. 

Sec. 105. Requiring the option of extension of dependent coverage for uninsured young adults. 

Sec. 106. Limitations on preexisting condition exclusions in group health plans 

in advance of applicability of new prohibition of preexisting 

condition exclusions. 

Sec. 107. Prohibiting acts of domestic violence from being treated as preexisting conditions. 

Sec. 108. Ending health insurance denials and delays of necessary treatment 

for children with deformities. 

Sec. 109. Elimination of lifetime limits. 

Sec. 110. Prohibition against postretirement reductions of retiree health benefits by group health plans. 

Sec. 111. Reinsurance program for retirees. 

Sec. 112. Wellness program grants. 

Sec. 113. Extension of COBRA continuation coverage. 

Sec. 114. State Health Access Program grants. 

Sec. 115. Administrative simplification. 

TITLE II—PROTECTIONS AND STANDARDS FOR QUALIFIED 

HEALTH BENEFITS PLANS 

Subtitle A—General Standards 

Sec. 201. Requirements reforming health insurance marketplace. 

Sec. 202. Protecting the choice to keep current coverage. 

Subtitle B—Standards Guaranteeing Access to Affordable Coverage 

Sec. 211. Prohibiting preexisting condition exclusions. 

Sec. 212. Guaranteed issue and renewal for insured plans and prohibiting rescissions. 

Sec. 213. Insurance rating rules. 
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Sec. 214. Nondiscrimination in benefits; parity in mental health and substance 

abuse disorder benefits. 

Sec. 215. Ensuring adequacy of provider networks. 

Sec. 216. Requiring the option of extension of dependent coverage for uninsured young adults. 

Sec. 217. Consistency of costs and coverage under qualified health benefits 

plans during plan year. 

Subtitle C—Standards Guaranteeing Access to Essential Benefits 

Sec. 221. Coverage of essential benefits package. 

Sec. 222. Essential benefits package defined. 

Sec. 223. Health Benefits Advisory Committee. 

Sec. 224. Process for adoption of recommendations; adoption of benefit standards. 

Subtitle D—Additional Consumer Protections 

Sec. 231. Requiring fair marketing practices by health insurers. 

Sec. 232. Requiring fair grievance and appeals mechanisms. 

Sec. 233. Requiring information transparency and plan disclosure. 

Sec. 234. Application to qualified health benefits plans not offered through the 

Health Insurance Exchange. 

Sec. 235. Timely payment of claims. 

Sec. 236. Standardized rules for coordination and subrogation of benefits. 

Sec. 237. Application of administrative simplification. 

Sec. 238. State prohibitions on discrimination against health care providers. 

Sec. 239. Protection of physician prescriber information. 

Sec. 240. Dissemination of advance care planning information. 

Subtitle E—Governance 

Sec. 241. Health Choices Administration; Health Choices Commissioner. 

Sec. 242. Duties and authority of Commissioner. 

Sec. 243. Consultation and coordination. 

Sec. 244. Health Insurance Ombudsman. 

Subtitle F—Relation to Other Requirements; Miscellaneous 

Sec. 251. Relation to other requirements. 

Sec. 252. Prohibiting discrimination in health care. 

Sec. 253. Whistleblower protection. 

Sec. 254. Construction regarding collective bargaining. 

Sec. 255. Severability. 

Sec. 256. Treatment of Hawaii Prepaid Health Care Act. 

Sec. 257. Actions by State attorneys general. 

Sec. 258. Application of State and Federal laws regarding abortion. 

Sec. 259. Nondiscrimination on abortion and respect for rights of conscience. 

Sec. 260. Authority of Federal Trade Commission. 

Sec. 261. Construction regarding standard of care. 

Sec. 262. Restoring application of antitrust laws to health sector insurers. 

Sec. 263. Study and report on methods to increase EHR use by small health 

care providers. 

Sec. 264. Performance assessment and accountability: application of GPRA. 

Sec. 265. Limitation on abortion funding. 
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TITLE III—HEALTH INSURANCE EXCHANGE AND RELATED 

PROVISIONS 

Subtitle A—Health Insurance Exchange 

Sec. 301. Establishment of Health Insurance Exchange; outline of duties; definitions. 

Sec. 302. Exchange-eligible individuals and employers. 

Sec. 303. Benefits package levels. 

Sec. 304. Contracts for the offering of Exchange-participating health benefits 

plans. 

Sec. 305. Outreach and enrollment of Exchange-eligible individuals and employers in Exchange-participating health benefits plan. 

Sec. 306. Other functions. 

Sec. 307. Health Insurance Exchange Trust Fund. 

Sec. 308. Optional operation of State-based health insurance exchanges. 

Sec. 309. Interstate health insurance compacts. 

Sec. 310. Health insurance cooperatives. 

Sec. 311. Retention of DOD and VA authority. 

Subtitle B—Public Health Insurance Option 

Sec. 321. Establishment and administration of a public health insurance option 

as an Exchange-qualified health benefits plan. 

Sec. 322. Premiums and financing. 

Sec. 323. Payment rates for items and services. 

Sec. 324. Modernized payment initiatives and delivery system reform. 

Sec. 325. Provider participation. 

Sec. 326. Application of fraud and abuse provisions. 

Sec. 327. Application of HIPAA insurance requirements. 

Sec. 328. Application of health information privacy, security, and electronic 

transaction requirements. 

Sec. 329. Enrollment in public health insurance option is voluntary. 

Sec. 330. Enrollment in public health insurance option by Members of Congress. 

Sec. 331. Reimbursement of Secretary of Veterans Affairs. 

Subtitle C—Individual Affordability Credits 

Sec. 341. Availability through Health Insurance Exchange. 

Sec. 342. Affordable credit eligible individual. 

Sec. 343. Affordability premium credit. 

Sec. 344. Affordability cost-sharing credit. 

Sec. 345. Income determinations. 

Sec. 346. Special rules for application to territories. 

Sec. 347. No Federal payment for undocumented aliens. 

TITLE IV—SHARED RESPONSIBILITY 

Subtitle A—Individual Responsibility 

Sec. 401. Individual responsibility. 

Subtitle B—Employer Responsibility 

PART 1—HEALTH COVERAGE PARTICIPATION REQUIREMENTS

Sec. 411. Health coverage participation requirements. 
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Sec. 412. Employer responsibility to contribute toward employee and dependent 

coverage. 

Sec. 413. Employer contributions in lieu of coverage. 

Sec. 414. Authority related to improper steering. 

Sec. 415. Impact study on employer responsibility requirements. 

Sec. 416. Study on employer hardship exemption. 

PART 2—SATISFACTION OF HEALTH COVERAGE PARTICIPATION

REQUIREMENTS

Sec. 421. Satisfaction of health coverage participation requirements under the 

Employee Retirement Income Security Act of 1974. 

Sec. 422. Satisfaction of health coverage participation requirements under the 

Internal Revenue Code of 1986. 

Sec. 423. Satisfaction of health coverage participation requirements under the 

Public Health Service Act. 

Sec. 424. Additional rules relating to health coverage participation requirements. 

TITLE V—AMENDMENTS TO INTERNAL REVENUE CODE OF 1986 

Subtitle A—Provisions Relating to Health Care Reform 

PART 1—SHARED RESPONSIBILITY

SUBPART A—INDIVIDUAL RESPONSIBILITY

Sec. 501. Tax on individuals without acceptable health care coverage. 

SUBPART B—EMPLOYER RESPONSIBILITY

Sec. 511. Election to satisfy health coverage participation requirements. 

Sec. 512. Health care contributions of nonelecting employers. 

PART 2—CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE

EXPENSES

Sec. 521. Credit for small business employee health coverage expenses. 

PART 3—LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES

Sec. 531. Distributions for medicine qualified only if for prescribed drug or insulin. 

Sec. 532. Limitation on health flexible spending arrangements under cafeteria 

plans. 

Sec. 533. Increase in penalty for nonqualified distributions from health savings 

accounts. 

Sec. 534. Denial of deduction for federal subsidies for prescription drug plans 

which have been excluded from gross income. 

PART 4—OTHER PROVISIONS TO CARRY OUT HEALTH INSURANCE REFORM

Sec. 541. Disclosures to carry out health insurance exchange subsidies. 

Sec. 542. Offering of exchange-participating health benefits plans through cafeteria plans. 

Sec. 543. Exclusion from gross income of payments made under reinsurance 

program for retirees. 
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Sec. 544. CLASS program treated in same manner as long-term care insurance. 

Sec. 545. Exclusion from gross income for medical care provided for Indians. 

Subtitle B—Other Revenue Provisions 

PART 1—GENERAL PROVISIONS

Sec. 551. Surcharge on high income individuals. 

Sec. 552. Excise tax on medical devices. 

Sec. 553. Expansion of information reporting requirements. 

Sec. 554. Repeal of worldwide allocation of interest. 

Sec. 555. Exclusion of unprocessed fuels from the cellulosic biofuel producer 

credit. 

PART 2—PREVENTION OF TAX AVOIDANCE

Sec. 561. Limitation on treaty benefits for certain deductible payments. 

Sec. 562. Codification of economic substance doctrine; penalties. 

Sec. 563. Certain large or publicly traded persons made subject to a more likely 

than not standard for avoiding penalties on underpayments. 

PART 3—PARITY IN HEALTH BENEFITS

Sec. 571. Certain health related benefits applicable to spouses and dependents 

extended to eligible beneficiaries. 

1 (c) GENERAL DEFINITIONS.—Except as otherwise 

2 provided, in this division: 

3 (1) ACCEPTABLE COVERAGE.—The term ‘‘ac4 ceptable coverage’’ has the meaning given such term 

5 in section 302(d)(2). 

6 (2) BASIC PLAN.—The term ‘‘basic plan’’ has 

7 the meaning given such term in section 303(c). 

8 (3) COMMISSIONER.—The term ‘‘Commis9 sioner’’ means the Health Choices Commissioner es10 tablished under section 241. 

11 (4) COST-SHARING.—The term ‘‘cost-sharing’’ 

12 includes deductibles, coinsurance, copayments, and 

13 similar charges, but does not include premiums, bal-
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1 ance billing amounts for non-network providers, or 

2 spending for non-covered services. 

3 (5) DEPENDENT.—The term ‘‘dependent’’ has 

4 the meaning given such term by the Commissioner 

5 and includes a spouse. 

6 (6) EMPLOYMENT-BASED HEALTH PLAN.—The 

7 term ‘‘employment-based health plan’’— 

8 (A) means a group health plan (as defined 

9 in section 733(a)(1) of the Employee Retire10 ment Income Security Act of 1974); 

11 (B) includes such a plan that is the fol12 lowing: 

13 (i) FEDERAL, STATE, AND TRIBAL

14 GOVERNMENTAL PLANS.—A governmental 

15 plan (as defined in section 3(32) of the 

16 Employee Retirement Income Security Act 

17 of 1974), including a health benefits plan 

18 offered under chapter 89 of title 5, United 

19 States Code. 

20 (ii) CHURCH PLANS.—A church plan 

21 (as defined in section 3(33) of the Em22 ployee Retirement Income Security Act of 

23 1974); and 

24 (C) excludes coverage described in section 

25 302(d)(2)(E) (relating to TRICARE). 
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1 (7) ENHANCED PLAN.—The term ‘‘enhanced 

2 plan’’ has the meaning given such term in section 

3 303(c). 

4 (8) ESSENTIAL BENEFITS PACKAGE.—The term 

5 ‘‘essential benefits package’’ is defined in section 

6 222(a). 

7 (9) EXCHANGE-PARTICIPATING HEALTH BENE8 FITS PLAN.—The term ‘‘Exchange-participating 

9 health benefits plan’’ means a qualified health bene10 fits plan that is offered through the Health Insur11 ance Exchange and may be purchased directly from 

12 the entity offering the plan or through enrollment 

13 agents and brokers. 

14 (10) FAMILY.—The term ‘‘family’’ means an 

15 individual and includes the individual’s dependents. 

16 (11) FEDERAL POVERTY LEVEL; FPL.—The 

17 terms ‘‘Federal poverty level’’ and ‘‘FPL’’ have the 

18 meaning given the term ‘‘poverty line’’ in section 

19 673(2) of the Community Services Block Grant Act 

20 (42 U.S.C. 9902(2)), including any revision required 

21 by such section. 

22 (12) HEALTH BENEFITS PLAN.—The term 

23 ‘‘health benefits plan’’ means health insurance cov24 erage and an employment-based health plan and in25 cludes the public health insurance option. 
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1 (13) HEALTH INSURANCE COVERAGE.—The 

2 term ‘‘health insurance coverage’’ has the meaning 

3 given such term in section 2791 of the Public 

4 Health Service Act, but does not include coverage in 

5 relation to its provision of excepted benefits— 

6 (A) described in paragraph (1) of sub7 section (c) of such section; or 

8 (B) described in paragraph (2), (3), or (4) 

9 of such subsection if the benefits are provided 

10 under a separate policy, certificate, or contract 

11 of insurance. 

12 (14) HEALTH INSURANCE ISSUER.—The term 

13 ‘‘health insurance issuer’’ has the meaning given 

14 such term in section 2791(b)(2) of the Public Health 

15 Service Act. 

16 (15) HEALTH INSURANCE EXCHANGE.—The 

17 term ‘‘Health Insurance Exchange’’ means the 

18 Health Insurance Exchange established under sec19 tion 301. 

20 (16) INDIAN.—The term ‘‘Indian’’ has the 

21 meaning given such term in section 4 of the Indian 

22 Health Care Improvement Act (24 U.S.C. 1603). 

23 (17) INDIAN HEALTH CARE PROVIDER.—The 

24 term ‘‘Indian health care provider’’ means a health 

25 care program operated by the Indian Health Service, 
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1 an Indian tribe, tribal organization, or urban Indian 

2 organization as such terms are defined in section 4 

3 of the Indian Health Care Improvement Act (25 

4 U.S.C. 1603). 

5 (18) MEDICAID.—The term ‘‘Medicaid’’ means 

6 a State plan under title XIX of the Social Security 

7 Act (whether or not the plan is operating under a 

8 waiver under section 1115 of such Act). 

9 (19) MEDICAID ELIGIBLE INDIVIDUAL.—The 

10 term ‘‘Medicaid eligible individual’’ means an indi11 vidual who is eligible for medical assistance under 

12 Medicaid. 

13 (20) MEDICARE.—The term ‘‘Medicare’’ means 

14 the health insurance programs under title XVIII of 

15 the Social Security Act. 

16 (21) PLAN SPONSOR.—The term ‘‘plan spon17 sor’’ has the meaning given such term in section 

18 3(16)(B) of the Employee Retirement Income Secu19 rity Act of 1974. 

20 (22) PLAN YEAR.—The term ‘‘plan year’’ 

21 means— 

22 (A) with respect to an employment-based 

23 health plan, a plan year as specified under such 

24 plan; or 
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1 (B) with respect to a health benefits plan 

2 other than an employment-based health plan, a 

3 12-month period as specified by the Commis4 sioner. 

5 (23) PREMIUM PLAN; PREMIUM-PLUS PLAN.— 

6 The terms ‘‘premium plan’’ and ‘‘premium-plus 

7 plan’’ have the meanings given such terms in section 

8 303(c). 

9 (24) QHBP OFFERING ENTITY.—The terms 

10 ‘‘QHBP offering entity’’ means, with respect to a 

11 health benefits plan that is— 

12 (A) a group health plan (as defined, sub13 ject to subsection (d), in section 733(a)(1) of 

14 the Employee Retirement Income Security Act 

15 of 1974), the plan sponsor in relation to such 

16 group health plan, except that, in the case of a 

17 plan maintained jointly by 1 or more employers 

18 and 1 or more employee organizations and with 

19 respect to which an employer is the primary 

20 source of financing, such term means such em21 ployer; 

22 (B) health insurance coverage, the health 

23 insurance issuer offering the coverage; 

24 (C) the public health insurance option, the 

25 Secretary of Health and Human Services; 
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1 (D) a non-Federal governmental plan (as 

2 defined in section 2791(d) of the Public Health 

3 Service Act), the State or political subdivision 

4 of a State (or agency or instrumentality of such 

5 State or subdivision) which establishes or main6 tains such plan; or 

7 (E) a Federal governmental plan (as de8 fined in section 2791(d) of the Public Health 

9 Service Act), the appropriate Federal official. 

10 (25) QUALIFIED HEALTH BENEFITS PLAN.— 

11 The term ‘‘qualified health benefits plan’’ means a 

12 health benefits plan that— 

13 (A) meets the requirements for such a plan 

14 under title II and includes the public health in15 surance option; and 

16 (B) is offered by a QHBP offering entity 

17 that meets the applicable requirements of such 

18 title with respect to such plan. 

19 (26) PUBLIC HEALTH INSURANCE OPTION.— 

20 The term ‘‘public health insurance option’’ means 

21 the public health insurance option as provided under 

22 subtitle B of title III. 

23 (27) SERVICE AREA; PREMIUM RATING AREA.— 

24 The terms ‘‘service area’’ and ‘‘premium rating 
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1 area’’ mean with respect to health insurance cov2 erage— 

3 (A) offered other than through the Health 

4 Insurance Exchange, such an area as estab5 lished by the QHBP offering entity of such cov6 erage in accordance with applicable State law; 

7 and 

8 (B) offered through the Health Insurance 

9 Exchange, such an area as established by such 

10 entity in accordance with applicable State law 

11 and applicable rules of the Commissioner for 

12 Exchange-participating health benefits plans. 

13 (28) STATE.—The term ‘‘State’’ means the 50 

14 States and the District of Columbia and includes— 

15 (A) for purposes of title I, Puerto Rico, the 

16 Virgin Islands, Guam, American Samoa, and 

17 the Northern Mariana Islands; and 

18 (B) for purposes of titles II and III, as 

19 elected under and subject to section 346, Puer20 to Rico, the Virgin Islands, Guam, American 

21 Samoa, and the Northern Mariana Islands. 

22 (29) STATE MEDICAID AGENCY.—The term 

23 ‘‘State Medicaid agency’’ means, with respect to a 

24 Medicaid plan, the single State agency responsible 
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1 for administering such plan under title XIX of the 

2 Social Security Act. 

3 (30) Y1, Y2, ETC.—The terms ‘‘Y1’’, ‘‘Y2’’, 

4 ‘‘Y3’’, ‘‘Y4’’, ‘‘Y5’’, and similar subsequently num5 bered terms, mean 2013 and subsequent years, re6 spectively. 

7 TITLE I—IMMEDIATE REFORMS 

8 SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM. 

9 (a) IN GENERAL.—The Secretary of Health and 

10 Human Services (in this section referred to as the ‘‘Sec11 retary’’) shall establish a temporary national high-risk 

12 pool program (in this section referred to as the ‘‘pro13 gram’’) to provide health benefits to eligible individuals 

14 during the period beginning on January 1, 2010, and, sub15 ject to subsection (h)(3)(B), ending on the date on which 

16 the Health Insurance Exchange is established. 

17 (b) ADMINISTRATION.—The Secretary may carry out 

18 this section directly or, pursuant to agreements, grants, 

19 or contracts with States, through State high-risk pool pro20 grams provided that the requirements of this section are 

21 met. For a State without a high-risk pool program, the 

22 Secretary may work with the State to coordinate with 

23 other forms of coverage expansions, such as State public24 private partnerships. 
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1 (c) ELIGIBILITY.—For purposes of this section, the 

2 term ‘‘eligible individual’’ means an individual who meets 

3 the requirements of subsection (i)(1)— 

4 (1) who— 

5 (A) is not eligible for— 

6 (i) benefits under title XVIII, XIX, or 

7 XXI of the Social Security Act; or 

8 (ii) coverage under an employment9 based health plan (not including coverage 

10 under a COBRA continuation provision, as 

11 defined in section 107(d)(1)); and 

12 (B) who— 

13 (i) is an eligible individual under sec14 tion 2741(b) of the Public Health Service 

15 Act; or 

16 (ii) is medically eligible for the pro17 gram by virtue of being an individual de18 scribed in subsection (d) at any time dur19 ing the 6-month period ending on the date 

20 the individual applies for high-risk pool 

21 coverage under this section; 

22 (2) who is the spouse or dependent of an indi23 vidual who is described in paragraph (1); 

24 (3) who has not had health insurance coverage 

25 or coverage under an employment-based health plan 
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1 for at least the 6-month period immediately pre2 ceding the date of the individual’s application for 

3 high-risk pool coverage under this section; or 

4 (4) who on or after October 29, 2009, had em5 ployment-based retiree health coverage (as defined in 

6 subsection (i)) and the annual increase in premiums 

7 for such individual under such coverage (for any cov8 erage period beginning on or after such date) ex9 ceeds such excessive percentage as the Secretary 

10 shall specify. 

11 For purposes of paragraph (1)(A)(ii), a person who is in 

12 a waiting period as defined in section 2701(b)(4) of the 

13 Public Health Service Act shall not be considered to be 

14 eligible for coverage under an employment-based health 

15 plan. 

16 (d) MEDICALLY ELIGIBLE REQUIREMENTS.—For 

17 purposes of subsection (c)(1)(B)(ii), an individual de18 scribed in this subsection is an individual— 

19 (1) who, during the 6-month period ending on 

20 the date the individual applies for high-risk pool cov21 erage under this section applied for individual health 

22 insurance coverage and— 

23 (A) was denied such coverage because of a 

24 preexisting condition or health status; or 

25 (B) was offered such coverage— 
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1 (i) under terms that limit the cov2 erage for such a preexisting condition; or 

3 (ii) at a premium rate that is above 

4 the premium rate for high risk pool cov5 erage under this section; or 

6 (2) who has an eligible medical condition as de7 fined by the Secretary. 

8 In making a determination under paragraph (1) of wheth9 er an individual was offered individual coverage at a pre10 mium rate above the premium rate for high risk pool cov11 erage, the Secretary shall make adjustments to offset dif12 ferences in premium rating that are attributable solely to 

13 differences in age rating. 

14 (e) ENROLLMENT.—To enroll in coverage in the pro15 gram, an individual shall— 

16 (1) submit to the Secretary an application for 

17 participation in the program, at such time, in such 

18 manner, and containing such information as the Sec19 retary shall require; 

20 (2) attest, consistent with subsection (i)(2), 

21 that the individual is an eligible individual and is a 

22 resident of one of the 50 States or the District of 

23 Columbia; and 

24 (3) if the individual had other prior health in25 surance coverage or coverage under an employment- 
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1 based health plan during the previous 6 months, 

2 provide information as to the nature and source of 

3 such coverage and reasons for its discontinuance. 

4 (f) PROTECTION AGAINST DUMPING RISKS BY IN5 SURERS.— 

6 (1) IN GENERAL.—The Secretary shall establish 

7 criteria for determining whether health insurance 

8 issuers and employment-based health plans have dis9 couraged an individual from remaining enrolled in 

10 prior coverage based on that individual’s health sta11 tus. 

12 (2) SANCTIONS.—An issuer or employment13 based health plan shall be responsible for reimburs14 ing the program for the medical expenses incurred 

15 by the program for an individual who, based on cri16 teria established by the Secretary, the Secretary 

17 finds was encouraged by the issuer to disenroll from 

18 health benefits coverage prior to enrolling in the pro19 gram. The criteria shall include at least the fol20 lowing circumstances: 

21 (A) In the case of prior coverage obtained 

22 through an employer, the provision by the em23 ployer, group health plan, or the issuer of 

24 money or other financial consideration for 

25 disenrolling from the coverage. 
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1 (B) In the case of prior coverage obtained 

2 directly from an issuer or under an employ3 ment-based health plan— 

4 (i) the provision by the issuer or plan 

5 of money or other financial consideration 

6 for disenrolling from the coverage; or 

7 (ii) in the case of an individual whose 

8 premium for the prior coverage exceeded 

9 the premium required by the program (ad10 justed based on the age factors applied to 

11 the prior coverage)— 

12 (I) the prior coverage is a policy 

13 that is no longer being actively mar14 keted (as defined by the Secretary) by 

15 the issuer; or 

16 (II) the prior coverage is a policy 

17 for which duration of coverage form 

18 issue or health status are factors that 

19 can be considered in determining pre20 miums at renewal. 

21 (3) CONSTRUCTION.—Nothing in this sub22 section shall be construed as constituting exclusive 

23 remedies for violations of criteria established under 

24 paragraph (1) or as preventing States from applying 
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1 or enforcing such paragraph or other provisions 

2 under law with respect to health insurance issuers. 

3 (g) COVERED BENEFITS, COST-SHARING, PREMIUMS, 

4 AND CONSUMER PROTECTIONS.— 

5 (1) PREMIUM.—The monthly premium charged 

6 to eligible individuals for coverage under the pro7 gram— 

8 (A) may vary by age so long as the ratio 

9 of the highest such premium to the lowest such 

10 premium does not exceed the ratio of 2 to 1; 

11 (B) shall be set at a level that does not ex12 ceed 125 percent of the prevailing standard rate 

13 for comparable coverage in the individual mar14 ket; and 

15 (C) shall be adjusted for geographic vari16 ation in costs. 

17 Health insurance issuers shall provide such informa18 tion as the Secretary may require to determine pre19 vailing standard rates under this paragraph. The 

20 Secretary shall establish standard rates in consulta21 tion with the National Association of Insurance 

22 Commissioners. 

23 (2) COVERED BENEFITS.—Covered benefits 

24 under the program shall be determined by the Sec25 retary and shall be consistent with the basic cat-
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1 egories in the essential benefits package described in 

2 section 222. Under such benefits package— 

3 (A) the annual deductible for such benefits 

4 may not be higher than $1,500 for an indi5 vidual or such higher amount for a family as 

6 determined by the Secretary; 

7 (B) there may not be annual or lifetime 

8 limits; and 

9 (C) the maximum cost-sharing with respect 

10 to an individual (or family) for a year shall not 

11 exceed $5,000 for an individual (or $10,000 for 

12 a family). 

13 (3) NO PREEXISTING CONDITION EXCLUSION

14 PERIODS.—No preexisting condition exclusion period 

15 shall be imposed on coverage under the program. 

16 (4) APPEALS.—The Secretary shall establish an 

17 appeals process for individuals to appeal a deter18 mination of the Secretary— 

19 (A) with respect to claims submitted under 

20 this section; and 

21 (B) with respect to eligibility determina22 tions made by the Secretary under this section. 

23 (5) STATE CONTRIBUTION, MAINTENANCE OF

24 EFFORT.—As a condition of providing health bene-
25 

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1 fits under this section to eligible individual residing 

2 in a State— 

3 (A) in the case of a State in which a quali4 fied high-risk pool (as defined under section 

5 2744(c)(2) of the Public Health Service Act) 

6 was in effect as of July 1, 2009, the Secretary 

7 shall require the State make a maintenance of 

8 effort payment each year that the high-risk pool 

9 is in effect equal to an amount not less than the 

10 amount of all sources of funding for high-risk 

11 pool coverage made by that State in the year 

12 ending July 1, 2009; and 

13 (B) in the case of a State which required 

14 health insurance issuers to contribute to a State 

15 high-risk pool or similar arrangement for the 

16 assessment against such issuers for pool losses, 

17 the State shall maintain such a contribution ar18 rangement among such issuers. 

19 (6) LIMITING PROGRAM EXPENDITURES.—The 

20 Secretary shall, with respect to the program— 

21 (A) establish procedures to protect against 

22 fraud, waste, and abuse under the program; 

23 and 

24 (B) provide for other program integrity 

25 methods. 
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1 (7) TREATMENT AS CREDITABLE COVERAGE.— 

2 Coverage under the program shall be treated, for 

3 purposes of applying the definition of ‘‘creditable 

4 coverage’’ under the provisions of title XXVII of the 

5 Public Health Service Act, part 6 of subtitle B of 

6 title I of Employee Retirement Income Security Act 

7 of 1974, and chapter 100 of the Internal Revenue 

8 Code of 1986 (and any other provision of law that 

9 references such provisions) in the same manner as 

10 if it were coverage under a State health benefits risk 

11 pool described in section 2701(c)(1)(G) of the Public 

12 Health Service Act. 

13 (h) FUNDING; TERMINATION OF AUTHORITY.— 

14 (1) IN GENERAL.—There is appropriated to the 

15 Secretary, out of any moneys in the Treasury not 

16 otherwise appropriated, $5,000,000,000 to pay 

17 claims against (and administrative costs of) the 

18 high-risk pool under this section in excess of the pre19 miums collected with respect to eligible individuals 

20 enrolled in the high-risk pool. Such funds shall be 

21 available without fiscal year limitation. 

22 (2) INSUFFICIENT FUNDS.—If the Secretary es23 timates for any fiscal year that the aggregate 

24 amounts available for payment of expenses of the 

25 high-risk pool will be less than the amount of the ex-
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1 penses, the Secretary shall make such adjustments 

2 as are necessary to eliminate such deficit, including 

3 reducing benefits, increasing premiums, or estab4 lishing waiting lists. 

5 (3) TERMINATION OF AUTHORITY.— 

6 (A) IN GENERAL.—Except as provided in 

7 subparagraph (B), coverage of eligible individ8 uals under a high-risk pool shall terminate as 

9 of the date on which the Health Insurance Ex10 change is established. 

11 (B) TRANSITION TO EXCHANGE.—The 

12 Secretary shall develop procedures to provide 

13 for the transition of eligible individuals who are 

14 enrolled in health insurance coverage offered 

15 through a high-risk pool established under this 

16 section to be enrolled in acceptable coverage. 

17 Such procedures shall ensure that there is no 

18 lapse in coverage with respect to the individual 

19 and may extend coverage offered through such 

20 a high-risk pool beyond 2012 if the Secretary 

21 determines necessary to avoid such a lapse. 

22 (i) APPLICATION AND VERIFICATION OF REQUIRE23 MENT OF CITIZENSHIP OR LAWFUL PRESENCE IN THE

24 UNITED STATES.— 
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1 (1) REQUIREMENT.—No individual shall be an 

2 eligible individual under this section unless the indi3 vidual is a citizen or national of the United States 

4 or is lawfully present in a State in the United States 

5 (other than as a nonimmigrant described in a sub6 paragraph (excluding subparagraphs (K), (T), (U), 

7 and (V)) of section 101(a)(15) of the Immigration 

8 and Nationality Act). 

9 (2) APPLICATION OF VERIFICATION PROCESS

10 FOR AFFORDABILITY CREDITS.—The provisions of 

11 paragraphs (4) (other than subparagraphs (F) and 

12 (H)(i)) and (5)(A) of section 341(b), and of sub13 sections (v) (other than paragraph (3)) and (x) of 

14 section 205 of the Social Security Act, shall apply to 

15 the verification of eligibility of an eligible individual 

16 by the Secretary (or by a State agency approved by 

17 the Secretary) for benefits under this section in the 

18 same manner as such provisions apply to the 

19 verification of eligibility of an affordable credit eligi20 ble individual for affordability credits by the Com21 missioner under section 341(b). The agreement re22 ferred to in section 205(v)(2)(A) of the Social Secu23 rity Act (as applied under this paragraph) shall also 

24 provide for funding, to be payable from the amount 

25 made available under subsection (h)(1), to the Com-
29 

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1 missioner of Social Security in such amount as is 

2 agreed to by such Commissioner and the Secretary. 

3 (j) EMPLOYMENT-BASED RETIREE HEALTH COV4 ERAGE.—In this section, the term ‘‘employment-based re5 tiree health coverage’’ means health insurance or other 

6 coverage of health care costs (whether provided by vol7 untary insurance coverage or pursuant to statutory or con8 tractual obligation) for individuals (or for such individuals 

9 and their spouses and dependents) under a group health 

10 plan based on their status as retired participants in such 

11 plan. 

12 SEC. 102. ENSURING VALUE AND LOWER PREMIUMS. 

13 (a) GROUP HEALTH INSURANCE COVERAGE.—Title 

14 XXVII of the Public Health Service Act is amended by 

15 inserting after section 2713 the following new section: 

16 ‘‘SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS. 

17 ‘‘(a) IN GENERAL.—Each health insurance issuer 

18 that offers health insurance coverage in the small or large 

19 group market shall provide that for any plan year in which 

20 the coverage has a medical loss ratio below a level specified 

21 by the Secretary (but not less than 85 percent), the issuer 

22 shall provide in a manner specified by the Secretary for 

23 rebates to enrollees of the amount by which the issuer’s 

24 medical loss ratio is less than the level so specified. 
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1 ‘‘(b) IMPLEMENTATION.—The Secretary shall estab2 lish a uniform definition of medical loss ratio and method3 ology for determining how to calculate it based on the av4 erage medical loss ratio in a health insurance issuer’s book 

5 of business for the small and large group market. Such 

6 methodology shall be designed to take into account the 

7 special circumstances of smaller plans, different types of 

8 plans, and newer plans. In determining the medical loss 

9 ratio, the Secretary shall exclude State taxes and licensing 

10 or regulatory fees. Such methodology shall be designed 

11 and exceptions shall be established to ensure adequate 

12 participation by health insurance issuers, competition in 

13 the health insurance market, and value for consumers so 

14 that their premiums are used for services. 

15 ‘‘(c) SUNSET.—Subsections (a) and (b) shall not 

16 apply to health insurance coverage on and after the first 

17 date that health insurance coverage is offered through the 

18 Health Insurance Exchange.’’. 

19 (b) INDIVIDUAL HEALTH INSURANCE COVERAGE.— 

20 Such title is further amended by inserting after section 

21 2753 the following new section: 

22 ‘‘SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS. 

23 ‘‘The provisions of section 2714 shall apply to health 

24 insurance coverage offered in the individual market in the 

25 same manner as such provisions apply to health insurance 
31 

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1 coverage offered in the small or large group market except 

2 to the extent the Secretary determines that the application 

3 of such section may destabilize the existing individual 

4 market.’’. 

5 (c) IMMEDIATE IMPLEMENTATION.—The amend6 ments made by this section shall apply in the group and 

7 individual market for plan years beginning on or after 

8 January 1, 2010, or as soon as practicable after such date. 

9 SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE. 

10 (a) CLARIFICATION REGARDING APPLICATION OF

11 GUARANTEED RENEWABILITY OF INDIVIDUAL AND

12 GROUP HEALTH INSURANCE COVERAGE.—Sections 2712 

13 and 2742 of the Public Health Service Act (42 U.S.C. 

14 300gg–12, 300gg–42) are each amended— 

15 (1) in its heading, by inserting ‘‘AND CON16 TINUATION IN FORCE, INCLUDING PROHIBI17 TION OF RESCISSION,’’ after ‘‘GUARANTEED RE18 NEWABILITY’’; and 

19 (2) in subsection (a), by inserting ‘‘, including 

20 without rescission,’’ after ‘‘continue in force’’. 

21 (b) SECRETARIAL GUIDANCE REGARDING RESCIS22 SIONS.— 

23 (1) GROUP HEALTH INSURANCE MARKET.—Sec24 tion 2712 of such Act (42 U.S.C. 300gg–12) is 

25 amended by adding at the end the following: 
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1 ‘‘(f) RESCISSION.—A health insurance issuer may re2 scind group health insurance coverage only upon clear and 

3 convincing evidence of fraud described in subsection 

4 (b)(2), under procedures that provide for independent, ex5 ternal third-party review.’’. 

6 (2) INDIVIDUAL HEALTH MARKET.—Section 

7 2742 of such Act (42 U.S.C. 300gg–42) is amended 

8 by adding at the end the following: 

9 ‘‘(f) RESCISSION.—A health insurance issuer may re10 scind individual health insurance coverage only upon clear 

11 and convincing evidence of fraud described in subsection 

12 (b)(2), under procedures that provide for independent, ex13 ternal third-party review.’’. 

14 (3) GUIDANCE.—The Secretary of Health and 

15 Human Services, no later than 90 days after the 

16 date of the enactment of this Act, shall issue guid17 ance implementing the amendments made by para18 graphs (1) and (2), including procedures for inde19 pendent, external third-party review. 

20 (c) OPPORTUNITY FOR INDEPENDENT, EXTERNAL

21 THIRD-PARTY REVIEW IN CERTAIN CASES.— 

22 (1) INDIVIDUAL MARKET.—Subpart 1 of part B 

23 of title XXVII of such Act (42 U.S.C. 300gg–41 et 

24 seq.) is amended by adding at the end the following: 
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1 ‘‘SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

2 THIRD-PARTY REVIEW IN CASES OF RESCIS3 SION. 

4 ‘‘(a) NOTICE AND REVIEW RIGHT.—If a health in5 surance issuer determines to rescind health insurance cov6 erage for an individual in the individual market, before 

7 such rescission may take effect the issuer shall provide the 

8 individual with notice of such proposed rescission and an 

9 opportunity for a review of such determination by an inde10 pendent, external third-party under procedures specified 

11 by the Secretary under section 2742(f). 

12 ‘‘(b) INDEPENDENT DETERMINATION.—If the indi13 vidual requests such review by an independent, external 

14 third-party of a rescission of health insurance coverage, 

15 the coverage shall remain in effect until such third party 

16 determines that the coverage may be rescinded under the 

17 guidance issued by the Secretary under section 2742(f).’’. 

18 (2) APPLICATION TO GROUP HEALTH INSUR19 ANCE.—Such title is further amended by adding 

20 after section 2702 the following new section: 

21 ‘‘SEC. 2703. OPPORTUNITY FOR INDEPENDENT, EXTERNAL 

22 THIRD-PARTY REVIEW IN CASES OF RESCIS23 SION. 

24 ‘‘The provisions of section 2746 shall apply to group 

25 health insurance coverage in the same manner as such 

26 provisions apply to individual health insurance coverage, 
34 

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1 except that any reference to section 2742(f) is deemed a 

2 reference to section 2712(f).’’. 

3 (d) EFFECTIVE DATE.—The amendments made by 

4 this section shall take effect on the date of the enactment 

5 of this Act and shall apply to rescissions occurring on and 

6 after July 1, 2010, with respect to health insurance cov7 erage issued before, on, or after such date. 

8 SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH IN9 SURANCE ISSUERS. 

10 (a) INITIAL PREMIUM REVIEW PROCESS.— 

11 (1) IN GENERAL.—The Secretary of Health and 

12 Human Services, in conjunction with States, shall 

13 establish a process for the annual review, beginning 

14 with 2010 and subject to subsection (c)(3)(A), of in15 creases in premiums for health insurance coverage. 

16 (2) JUSTIFICATION AND DISCLOSURE.— Such 

17 process shall require health insurance issuers to sub18 mit a justification for any premium increase prior to 

19 implementation of the increase. Such issuers shall 

20 prominently post such information on their websites. 

21 The Secretary shall ensure the public disclosure of 

22 information on such increases and justifications for 

23 all health insurance issuers. 

24 (b) CONTINUING PREMIUM REVIEW PROCESS.— 
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1 (1) INFORMING COMMISSIONER OF PREMIUM

2 INCREASE PATTERNS.—As a condition of receiving a 

3 grant under subsection (c)(1), a State, through its 

4 Commissioner of Insurance, shall— 

5 (A) provide the Health Choices Commis6 sioner with information about trends in pre7 mium increases in health insurance coverage in 

8 premium rating areas in the State; and 

9 (B) make recommendations, as appro10 priate, to such Commissioner about whether 

11 particular health insurance issuers should be 

12 excluded from participation in the Health In13 surance Exchange based on a pattern of exces14 sive or unjustified premium increases. 

15 (2) COMMISSIONER AUTHORITY REGARDING EX16 CHANGE PARTICIPATION.—In making determinations 

17 concerning entering into contracts with QHBP offer18 ing entities for the offering of Exchange-partici19 pating health plans under section 304, the Commis20 sioner shall take into account the information and 

21 recommendations provided under paragraph (1). 

22 (3) MONITORING BY COMMISSIONER OF PRE23 MIUM INCREASES.— 

24 (A) IN GENERAL.—Beginning in 2014, the 

25 Commissioner, in conjunction with the States 
36 

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1 and in place of the monitoring by the Secretary 

2 under subsection (a)(1) and consistent with the 

3 provisions of subsection (a)(2), shall monitor 

4 premium increases of health insurance coverage 

5 offered inside the Health Insurance Exchange 

6 under section 304 and outside of the Exchange. 

7 (B) CONSIDERATION IN OPENING EX8 CHANGE.—In determining under section 

9 302(e)(4) whether to make additional larger 

10 employers eligible to participate in the Health 

11 Insurance Exchange, the Commissioner shall 

12 take into account any excess of premium 

13 growth outside the Exchange as compared to 

14 the rate of such growth inside the Exchange, 

15 including information reported by the States. 

16 (c) GRANTS IN SUPPORT OF PROCESS.— 

17 (1) PREMIUM REVIEW GRANTS DURING 2010

18 THROUGH 2014.—The Secretary shall carry out a 

19 program of grants to States during the 5-year period 

20 beginning with 2010 to assist them in carrying out 

21 subsection (a), including— 

22 (A) in reviewing and, if appropriate under 

23 State law, approving premium increases for 

24 health insurance coverage; and 
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1 (B) in providing information and rec2 ommendations to the Commissioner under sub3 section (b)(1). 

4 (2) FUNDING.— 

5 (A) IN GENERAL.—Out of any funds in the 

6 Treasury not otherwise appropriated, there are 

7 appropriated to the Secretary $1,000,000,000, 

8 to be available for expenditure for grants under 

9 paragraph (1) and subparagraph (B). 

10 (B) FURTHER AVAILABILITY FOR INSUR11 ANCE REFORM AND CONSUMER PROTECTION

12 GRANTS.—If the amounts appropriated under 

13 subparagraph (A) are not fully obligated under 

14 grants under paragraph (1) by the end of 2014, 

15 any remaining funds shall remain available to 

16 the Secretary for grants to States for planning 

17 and implementing the insurance reforms and 

18 consumer protections under title II. 

19 (C) ALLOCATION.—The Secretary shall es20 tablish a formula for determining the amount of 

21 any grant to a State under this subsection. 

22 Under such formula— 

23 (i) the Secretary shall consider the 

24 number of plans of health insurance cov-
38 

•HR 3962 EH

1 erage offered in each State and the popu2 lation of the State; and 

3 (ii) no State qualifying for a grant 

4 under paragraph (1) shall receive less than 

5 $1,000,000, or more than $5,000,000 for a 

6 grant year. 

7 SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DE8 PENDENT COVERAGE FOR UNINSURED 

9 YOUNG ADULTS. 

10 (a) UNDER GROUP HEALTH PLANS.— 

11 (1) PHSA.—Title XXVII of the Public Health 

12 Service Act is amended by inserting after section 

13 2702 the following new section: 

14 ‘‘SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DE15 PENDENT COVERAGE FOR UNINSURED 

16 YOUNG ADULTS. 

17 ‘‘(a) IN GENERAL.—A group health plan and a health 

18 insurance issuer offering health insurance coverage in con19 nection with a group health plan that provides coverage 

20 for dependent children shall make available such coverage, 

21 at the option of the participant involved, for one or more 

22 qualified children (as defined in subsection (b)) of the par23 ticipant. 

24 ‘‘(b) QUALIFIED CHILD DEFINED.—In this section, 

25 the term ‘qualified child’ means, with respect to a partici-
39 

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1 pant in a group health plan or group health insurance cov2 erage, an individual who (but for age) would be treated 

3 as a dependent child of the participant under such plan 

4 or coverage and who— 

5 ‘‘(1) is under 27 years of age; and 

6 ‘‘(2) is not enrolled as a participant, bene7 ficiary, or enrollee (other than under this section, 

8 section 2746, or section 704 of the Employee Retire9 ment Income Security Act of 1974) under any 

10 health insurance coverage or group health plan. 

11 ‘‘(c) PREMIUMS.—Nothing in this section shall be 

12 construed as preventing a group health plan or health in13 surance issuer with respect to group health insurance cov14 erage from increasing the premiums otherwise required for 

15 coverage provided under this section consistent with 

16 standards established by the Secretary based upon family 

17 size.’’. 

18 (2) EMPLOYEE RETIREMENT INCOME SECURITY

19 ACT OF 1974.— 

20 (A) IN GENERAL.—Part 7 of subtitle B of 

21 title I of the Employee Retirement Income Se22 curity Act of 1974 is amended by inserting 

23 after section 703 the following new section: 
40 

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1 ‘‘SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DE2 PENDENT COVERAGE FOR UNINSURED 

3 YOUNG ADULTS. 

4 ‘‘(a) IN GENERAL.—A group health plan and a health 

5 insurance issuer offering health insurance coverage in con6 nection with a group health plan that provides coverage 

7 for dependent children shall make available such coverage, 

8 at the option of the participant involved, for one or more 

9 qualified children (as defined in subsection (b)) of the par10 ticipant. 

11 ‘‘(b) QUALIFIED CHILD DEFINED.—In this section, 

12 the term ‘qualified child’ means, with respect to a partici13 pant in a group health plan or group health insurance cov14 erage, an individual who (but for age) would be treated 

15 as a dependent child of the participant under such plan 

16 or coverage and who— 

17 ‘‘(1) is under 27 years of age; and 

18 ‘‘(2) is not enrolled as a participant, bene19 ficiary, or enrollee (other than under this section) 

20 under any health insurance coverage or group health 

21 plan. 

22 ‘‘(c) PREMIUMS.—Nothing in this section shall be 

23 construed as preventing a group health plan or health in24 surance issuer with respect to group health insurance cov25 erage from increasing the premiums otherwise required for 

26 coverage provided under this section consistent with 
41 

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1 standards established by the Secretary based upon family 

2 size.’’. 

3 (B) CLERICAL AMENDMENT.—The table of 

4 contents of such Act is amended by inserting 

5 after the item relating to section 703 the fol6 lowing new item: 

‘‘Sec. 704. Requiring the option of extension of dependent coverage for uninsured young adults.’’. 

7 (3) IRC.— 

8 (A) IN GENERAL.—Subchapter A of chap9 ter 100 of the Internal Revenue Code of 1986 

10 is amended by adding at the end the following 

11 new section: 

12 ‘‘SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DE13 PENDENT COVERAGE FOR UNINSURED 

14 YOUNG ADULTS. 

15 ‘‘(a) IN GENERAL.—A group health plan that pro16 vides coverage for dependent children shall make available 

17 such coverage, at the option of the participant involved, 

18 for one or more qualified children (as defined in subsection 

19 (b)) of the participant. 

20 ‘‘(b) QUALIFIED CHILD DEFINED.—In this section, 

21 the term ‘qualified child’ means, with respect to a partici22 pant in a group health plan, an individual who (but for 

23 age) would be treated as a dependent child of the partici24 pant under such plan and who— 
42 

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1 ‘‘(1) is under 27 years of age; and 

2 ‘‘(2) is not enrolled as a participant, bene3 ficiary, or enrollee (other than under this section, 

4 section 704 of the Employee Retirement Income Se5 curity Act of 1974, or section 2704 or 2746 of the 

6 Public Health Service Act) under any health insur7 ance coverage or group health plan. 

8 ‘‘(c) PREMIUMS.—Nothing in this section shall be 

9 construed as preventing a group health plan from increas10 ing the premiums otherwise required for coverage provided 

11 under this section consistent with standards established 

12 by the Secretary based upon family size.’’. 

13 (B) CLERICAL AMENDMENT.—The table of 

14 sections of such chapter is amended by insert15 ing after the item relating to section 9803 the 

16 following: 

‘‘Sec. 9804. Requiring the option of extension of dependent coverage for uninsured young adults.’’. 

17 (b) INDIVIDUAL HEALTH INSURANCE COVERAGE.— 

18 Title XXVII of the Public Health Service Act is amended 

19 by inserting after section 2745 the following new section: 

20 ‘‘SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DE21 PENDENT COVERAGE FOR UNINSURED 

22 YOUNG ADULTS. 

23 ‘‘The provisions of section 2703 shall apply to health 

24 insurance coverage offered by a health insurance issuer 
43 

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1 in the individual market in the same manner as they apply 

2 to health insurance coverage offered by a health insurance 

3 issuer in connection with a group health plan in the small 

4 or large group market.’’. 

5 (c) EFFECTIVE DATES.— 

6 (1) GROUP HEALTH PLANS.—The amendments 

7 made by subsection (a) shall apply to group health 

8 plans for plan years beginning on or after January 

9 1, 2010. 

10 (2) INDIVIDUAL HEALTH INSURANCE COV11 ERAGE.—Section 2746 of the Public Health Service 

12 Act, as inserted by subsection (b), shall apply with 

13 respect to health insurance coverage offered, sold, 

14 issued, renewed, in effect, or operated in the indi15 vidual market on or after January 1, 2010. 

16 SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EX17 CLUSIONS IN GROUP HEALTH PLANS IN AD18 VANCE OF APPLICABILITY OF NEW PROHIBI19 TION OF PREEXISTING CONDITION EXCLU20 SIONS. 

21 (a) AMENDMENTS TO THE EMPLOYEE RETIREMENT

22 INCOME SECURITY ACT OF 1974.— 

23 (1) REDUCTION IN LOOK-BACK PERIOD.—Sec24 tion 701(a)(1) of the Employee Retirement Income 

25 Security Act of 1974 (29 U.S.C. 1181(a)(1)) is 
44 

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1 amended by striking ‘‘6-month period’’ and inserting 

2 ‘‘30-day period’’. 

3 (2) REDUCTION IN PERMITTED PREEXISTING

4 CONDITION LIMITATION PERIOD.—Section 701(a)(2) 

5 of such Act (29 U.S.C. 1181(a)(2)) is amended by 

6 striking ‘‘12 months’’ and inserting ‘‘3 months’’, 

7 and by striking ‘‘18 months’’ and inserting ‘‘9 

8 months’’. 

9 (3) SUNSET OF INTERIM LIMITATION.—Section 

10 701 of such Act (29 U.S.C. 1181) is amended by 

11 adding at the end the following new subsection: 

12 ‘‘(h) TERMINATION.—This section shall cease to 

13 apply to any group health plan as of the date that such 

14 plan becomes subject to the requirements of section 211 

15 of the (relating to prohibiting preexisting condition exclu16 sions).’’. 

17 (b) AMENDMENTS TO THE INTERNAL REVENUE

18 CODE OF 1986.— 

19 (1) REDUCTION IN LOOK-BACK PERIOD.—Sec20 tion 9801(a)(1) of the Internal Revenue Code of 

21 1986 is amended by striking ‘‘6-month period’’ and 

22 inserting ‘‘30-day period’’. 

23 (2) REDUCTION IN PERMITTED PREEXISTING

24 CONDITION LIMITATION PERIOD.—Section 

25 9801(a)(2) of such Code is amended by striking ‘‘12 
45 

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1 months’’ and inserting ‘‘3 months’’, and by striking 

2 ‘‘18 months’’ and inserting ‘‘9 months’’. 

3 (3) SUNSET OF INTERIM LIMITATION.—Section 

4 9801 of such Code is amended by adding at the end 

5 the following new subsection: 

6 ‘‘(g) TERMINATION.—This section shall cease to 

7 apply to any group health plan as of the date that such 

8 plan becomes subject to the requirements of section 211 

9 of the Affordable Health Care for America Act (relating 

10 to prohibiting preexisting condition exclusions).’’. 

11 (c) AMENDMENTS TO PUBLIC HEALTH SERVICE

12 ACT.— 

13 (1) REDUCTION IN LOOK-BACK PERIOD.—Sec14 tion 2701(a)(1) of the Public Health Service Act (42 

15 U.S.C. 300gg(a)(1)) is amended by striking ‘‘6- 

16 month period’’ and inserting ‘‘30-day period’’. 

17 (2) REDUCTION IN PERMITTED PREEXISTING

18 CONDITION LIMITATION PERIOD.—Section 

19 2701(a)(2) of such Act (42 U.S.C. 300gg(a)(2)) is 

20 amended by striking ‘‘12 months’’ and inserting ‘‘3 

21 months’’, and by striking ‘‘18 months’’ and inserting 

22 ‘‘9 months’’. 

23 (3) SUNSET OF INTERIM LIMITATION.—Section 

24 2701 of such Act (42 U.S.C. 300gg) is amended by 

25 adding at the end the following new subsection: 
46 

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1 ‘‘(h) TERMINATION.—This section shall cease to 

2 apply to any group health plan as of the date that such 

3 plan becomes subject to the requirements of section 211 

4 of the (relating to prohibiting preexisting condition exclu5 sions).’’. 

6 (4) MISCELLANEOUS TECHNICAL AMEND7 MENT.—Section 2702(a)(2) of such Act (42 U.S.C. 

8 300gg–1) is amended by striking ‘‘701’’ and insert9 ing ‘‘2701’’. 

10 (d) EFFECTIVE DATE.— 

11 (1) IN GENERAL.—Except as provided in para12 graph (2), the amendments made by this section 

13 shall apply with respect to group health plans for 

14 plan years beginning on or after January 1, 2010. 

15 (2) SPECIAL RULE FOR COLLECTIVE BAR16 GAINING AGREEMENTS.—In the case of a group 

17 health plan maintained pursuant to 1 or more collec18 tive bargaining agreements between employee rep19 resentatives and 1 or more employers ratified before 

20 the date of the enactment of this Act, the amend21 ments made by this section shall not apply to plan 

22 years beginning before the earlier of— 

23 (A) the date on which the last of the col24 lective bargaining agreements relating to the 

25 plan terminates (determined without regard to 
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1 any extension thereof agreed to after the date 

2 of the enactment of this Act); 

3 (B) 3 years after the date of the enact4 ment of this Act. 

5 SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE 

6 FROM BEING TREATED AS PREEXISTING CON7 DITIONS. 

8 (a) ERISA.—Section 701(d)(3) of the Employee Re9 tirement Income Security Act of 1974 (29 U.S.C. ) is 

10 amended— 

11 (1) in the heading, by inserting ‘‘OR DOMESTIC

12 VIOLENCE’’ after ‘‘PREGNANCY’’; and 

13 (2) by inserting ‘‘or domestic violence’’ after 

14 ‘‘relating to pregnancy’’. 

15 (b) PHSA.— 

16 (1) GROUP MARKET.—Section 2701(d)(3) of 

17 the Public Health Service Act (42 U.S.C. 

18 300gg(d)(3)) is amended— 

19 (A) in the heading, by inserting ‘‘OR DO20 MESTIC VIOLENCE’’ after ‘‘PREGNANCY’’; and 

21 (B) by inserting ‘‘or domestic violence’’ 

22 after ‘‘relating to pregnancy’’. 

23 (2) INDIVIDUAL MARKET.—Title XXVII of such 

24 Act is amended by inserting after section 2753 the 

25 following new section: 
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1 ‘‘SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PRE2 EXISTING CONDITION. 

3 ‘‘A health insurance issuer offering health insurance 

4 coverage in the individual market may not, on the basis 

5 of domestic violence, impose any preexisting condition ex6 clusion (as defined in section 2701(b)(1)(A)) with respect 

7 to such coverage.’’. 

8 (c) IRC.—Section 9801(d)(3) of the Internal Rev9 enue Code of 1986 is amended— 

10 (1) in the heading, by inserting ‘‘OR DOMESTIC

11 VIOLENCE’’ after ‘‘PREGNANCY’’; and 

12 (2) by inserting ‘‘or domestic violence’’ after 

13 ‘‘relating to pregnancy’’. 

14 (d) EFFECTIVE DATES.— 

15 (1) Except as otherwise provided in this sub16 section, the amendments made by this section shall 

17 apply with respect to group health plans (and health 

18 insurance issuers offering group health insurance 

19 coverage) for plan years beginning on or after Janu20 ary 1, 2010. 

21 (2) The amendment made by subsection (b)(2) 

22 shall apply with respect to health insurance coverage 

23 offered, sold, issued, renewed, in effect, or operated 

24 in the individual market on or after such date. 
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1 SEC. 108. ENDING HEALTH INSURANCE DENIALS AND 

2 DELAYS OF NECESSARY TREATMENT FOR 

3 CHILDREN WITH DEFORMITIES. 

4 (a) AMENDMENTS TO THE EMPLOYEE RETIREMENT

5 INCOME SECURITY ACT OF 1974.— 

6 (1) IN GENERAL.—Subpart B of part 7 of sub7 title B of title I of the Employee Retirement Income 

8 Security Act of 1974 is amended by adding at the 

9 end the following new section: 

10 ‘‘SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR 

11 CHILD’S CONGENITAL OR DEVELOPMENTAL 

12 DEFORMITY OR DISORDER. 

13 ‘‘(a) REQUIREMENTS FOR TREATMENT FOR CHIL14 DREN WITH DEFORMITIES.— 

15 ‘‘(1) IN GENERAL.—A group health plan, and a 

16 health insurance issuer offering group health insur17 ance coverage, that provides coverage for surgical 

18 benefits shall provide coverage for outpatient and in19 patient diagnosis and treatment of a minor child’s 

20 congenital or developmental deformity, disease, or 

21 injury. A minor child shall include any individual 

22 who is 21 years of age or younger. 

23 ‘‘(2) TREATMENT DEFINED.— 

24 ‘‘(A) IN GENERAL.—In this section, the 

25 term ‘treatment’ includes reconstructive sur26 gical procedures (procedures that are generally 
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1 performed to improve function, but may also be 

2 performed to approximate a normal appear3 ance) that are performed on abnormal struc4 tures of the body caused by congenital defects, 

5 developmental abnormalities, trauma, infection, 

6 tumors, or disease, including— 

7 ‘‘(i) procedures that do not materially 

8 affect the function of the body part being 

9 treated; and 

10 ‘‘(ii) procedures for secondary condi11 tions and follow-up treatment. 

12 ‘‘(B) EXCEPTION.—Such term does not in13 clude cosmetic surgery performed to reshape 

14 normal structures of the body to improve ap15 pearance or self-esteem. 

16 ‘‘(b) NOTICE.—A group health plan under this part 

17 shall comply with the notice requirement under section 

18 713(b) (other than paragraph (3)) with respect to the re19 quirements of this section.’’. 

20 (2) CONFORMING AMENDMENT.— 

21 (A) Subsection (c) of section 731 of such 

22 Act is amended by striking ‘‘section 711’’ and 

23 inserting ‘‘sections 711 and 715’’. 
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1 (B) The table of contents in section 1 of 

2 such Act is amended by inserting after the item 

3 relating to section 714 the following new item: 

‘‘Sec. 715. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

4 (b) AMENDMENTS TO THE INTERNAL REVENUE

5 CODE OF 1986.— 

6 (1) IN GENERAL.—Subchapter B of chapter 

7 100 of the Internal Revenue Code of 1986 is amend8 ed by adding at the end the following new section: 

9 ‘‘SEC. 9814. STANDARDS RELATING TO BENEFITS FOR 

10 MINOR CHILD’S CONGENITAL OR DEVELOP11 MENTAL DEFORMITY OR DISORDER. 

12 ‘‘(a) REQUIREMENTS FOR TREATMENT FOR CHIL13 DREN WITH DEFORMITIES.—A group health plan that 

14 provides coverage for surgical benefits shall provide cov15 erage for outpatient and inpatient diagnosis and treat16 ment of a minor child’s congenital or developmental de17 formity, disease, or injury. A minor child shall include any 

18 individual who is 21 years of age or younger. 

19 ‘‘(b) TREATMENT DEFINED.— 

20 ‘‘(1) IN GENERAL.—In this section, the term 

21 ‘treatment’ includes reconstructive surgical proce22 dures (procedures that are generally performed to 

23 improve function, but may also be performed to ap24 proximate a normal appearance) that are performed 
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1 on abnormal structures of the body caused by con2 genital defects, developmental abnormalities, trau3 ma, infection, tumors, or disease, including— 

4 ‘‘(A) procedures that do not materially af5 fect the function of the body part being treated, 

6 and 

7 ‘‘(B) procedures for secondary conditions 

8 and follow-up treatment. 

9 ‘‘(2) EXCEPTION.—Such term does not include 

10 cosmetic surgery performed to reshape normal struc11 tures of the body to improve appearance or self-es12 teem.’’. 

13 (2) CLERICAL AMENDMENT.—The table of sec14 tions for subchapter B of chapter 100 of such Code 

15 is amended by adding at the end the following new 

16 item: 

‘‘Sec. 9814. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

17 (c) AMENDMENTS TO THE PUBLIC HEALTH SERVICE

18 ACT.— 

19 (1) IN GENERAL.—Subpart 2 of part A of title 

20 XXVII of the Public Health Service Act is amended 

21 by adding at the end the following new section: 
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1 ‘‘SEC. 2708. STANDARDS RELATING TO BENEFITS FOR 

2 MINOR CHILD’S CONGENITAL OR DEVELOP3 MENTAL DEFORMITY OR DISORDER. 

4 ‘‘(a) REQUIREMENTS FOR TREATMENT FOR CHIL5 DREN WITH DEFORMITIES.— 

6 ‘‘(1) IN GENERAL.—A group health plan, and a 

7 health insurance issuer offering group health insur8 ance coverage, that provides coverage for surgical 

9 benefits shall provide coverage for outpatient and in10 patient diagnosis and treatment of a minor child’s 

11 congenital or developmental deformity, disease, or 

12 injury. A minor child shall include any individual 

13 who is 21 years of age or younger. 

14 ‘‘(2) TREATMENT DEFINED.— 

15 ‘‘(A) IN GENERAL.—In this section, the 

16 term ‘treatment’ includes reconstructive sur17 gical procedures (procedures that are generally 

18 performed to improve function, but may also be 

19 performed to approximate a normal appear20 ance) that are performed on abnormal struc21 tures of the body caused by congenital defects, 

22 developmental abnormalities, trauma, infection, 

23 tumors, or disease, including— 

24 ‘‘(i) procedures that do not materially 

25 affect the function of the body part being 

26 treated; and 
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1 ‘‘(ii) procedures for secondary condi2 tions and follow-up treatment. 

3 ‘‘(B) EXCEPTION.—Such term does not in4 clude cosmetic surgery performed to reshape 

5 normal structures of the body to improve ap6 pearance or self-esteem. 

7 ‘‘(b) NOTICE.—A group health plan under this part 

8 shall comply with the notice requirement under section 

9 715(b) of the Employee Retirement Income Security Act 

10 of 1974 with respect to the requirements of this section 

11 as if such section applied to such plan.’’. 

12 (2) INDIVIDUAL HEALTH INSURANCE.—Subpart 

13 2 of part B of title XXVII of the Public Health 

14 Service Act, as amended by section 161(b), is fur15 ther amended by adding at the end the following 

16 new section: 

17 ‘‘SEC. 2755. STANDARDS RELATING TO BENEFITS FOR 

18 MINOR CHILD’S CONGENITAL OR DEVELOP19 MENTAL DEFORMITY OR DISORDER. 

20 ‘‘The provisions of section 2708 shall apply to health 

21 insurance coverage offered by a health insurance issuer 

22 in the individual market in the same manner as such pro23 visions apply to health insurance coverage offered by a 

24 health insurance issuer in connection with a group health 

25 plan in the small or large group market.’’. 
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1 (3) CONFORMING AMENDMENTS.— 

2 (A) Section 2723(c) of such Act (42 

3 U.S.C. 300gg–23(c)) is amended by striking 

4 ‘‘section 2704’’ and inserting ‘‘sections 2704 

5 and 2708’’. 

6 (B) Section 2762(b)(2) of such Act (42 

7 U.S.C. 300gg–62(b)(2)) is amended by striking 

8 ‘‘section 2751’’ and inserting ‘‘sections 2751 

9 and 2755’’. 

10 (d) EFFECTIVE DATES.— 

11 (1) The amendments made by this section shall 

12 apply with respect to group health plans (and health 

13 insurance issuers offering group health insurance 

14 coverage) for plan years beginning on or after Janu15 ary 1, 2010. 

16 (2) The amendment made by subsection (c)(2) 

17 shall apply with respect to health insurance coverage 

18 offered, sold, issued, renewed, in effect, or operated 

19 in the individual market on or after such date. 

20 (e) COORDINATION.—Section 104(1) of the Health 

21 Insurance Portability and Accountability Act of 1996 is 

22 amended by striking ‘‘(and the amendments made by this 

23 subtitle and section 401)’’ and inserting ‘‘, part 7 of sub24 title B of title I of the Employee Retirement Income Secu25 rity Act of 1974, parts A and C of title XXVII of the 
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1 Public Health Service Act, and chapter 100 of the Internal 

2 Revenue Code of 1986’’. 

3 SEC. 109. ELIMINATION OF LIFETIME LIMITS. 

4 (a) AMENDMENTS TO THE EMPLOYEE RETIREMENT

5 INCOME SECURITY ACT OF 1974.— 

6 (1) IN GENERAL.—Subpart B of part 7 of sub7 title B of title I of the Employee Retirement Income 

8 Security Act of 1974 (29 U.S.C. 1185 et seq.), as 

9 amended by section 108, is amended by adding at 

10 the end the following: 

11 ‘‘SEC. 716. ELIMINATION OF LIFETIME AGGREGATE LIMITS. 

12 ‘‘(a) IN GENERAL.—A group health plan and a health 

13 insurance issuer providing health insurance coverage in 

14 connection with a group health plan, may not impose an 

15 aggregate dollar lifetime limit with respect to benefits pay16 able under the plan or coverage. 

17 ‘‘(b) DEFINITION.—In this section, the term ‘aggre18 gate dollar lifetime limit’ means, with respect to benefits 

19 under a group health plan or health insurance coverage 

20 offered in connection with a group health plan, a dollar 

21 limitation on the total amount that may be paid with re22 spect to such benefits under the plan or health insurance 

23 coverage with respect to an individual or other coverage 

24 unit on a lifetime basis.’’. 
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1 (2) CLERICAL AMENDMENT.—The table of con2 tents in section 1 of such Act, is amended by insert3 ing after the item relating to section 715 the fol4 lowing new item: 

‘‘Sec. 716. Elimination of lifetime aggregate limits.’’. 

5 (b) AMENDMENTS TO THE INTERNAL REVENUE

6 CODE OF 1986.— 

7 (1) IN GENERAL.—Subchapter B of chapter 

8 100 of the Internal Revenue Code of 1986, as 

9 amended by section 108(b), is amended by adding at 

10 the end the following new section: 

11 ‘‘SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIM12 ITS. 

13 ‘‘(a) IN GENERAL.—A group health plan may not im14 pose an aggregate dollar lifetime limit with respect to ben15 efits payable under the plan. 

16 ‘‘(b) DEFINITION.—In this section, the term ‘aggre17 gate dollar lifetime limit’ means, with respect to benefits 

18 under a group health plan a dollar limitation on the total 

19 amount that may be paid with respect to such benefits 

20 under the plan with respect to an individual or other cov21 erage unit on a lifetime basis.’’. 

22 (2) CLERICAL AMENDMENT.—The table of sec23 tions for subchapter B of chapter 100 of such Code, 

24 as amended by section 108(b), is amended by adding 

25 at the end the following new item: 
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‘‘Sec. 9854. Standards relating to benefits for minor child’s congenital or developmental deformity or disorder.’’. 

1 (c) AMENDMENT TO THE PUBLIC HEALTH SERVICE

2 ACT RELATING TO THE GROUP MARKET.— 

3 (1) IN GENERAL.—Subpart 2 of part A of title 

4 XXVII of the Public Health Service Act (42 U.S.C. 

5 300gg–4 et seq.) as amended by section 108(c)(1), 

6 is amended by adding at the end the following: 

7 ‘‘SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIM8 ITS. 

9 ‘‘(a) IN GENERAL.—A group health plan and a health 

10 insurance issuer providing health insurance coverage in 

11 connection with a group health plan, may not impose an 

12 aggregate dollar lifetime limit with respect to benefits pay13 able under the plan or coverage. 

14 ‘‘(b) DEFINITION.—In this section, the term ‘aggre15 gate dollar lifetime limit’ means, with respect to benefits 

16 under a group health plan or health insurance coverage, 

17 a dollar limitation on the total amount that may be paid 

18 with respect to such benefits under the plan or health in19 surance coverage with respect to an individual or other 

20 coverage unit on a lifetime basis.’’. 

21 (2) INDIVIDUAL MARKET.—Subpart 2 of part B 

22 of title XXVII of the Public Health Service Act (42 

23 U.S.C. 300gg–51 et seq.), as amended by section 
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1 108(c)(2), is amended by adding at the end the fol2 lowing: 

3 ‘‘SEC. 2756. ELIMINATION OF LIFETIME AGGREGATE LIM4 ITS. 

5 ‘‘The provisions of section 2709 shall apply to health 

6 insurance coverage offered by a health insurance issuer 

7 in the individual market in the same manner as they apply 

8 to health insurance coverage offered by a health insurance 

9 issuer in connection with a group health plan in the small 

10 or large group market.’’. 

11 (d) EFFECTIVE DATES.— 

12 (1) The amendments made by this section shall 

13 apply with respect to group health plans (and health 

14 insurance issuers offering group health insurance 

15 coverage) for plan years beginning on or after Janu16 ary 1, 2010. 

17 (2) The amendment made by subsection (c)(2) 

18 shall apply with respect to health insurance coverage 

19 offered, sold, issued, renewed, in effect, or operated 

20 in the individual market on or after such date. 

21 SEC. 110. PROHIBITION AGAINST POSTRETIREMENT RE22 DUCTIONS OF RETIREE HEALTH BENEFITS 

23 BY GROUP HEALTH PLANS. 

24 (a) IN GENERAL.—Part 7 of subtitle B of title I of 

25 the Employee Retirement Income Security Act of 1974, 
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1 as amended by sections 108 and 109, is amended by in2 serting after section 716 the following new section: 

3 ‘‘SEC. 717. PROTECTION AGAINST POSTRETIREMENT RE4 DUCTION OF RETIREE HEALTH BENEFITS. 

5 ‘‘(a) IN GENERAL.—Every group health plan shall 

6 contain a provision which expressly bars the plan, or any 

7 fiduciary of the plan, from reducing the benefits provided 

8 under the plan to a retired participant, or beneficiary of 

9 such participant, if such reduction affects the benefits pro10 vided to the participant or beneficiary as of the date the 

11 participant retired for purposes of the plan and such re12 duction occurs after the participant’s retirement unless 

13 such reduction is also made with respect to active partici14 pants. Nothing in this section shall prohibit a plan from 

15 enforcing a total aggregate cap on amounts paid for re16 tiree health coverage that is part of the plan at the time 

17 of retirement. 

18 ‘‘(b) NO REDUCTION.—Notwithstanding that a group 

19 health plan may contain a provision reserving the general 

20 power to amend or terminate the plan or a provision spe21 cifically authorizing the plan to make post-retirement re22 ductions in retiree health benefits, it shall be prohibited 

23 for any group health plan, whether through amendment 

24 or otherwise, to reduce the benefits provided to a retired 

25 participant or the participant’s beneficiary under the 
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1 terms of the plan if such reduction of benefits occurs after 

2 the date the participant retired for purposes of the plan 

3 and reduces benefits that were provided to the participant, 

4 or the participant’s beneficiary, as of the date the partici5 pant retired unless such reduction is also made with re6 spect to active participants. 

7 ‘‘(c) REDUCTION DESCRIBED.— For purposes of this 

8 section, a reduction in benefits— 

9 ‘‘(1) with respect to premiums occurs under a 

10 group health plan when a participant’s (or bene11 ficiary’s) share of the total premium (or, in the case 

12 of a self-insured plan, the costs of coverage) of the 

13 plan substantially increases; or 

14 ‘‘(2) with respect to other cost-sharing and ben15 efits under a group health plan occurs when there is 

16 a substantial decrease in the actuarial value of the 

17 benefit package under the plan. 

18 For purposes of this section, the term ‘substantial’ means 

19 an increase in the total premium share or a decrease in 

20 the actuarial value of the benefit package that is greater 

21 than 5 percent.’’ 

22 (b) CONFORMING AMENDMENT.—The table of con23 tents in section 1 of such Act, as amended by sections 

24 108 and 109, is amended by inserting after the item relat25 ing to section 716 the following new item: 
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‘‘Sec. 717. Protection against postretirement reduction of retiree health benefits.’’. 

1 (c) WAIVER.—An employer may, in a form and man2 ner which shall be prescribed by the Secretary of Labor, 

3 apply for a waiver from this provision if the employer can 

4 reasonably demonstrate that meeting the requirements of 

5 this section would impose an undue hardship on the em6 ployer. 

7 (d) EFFECTIVE DATE.—The amendments made by 

8 this section shall take effect on the date of the enactment 

9 of this Act. 

10 SEC. 111. REINSURANCE PROGRAM FOR RETIREES. 

11 (a) ESTABLISHMENT.— 

12 (1) IN GENERAL.—Not later than 90 days after 

13 the date of the enactment of this Act, the Secretary 

14 of Health and Human Services shall establish a tem15 porary reinsurance program (in this section referred 

16 to as the ‘‘reinsurance program’’) to provide reim17 bursement to assist participating employment-based 

18 plans with the cost of providing health benefits to 

19 retirees and to eligible spouses, surviving spouses 

20 and dependents of such retirees. 

21 (2) DEFINITIONS.—For purposes of this sec22 tion: 
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1 (A) The term ‘‘eligible employment-based 

2 plan’’ means a group health plan or employ3 ment-based health plan that— 

4 (i) is — 

5 (I) maintained by one or more 

6 employers (including without limita7 tion any State or political subdivision 

8 thereof, or any agency or instrumen9 tality of any of the foregoing), former 

10 employers or employee organizations 

11 or associations, or a voluntary employ12 ees’ beneficiary association, or a com13 mittee or board of individuals ap14 pointed to administer such plan; or 

15 (II) a multiemployer plan (as de16 fined in section 3(37) of the Employee 

17 Retirement Income Security Act of 

18 1974); and 

19 (ii) provides health benefits to retir20 ees. 

21 (B) The term ‘‘health benefits’’ means 

22 medical, surgical, hospital, prescription drug, 

23 and such other benefits as shall be determined 

24 by the Secretary, whether self-funded or deliv-
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1 ered through the purchase of insurance or oth2 erwise. 

3 (C) The term ‘‘participating employment4 based plan’’ means an eligible employment5 based plan that is participating in the reinsur6 ance program. 

7 (D) The term ‘‘retiree’’ means, with re8 spect to a participating employment-benefit 

9 plan, an individual who— 

10 (i) is 55 years of age or older; 

11 (ii) is not eligible for coverage under 

12 title XVIII of the Social Security Act; and 

13 (iii) is not an active employee of an 

14 employer maintaining the plan or of any 

15 employer that makes or has made substan16 tial contributions to fund such plan. 

17 (E) The term ‘‘Secretary’’ means Sec18 retary of Health and Human Services. 

19 (b) PARTICIPATION.—To be eligible to participate in 

20 the reinsurance program, an eligible employment-based 

21 plan shall submit to the Secretary an application for par22 ticipation in the program, at such time, in such manner, 

23 and containing such information as the Secretary shall re24 quire. 

25 (c) PAYMENT.— 
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1 (1) SUBMISSION OF CLAIMS.— 

2 (A) IN GENERAL.—Under the reinsurance 

3 program, a participating employment-based 

4 plan shall submit claims for reimbursement to 

5 the Secretary which shall contain documenta6 tion of the actual costs of the items and serv7 ices for which each claim is being submitted. 

8 (B) BASIS FOR CLAIMS.—Each claim sub9 mitted under subparagraph (A) shall be based 

10 on the actual amount expended by the partici11 pating employment-based plan involved within 

12 the plan year for the appropriate employment 

13 based health benefits provided to a retiree or to 

14 the spouse, surviving spouse, or dependent of a 

15 retiree. In determining the amount of any claim 

16 for purposes of this subsection, the partici17 pating employment-based plan shall take into 

18 account any negotiated price concessions (such 

19 as discounts, direct or indirect subsidies, re20 bates, and direct or indirect remunerations) ob21 tained by such plan with respect to such health 

22 benefits. For purposes of calculating the 

23 amount of any claim, the costs paid by the re24 tiree or by the spouse, surviving spouse, or de25 pendent of the retiree in the form of 
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1 deductibles, copayments, and coinsurance shall 

2 be included along with the amounts paid by the 

3 participating employment-based plan. 

4 (2) PROGRAM PAYMENTS AND LIMIT.—If the 

5 Secretary determines that a participating employ6 ment-based plan has submitted a valid claim under 

7 paragraph (1), the Secretary shall reimburse such 

8 plan for 80 percent of that portion of the costs at9 tributable to such claim that exceeds $15,000, but is 

10 less than $90,000. Such amounts shall be adjusted 

11 each year based on the percentage increase in the 

12 medical care component of the Consumer Price 

13 Index (rounded to the nearest multiple of $1,000) 

14 for the year involved. 

15 (3) USE OF PAYMENTS.—Amounts paid to a 

16 participating employment-based plan under this sub17 section shall only be used to reduce the costs of 

18 health care provided by the plan by reducing pre19 mium costs for the employer or employee association 

20 maintaining the plan, and reducing premium con21 tributions, deductibles, copayments, coinsurance, or 

22 other out-of-pocket costs for plan participants and 

23 beneficiaries. Where the benefits are provided by an 

24 employer to members of a represented bargaining 

25 unit, the allocation of payments among these pur-
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1 poses shall be subject to collective bargaining. 

2 Amounts paid to the plan under this subsection shall 

3 not be used as general revenues by the employer or 

4 employee association maintaining the plan or for any 

5 other purposes. The Secretary shall develop a mech6 anism to monitor the appropriate use of such pay7 ments by such plans. 

8 (4) APPEALS AND PROGRAM PROTECTIONS.— 

9 The Secretary shall establish— 

10 (A) an appeals process to permit partici11 pating employment-based plans to appeal a de12 termination of the Secretary with respect to 

13 claims submitted under this section; and 

14 (B) procedures to protect against fraud, 

15 waste, and abuse under the program. 

16 (5) AUDITS.—The Secretary shall conduct an17 nual audits of claims data submitted by partici18 pating employment-based plans under this section to 

19 ensure that they are in compliance with the require20 ments of this section. 

21 (d) RETIREE RESERVE TRUST FUND.— 

22 (1) ESTABLISHMENT.— 

23 (A) IN GENERAL.—There is established in 

24 the Treasury of the United States a trust fund 

25 to be known as the ‘‘Retiree Reserve Trust 
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1 Fund’’ (referred to in this section as the ‘‘Trust 

2 Fund’’), that shall consist of such amounts as 

3 may be appropriated or credited to the Trust 

4 Fund as provided for in this subsection to en5 able the Secretary to carry out the reinsurance 

6 program. Such amounts shall remain available 

7 until expended. 

8 (B) FUNDING.—There are hereby appro9 priated to the Trust Fund, out of any moneys 

10 in the Treasury not otherwise appropriated, an 

11 amount requested by the Secretary as necessary 

12 to carry out this section, except that the total 

13 of all such amounts requested shall not exceed 

14 $10,000,000,000. 

15 (C) APPROPRIATIONS FROM THE TRUST

16 FUND.— 

17 (i) IN GENERAL.—Amounts in the 

18 Trust Fund are appropriated to provide 

19 funding to carry out the reinsurance pro20 gram and shall be used to carry out such 

21 program. 

22 (ii) LIMITATION TO AVAILABLE

23 FUNDS.—The Secretary has the authority 

24 to stop taking applications for participa25 tion in the program or take such other 
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1 steps in reducing expenditures under the 

2 reinsurance program in order to ensure 

3 that expenditures under the reinsurance 

4 program do not exceed the funds available 

5 under this subsection. 

6 SEC. 112. WELLNESS PROGRAM GRANTS. 

7 (a) ALLOWANCE OF GRANT.— 

8 (1) IN GENERAL.—For purposes of this section, 

9 the Secretaries of Health and Human Services and 

10 Labor shall jointly award wellness grants as deter11 mined under this section. Wellness program grants 

12 shall be awarded to small employers (as defined by 

13 the Secretary) for any plan year in an amount equal 

14 to 50 percent of the costs paid or incurred by such 

15 employers in connection with a qualified wellness 

16 program during the plan year. For purposes of the 

17 preceding sentence, in the case of any qualified 

18 wellness program offered as part of an employment19 based health plan, only costs attributable to the 

20 qualified wellness program and not to the health 

21 plan, or health insurance coverage offered in connec22 tion with such a plan, may be taken into account. 

23 (2) LIMITATIONS.— 
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1 (A) PERIOD.—A wellness grant awarded to 

2 an employer under this section shall be for up 

3 to 3 years. 

4 (B) AMOUNT.—The amount of the grant 

5 under paragraph (1) for an employer shall not 

6 exceed— 

7 (i) the product of $150 and the num8 ber of employees of the employer for any 

9 plan year; and 

10 (ii) $50,000 for the entire period of 

11 the grant. 

12 (b) QUALIFIED WELLNESS PROGRAM.—For purposes 

13 of this section: 

14 (1) QUALIFIED WELLNESS PROGRAM.—The 

15 term ‘‘qualified wellness program’’ means a program 

16 that— 

17 (A) includes any 3 wellness components de18 scribed in subsection (c); and 

19 (B) is to be certified jointly by the Sec20 retary of Health and Human Services and the 

21 Secretary of Labor, in coordination with the Di22 rector of the Centers for Disease Control and 

23 Prevention, as a qualified wellness program 

24 under this section. 
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1 (2) PROGRAMS MUST BE CONSISTENT WITH RE2 SEARCH AND BEST PRACTICES.— 

3 (A) IN GENERAL.—The Secretary of 

4 Health and Human Services and the Secretary 

5 of Labor shall not certify a program as a quali6 fied wellness program unless the program— 

7 (i) is consistent with evidence-based 

8 research and best practices, as identified 

9 by persons with expertise in employer 

10 health promotion and wellness programs; 

11 (ii) includes multiple, evidence-based 

12 strategies which are based on the existing 

13 and emerging research and careful sci14 entific reviews, including the Guide to 

15 Community Preventative Services, the 

16 Guide to Clinical Preventative Services, 

17 and the National Registry for Effective 

18 Programs; and 

19 (iii) includes strategies which focus on 

20 prevention and support for employee popu21 lations at risk of poor health outcomes. 

22 (B) PERIODIC UPDATING AND REVIEW.— 

23 The Secretaries of Health and Human Services 

24 and Labor, in consultation with other appro25 priate agencies shall jointly establish procedures 
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1 for periodic review, evaluation, and update of 

2 the programs under this subsection. 

3 (3) HEALTH LITERACY AND ACCESSIBILITY.— 

4 The Secretaries of Health and Human Services and 

5 Labor shall jointly, as part of the certification proc6 ess— 

7 (A) ensure that employers make the pro8 grams culturally competent, physically and pro9 grammatically accessible (including for individ10 uals with disabilities), and appropriate to the 

11 health literacy needs of the employees covered 

12 by the programs; 

13 (B) require a health literacy component to 

14 provide special assistance and materials to em15 ployees with low literacy skills, limited English 

16 and from underserved populations; and 

17 (C) require the Secretaries to compile and 

18 disseminate to employer health plans informa19 tion on model health literacy curricula, instruc20 tional programs, and effective intervention 

21 strategies. 

22 (c) WELLNESS PROGRAM COMPONENTS.—For pur23 poses of this section, the wellness program components de24 scribed in this subsection are the following: 
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1 (1) HEALTH AWARENESS COMPONENT.—A 

2 health awareness component which provides for the 

3 following: 

4 (A) HEALTH EDUCATION.—The dissemina5 tion of health information which addresses the 

6 specific needs and health risks of employees. 

7 (B) HEALTH SCREENINGS.—The oppor8 tunity for periodic screenings for health prob9 lems and referrals for appropriate follow-up 

10 measures. 

11 (2) EMPLOYEE ENGAGEMENT COMPONENT.— 

12 An employee engagement component which provides 

13 for the active engagement of employees in worksite 

14 wellness programs through worksite assessments and 

15 program planning, onsite delivery, evaluation, and 

16 improvement efforts. 

17 (3) BEHAVIORAL CHANGE COMPONENT.—A be18 havioral change component which encourages 

19 healthy living through counseling, seminars, on-line 

20 programs, self-help materials, or other programs 

21 which provide technical assistance and problem solv22 ing skills. Such component may include programs re23 lating to— 

24 (A) tobacco use; 

25 (B) obesity; 
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1 (C) stress management; 

2 (D) physical fitness; 

3 (E) nutrition; 

4 (F) substance abuse; 

5 (G) depression; and 

6 (H) mental health promotion. 

7 (4) SUPPORTIVE ENVIRONMENT COMPONENT.— 

8 A supportive environment component which includes 

9 the following: 

10 (A) ON-SITE POLICIES.—Policies and serv11 ices at the worksite which promote a healthy 

12 lifestyle, including policies relating to— 

13 (i) tobacco use at the worksite; 

14 (ii) the nutrition of food available at 

15 the worksite through cafeterias and vend16 ing options; 

17 (iii) minimizing stress and promoting 

18 positive mental health in the workplace; 

19 and 

20 (iv) the encouragement of physical ac21 tivity before, during, and after work hours. 

22 (d) PARTICIPATION REQUIREMENT.—No grant shall 

23 be allowed under subsection (a) unless the Secretaries of 

24 Health and Human Services and Labor, in consultation 

25 with other appropriate agencies, jointly certify, as a part 
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1 of any certification described in subsection (b), that each 

2 wellness program component of the qualified wellness pro3 gram— 

4 (1) shall be available to all employees of the 

5 employer; 

6 (2) shall not mandate participation by employ7 ees; and 

8 (3) may provide a financial reward for partici9 pation of an individual in such program so long as 

10 such reward is not tied to the premium or cost-shar11 ing of the individual under the health benefits plan. 

12 (e) PRIVACY PROTECTIONS.—Data gathered for pur13 poses of the employer wellness program may be used solely 

14 for the purposes of administering the program. The Secre15 taries of Health and Human Services and Labor shall de16 velop standards to ensure such data remain confidential 

17 and are not used for purposes beyond those for admin18 istering the program. 

19 (f) CERTAIN COSTS NOT INCLUDED.—For purposes 

20 of this section, costs paid or incurred by an employer for 

21 food or health insurance shall not be taken into account 

22 under subsection (a). 

23 (g) OUTREACH.—The Secretaries of Health and 

24 Human Services and Labor, in conjunction with other ap25 propriate agencies and members of the business commu-
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1 nity, shall jointly institute an outreach program to inform 

2 businesses about the availability of the wellness program 

3 grant as well as to educate businesses on how to develop 

4 programs according to recognized and promising practices 

5 and on how to measure the success of implemented pro6 grams. 

7 (h) EFFECTIVE DATE.—This section shall take effect 

8 on July 1, 2010. 

9 (i) AUTHORIZATION OF APPROPRIATIONS.—There 

10 are authorized to be appropriated such sums as are nec11 essary to carry out this section. 

12 SEC. 113. EXTENSION OF COBRA CONTINUATION COV13 ERAGE. 

14 (a) EXTENSION OF CURRENT PERIODS OF CONTINU15 ATION COVERAGE.— 

16 (1) IN GENERAL.—In the case of any individual 

17 who is, under a COBRA continuation coverage pro18 vision, covered under COBRA continuation coverage 

19 on or after the date of the enactment of this Act, 

20 the required period of any such coverage which has 

21 not subsequently terminated under the terms of such 

22 provision for any reason other than the expiration of 

23 a period of a specified number of months shall, not24 withstanding such provision and subject to sub25 section (b), extend to the earlier of the date on 
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1 which such individual becomes eligible for acceptable 

2 coverage or the date on which such individual be3 comes eligible for health insurance coverage through 

4 the Health Insurance Exchange (or a State-based 

5 Health Insurance Exchange operating in a State or 

6 group of States). 

7 (2) NOTICE.—As soon as practicable after the 

8 date of the enactment of this Act, the Secretary of 

9 Labor, in consultation with the Secretary of the 

10 Treasury and the Secretary of Health and Human 

11 Services, shall, in consultation with administrators 

12 of the group health plans (or other entities) that 

13 provide or administer the COBRA continuation cov14 erage involved, provide rules setting forth the form 

15 and manner in which prompt notice to individuals of 

16 the continued availability of COBRA continuation 

17 coverage to such individuals under paragraph (1). 

18 (b) CONTINUED EFFECT OF OTHER TERMINATING

19 EVENTS.—Notwithstanding subsection (a), any required 

20 period of COBRA continuation coverage which is extended 

21 under such subsection shall terminate upon the occur22 rence, prior to the date of termination otherwise provided 

23 in such subsection, of any terminating event specified in 

24 the applicable continuation coverage provision other than 

25 the expiration of a period of a specified number of months. 
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1 (c) ACCESS TO STATE HEALTH BENEFITS RISK

2 POOLS.—This section shall supersede any provision of the 

3 law of a State or political subdivision thereof to the extent 

4 that such provision has the effect of limiting or precluding 

5 access by a qualified beneficiary whose COBRA continu6 ation coverage has been extended under this section to a 

7 State health benefits risk pool recognized by the Commis8 sioner for purposes of this section solely by reason of the 

9 extension of such coverage beyond the date on which such 

10 coverage otherwise would have expired. 

11 (d) DEFINITIONS.—For purposes of this section— 

12 (1) COBRA CONTINUATION COVERAGE.—The 

13 term ‘‘COBRA continuation coverage’’ means con14 tinuation coverage provided pursuant to part 6 of 

15 subtitle B of title I of the Employee Retirement In16 come Security Act of 1974 (other than under section 

17 609), title XXII of the Public Health Service Act, 

18 section 4980B of the Internal Revenue Code of 1986 

19 (other than subsection (f)(1) of such section insofar 

20 as it relates to pediatric vaccines), or section 8905a 

21 of title 5, United States Code, or under a State pro22 gram that provides comparable continuation cov23 erage. Such term does not include coverage under a 

24 health flexible spending arrangement under a cafe-
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1 teria plan within the meaning of section 125 of the 

2 Internal Revenue Code of 1986. 

3 (2) COBRA CONTINUATION PROVISION.—The 

4 term ‘‘COBRA continuation provision’’ means the 

5 provisions of law described in paragraph (1). 

6 SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS. 

7 (a) IN GENERAL.—The Secretary of Health and 

8 Human Services (in this section referred to as the ‘‘Sec9 retary’’) shall provide grants to States (as defined for pur10 poses of title XIX of the Social Security Act) to establish 

11 programs to expand access to affordable health care cov12 erage for the uninsured populations in that State in a 

13 manner consistent with reforms to take effect under this 

14 division in Y1. 

15 (b) TYPES OF PROGRAMS.—The types of programs 

16 for which grants are available under subsection (a) include 

17 the following: 

18 (1) STATE INSURANCE EXCHANGES.—State in19 surance exchanges that develop new, less expensive, 

20 portable benefit packages for small employers and 

21 part-time and seasonal workers. 

22 (2) COMMUNITY COVERAGE PROGRAM.—Com23 munity coverage with shared responsibility between 

24 employers, governmental or nonprofit entity, and the 

25 individual. 
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1 (3) REINSURANCE PLAN PROGRAM.—Reinsur2 ance plans that subsidize a certain share of carrier 

3 losses within a certain risk corridor health insurance 

4 premium assistance. 

5 (4) TRANSPARENT MARKETPLACE PROGRAM.— 

6 Transparent marketplace that provides an organized 

7 structure for the sale of insurance products such as 

8 a Web exchange or portal. 

9 (5) AUTOMATED ENROLLMENT PROGRAM.— 

10 Statewide or automated enrollment systems for pub11 lic assistance programs. 

12 (6) INNOVATIVE STRATEGIES.—Innovative 

13 strategies to insure low-income childless adults. 

14 (7) PURCHASING COLLABORATIVES.—Not-for15 profit business/consumer collaborative that provides 

16 direct contract health care service purchasing op17 tions for group plan sponsors. 

18 (c) ELIGIBILITY AND ADMINISTRATION.— 

19 (1) IMPLEMENTATION OF KEY STATUTORY OR

20 REGULATORY CHANGES.—In order to be awarded a 

21 grant under this section for a program, a State shall 

22 demonstrate that— 

23 (A) it has achieved the key State and local 

24 statutory or regulatory changes required to 

25 begin implementing the new program within 1 
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1 year after the initiation of funding under the 

2 grant; and 

3 (B) it will be able to sustain the program 

4 without Federal funding after the end of the 

5 period of the grant. 

6 (2) INELIGIBILITY.—A State that has already 

7 developed a comprehensive health insurance access 

8 program is not eligible for a grant under this sec9 tion. 

10 (3) APPLICATION REQUIRED.—No State shall 

11 receive a grant under this section unless the State 

12 has approved by the Secretary such an application, 

13 in such form and manner as the Secretary specifies. 

14 (4) ADMINISTRATION BASED ON CURRENT PRO15 GRAM.—The program under this section is intended 

16 to build on the State Health Access Program funded 

17 under the Omnibus Appropriations Act, 2009 (Pub18 lic Law 111–8). 

19 (d) FUNDING LIMITATIONS.— 

20 (1) IN GENERAL.—A grant under this section 

21 shall— 

22 (A) only be available for expenditures be23 fore Y1; and 

24 (B) only be used to supplement, and not 

25 supplant, funds otherwise provided. 
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1 (2) MATCHING FUND REQUIREMENT.— 

2 (A) IN GENERAL.—Subject to subpara3 graph (B), no grant may be awarded to a State 

4 unless the State demonstrates the seriousness 

5 of its effort by matching at least 20 percent of 

6 the grant amount through non-Federal re7 sources, which may be a combination of State, 

8 local, private dollars from insurers, providers, 

9 and other private organizations. 

10 (B) WAIVER.—The Secretary may waive 

11 the requirement of subparagraph (A) if the 

12 State demonstrates to the Secretary financial 

13 hardship in complying with such requirement. 

14 (e) STUDY.—The Secretary shall review, study, and 

15 benchmark the progress and results of the programs fund16 ed under this section. 

17 (f) REPORT.—Each State receiving a grant under 

18 this section shall submit to the Secretary a report on best 

19 practices and lessons learned through the grant to inform 

20 the health reform coverage expansions under this division 

21 beginning in Y1. 

22 (g) FUNDING.—There are authorized to be appro23 priated such sums as may be necessary to carry out this 

24 section. 
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1 SEC. 115. ADMINISTRATIVE SIMPLIFICATION. 

2 (a) STANDARDIZING ELECTRONIC ADMINISTRATIVE

3 TRANSACTIONS.— 

4 (1) IN GENERAL.—Part C of title XI of the So5 cial Security Act (42 U.S.C. 1320d et seq.) is 

6 amended by inserting after section 1173 the fol7 lowing new sections: 

8 ‘‘SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE 

9 TRANSACTIONS. 

10 ‘‘(a) STANDARDS FOR FINANCIAL AND ADMINISTRA11 TIVE TRANSACTIONS.— 

12 ‘‘(1) IN GENERAL.—The Secretary shall adopt 

13 and regularly update standards consistent with the 

14 goals described in paragraph (2). 

15 ‘‘(2) GOALS FOR FINANCIAL AND ADMINISTRA16 TIVE TRANSACTIONS.—The goals for standards 

17 under paragraph (1) are that such standards shall, 

18 to the extent practicable— 

19 ‘‘(A) be unique with no conflicting or re20 dundant standards; 

21 ‘‘(B) be authoritative, permitting no addi22 tions or constraints for electronic transactions, 

23 including companion guides; 

24 ‘‘(C) be comprehensive, efficient and ro25 bust, requiring minimal augmentation by paper 
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1 transactions or clarification by further commu2 nications; 

3 ‘‘(D) enable the real-time (or near real4 time) determination of an individual’s financial 

5 responsibility at the point of service and, to the 

6 extent possible, prior to service, including 

7 whether the individual is eligible for a specific 

8 service with a specific physician at a specific fa9 cility, on a specific date or range of dates, in10 clude utilization of a machine-readable health 

11 plan beneficiary identification card or similar 

12 mechanism; 

13 ‘‘(E) enable, where feasible, near real-time 

14 adjudication of claims; 

15 ‘‘(F) provide for timely acknowledgment, 

16 response, and status reporting applicable to any 

17 electronic transaction deemed appropriate by 

18 the Secretary; 

19 ‘‘(G) describe all data elements (such as 

20 reason and remark codes) in unambiguous 

21 terms, not permit optional fields, require that 

22 data elements be either required or conditioned 

23 upon set values in other fields, and prohibit ad24 ditional conditions except where required by (or 
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1 to implement) State or Federal law or to pro2 tect against fraud and abuse; and 

3 ‘‘(H) harmonize all common data elements 

4 across administrative and clinical transaction 

5 standards. 

6 ‘‘(3) TIME FOR ADOPTION.—Not later than 2 

7 years after the date of the enactment of this section, 

8 the Secretary shall adopt standards under this sec9 tion by interim, final rule. 

10 ‘‘(4) REQUIREMENTS FOR SPECIFIC STAND11 ARDS.—The standards under this section shall be 

12 developed, adopted, and enforced so as to— 

13 ‘‘(A) clarify, refine, complete, and expand, 

14 as needed, the standards required under section 

15 1173; 

16 ‘‘(B) require paper versions of standard17 ized transactions to comply with the same 

18 standards as to data content such that a fully 

19 compliant, equivalent electronic transaction can 

20 be populated from the data from a paper 

21 version; 

22 ‘‘(C) enable electronic funds transfers, in 

23 order to allow automated reconciliation with the 

24 related health care payment and remittance ad25 vice; 
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1 ‘‘(D) require timely and transparent claim 

2 and denial management processes, including 

3 uniform claim edits, uniform reason and remark 

4 denial codes, tracking, adjudication, and appeal 

5 processing; 

6 ‘‘(E) require the use of a standard elec7 tronic transaction with which health care pro8 viders may quickly and efficiently enroll with a 

9 health plan to conduct the other electronic 

10 transactions provided for in this part; and 

11 ‘‘(F) provide for other requirements relat12 ing to administrative simplification as identified 

13 by the Secretary, in consultation with stake14 holders. 

15 ‘‘(5) BUILDING ON EXISTING STANDARDS.—In 

16 adopting the standards under this section, the Sec17 retary shall consider existing and planned standards. 

18 ‘‘(6) IMPLEMENTATION AND ENFORCEMENT.— 

19 Not later than 6 months after the date of the enact20 ment of this section, the Secretary shall submit to 

21 the appropriate committees of Congress a plan for 

22 the implementation and enforcement, by not later 

23 than 5 years after such date of enactment, of the 

24 standards under this section. Such plan shall in25 clude— 
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1 ‘‘(A) a process and timeframe with mile2 stones for developing the complete set of stand3 ards; 

4 ‘‘(B) a proposal for accommodating nec5 essary changes between version changes and a 

6 process for upgrading standards as often as an7 nually by interim, final rulemaking; 

8 ‘‘(C) programs to provide incentives for, 

9 and ease the burden of, implementation for cer10 tain health care providers, with special consid11 eration given to such providers serving rural or 

12 underserved areas and ensure coordination with 

13 standards, implementation specifications, and 

14 certification criteria being adopted under the 

15 HITECH Act; 

16 ‘‘(D) programs to provide incentives for, 

17 and ease the burden of, health care providers 

18 who volunteer to participate in the process of 

19 setting standards for electronic transactions; 

20 ‘‘(E) an estimate of total funds needed to 

21 ensure timely completion of the implementation 

22 plan; and 

23 ‘‘(F) an enforcement process that includes 

24 timely investigation of complaints, random au25 dits to ensure compliance, civil monetary and 
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1 programmatic penalties for noncompliance con2 sistent with existing laws and regulations, and 

3 a fair and reasonable appeals process building 

4 off of enforcement provisions under this part, 

5 and concurrent State enforcement jurisdiction. 

6 The Secretary may promulgate an annual audit and 

7 certification process to ensure that all health plans 

8 and clearinghouses are both syntactically and func9 tionally compliant with all the standard transactions 

10 mandated pursuant to the administrative simplifica11 tion provisions of this part and the Health Insurance 

12 Portability and Accountability Act of 1996. 

13 ‘‘(b) LIMITATIONS ON USE OF DATA.—Nothing in 

14 this section shall be construed to permit the use of infor15 mation collected under this section in a manner that would 

16 violate State or Federal law. 

17 ‘‘(c) PROTECTION OF DATA.—The Secretary shall en18 sure (through the promulgation of regulations or other19 wise) that all data collected pursuant to subsection (a) are 

20 used and disclosed in a manner that meets the HIPAA 

21 privacy and security law (as defined in section 3009(a)(2) 

22 of the Public Health Service Act), including any privacy 

23 or security standard adopted under section 3004 of such 

24 Act. 
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1 ‘‘SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OP2 ERATING RULES. 

3 ‘‘(a) IN GENERAL.—The Secretary shall adopt a sin4 gle, binding, comprehensive companion guide, that in5 cludes operating rules for each X12 Version 5010 trans6 action described in section 1173(a)(2), to be effective until 

7 the new version of these transactions which comply with 

8 section 1173A are adopted and implemented. 

9 ‘‘(b) COMPANION GUIDE AND OPERATING RULES

10 DEVELOPMENT.—In adopting such interim companion 

11 guide and rules, the Secretary shall comply with section 

12 1172, except that a nonprofit entity that meets the fol13 lowing criteria shall also be consulted: 

14 ‘‘(1) The entity focuses its mission on adminis15 trative simplification. 

16 ‘‘(2) The entity uses a multistakeholder process 

17 that creates consensus-based companion guides, in18 cluding operating rules using a voting process that 

19 ensures balanced representation by the critical 

20 stakeholders (including health plans and health care 

21 providers) so that no one group dominates the entity 

22 and shall include others such as standards develop23 ment organizations, and relevant Federal or State 

24 agencies. 

25 ‘‘(3) The entity has in place a public set of 

26 guiding principles that ensure the companion guide 
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1 and operating rules and process are open and trans2 parent. 

3 ‘‘(4) The entity coordinates its activities with 

4 the HIT Policy Committee, and the HIT Standards 

5 Committee (established under title XXX of the Pub6 lic Health Service Act) and complements the efforts 

7 of the Office of the National Healthcare Coordinator 

8 and its related health information exchange goals. 

9 ‘‘(5) The entity incorporates the standards 

10 issued under Health Insurance Portability and Ac11 countability Act of 1996 and this part, and in devel12 oping the companion guide and operating rules does 

13 not change the definition, data condition or use of 

14 a data element or segment in a standard, add any 

15 elements or segments to the maximum defined data 

16 set, use any codes or data elements that are either 

17 marked ‘not used’ in the standard’s implementation 

18 specifications or are not in the standard’s implemen19 tation specifications, or change the meaning or in20 tent of the standard’s implementation specifications. 

21 ‘‘(6) The entity uses existing market research 

22 and proven best practices. 

23 ‘‘(7) The entity has a set of measures that 

24 allow for the evaluation of their market impact and 

25 public reporting of aggregate stakeholder impact. 
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1 ‘‘(8) The entity supports nondiscrimination and 

2 conflict of interest policies that demonstrate a com3 mitment to open, fair, and nondiscriminatory prac4 tices. 

5 ‘‘(9) The entity allows for public reviews and 

6 comment on updates of the companion guide, includ7 ing the operating rules. 

8 ‘‘(c) IMPLEMENTATION.—The Secretary shall adopt 

9 a single, binding companion guide, including operating 

10 rules under this section, for each transaction, to become 

11 effective with the X12 Version 5010 transaction imple12 mentation, or as soon thereafter as feasible. The com13 panion guide, including operating rules for the trans14 actions for eligibility for health plan and health claims sta15 tus under this section shall be adopted not later than Oc16 tober 1, 2011, in a manner such that such set of rules 

17 is effective beginning not later than January 1, 2013. The 

18 companion guide, including operating rules for the remain19 der of the transactions described in section 1173(a)(2) 

20 shall be adopted not later than October 1, 2012, in a man21 ner such that such set of rules is effective beginning not 

22 later than January 1, 2014.’’. 

23 (2) DEFINITIONS.—Section 1171 of such Act 

24 (42 U.S.C. 1320d) is amended— 
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1 (A) in paragraph (1), by inserting ‘‘, and 

2 associated operational guidelines and instruc3 tions, as determined appropriate by the Sec4 retary’’ after ‘‘medical procedure codes’’; and 

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

6 paragraph: 

7 ‘‘(10) OPERATING RULES.—The term ‘oper8 ating rules’ means business rules for using and proc9 essing transactions, such as service level require10 ments, which do not impact the implementation 

11 specifications or other data content requirements.’’. 

12 (3) CONFORMING AMENDMENT.—Section 

13 1179(a) of such Act (42 U.S.C. 1320d–8(a)) is 

14 amended, in the matter before paragraph (1)— 

15 (A) by inserting ‘‘on behalf of an indi16 vidual’’ after ‘‘1978)’’; and 

17 (B) by inserting ‘‘on behalf of an indi18 vidual’’ after ‘‘for a financial institution’’. 

19 (b) STANDARDS FOR CLAIMS ATTACHMENTS AND

20 COORDINATION OF BENEFITS.— 

21 (1) STANDARD FOR HEALTH CLAIMS ATTACH22 MENTS.—Not later than 1 year after the date of the 

23 enactment of this Act, the Secretary of Health and 

24 Human Services shall promulgate an interim, final 

25 rule to establish a standard for health claims attach-
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1 ment transaction described in section 1173(a)(2)(B) 

2 of the Social Security Act (42 U.S.C. 1320d– 

3 2(a)(2)(B)) and coordination of benefits. 

4 (2) REVISION IN PROCESSING PAYMENT TRANS5 ACTIONS BY FINANCIAL INSTITUTIONS.— 

6 (A) IN GENERAL.—Section 1179 of the So7 cial Security Act (42 U.S.C. 1320d–8) is 

8 amended, in the matter before paragraph (1)— 

9 (i) by striking ‘‘or is engaged’’ and in10 serting ‘‘and is engaged’’; and 

11 (ii) by inserting ‘‘(other than as a 

12 business associate for a covered entity)’’ 

13 after ‘‘for a financial institution’’. 

14 (B) COMPLIANCE DATE.—The amend15 ments made by subparagraph (A) shall apply to 

16 transactions occurring on or after such date 

17 (not later than January 1, 2014) as the Sec18 retary of Health and Human Services shall 

19 specify. 

20 (c) STANDARDS FOR FIRST REPORT OF INJURY.— 

21 Not later than January 1, 2014, the Secretary of Health 

22 and Human Services shall promulgate an interim final 

23 rule to establish a standard for the first report of injury 

24 transaction described in section 1173(a)(2)(G) of the So25 cial Security Act (42 U.S.C. 1320d–2(a)(2)(G)). 
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1 (d) UNIQUE HEALTH PLAN IDENTIFIER.—Not later 

2 October 1, 2012, the Secretary of Health and Human 

3 Services shall promulgate an interim final rule to establish 

4 a unique health plan identifier described in section 

5 1173(b) of the Social Security Act (42 U.S.C. 1320d– 

6 2(b)) based on the input of the National Committee of 

7 Vital and Health Statistics and consultation with health 

8 plans, health care providers, and other interested parties. 

9 (e) EXPANSION OF ELECTRONIC TRANSACTIONS IN

10 MEDICARE.—Section 1862(a) of the Social Security Act 

11 (42 U.S.C. 1395y(a)) is amended— 

12 (1) in paragraph (23), by striking ‘‘or’’ at the 

13 end; 

14 (2) in paragraph (24), by striking the period 

15 and inserting ‘‘; or’’; and 

16 (3) by inserting after paragraph (24) the fol17 lowing new paragraph: 

18 ‘‘(25) subject to subsection (h), not later than 

19 January 1, 2015, for which the payment is other 

20 than by electronic funds transfer (EFT) so long as 

21 the Secretary has adopted and implemented a stand22 ard for electronic funds transfer under section 

23 1173A.’’. 
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1 (f) EXPANSION OF PENALTIES.—Section 1176 of 

2 such Act (42 U.S.C. 1320d–5) is amended by adding at 

3 the end the following new subsection: 

4 ‘‘(c) EXPANSION OF PENALTY AUTHORITY.—The 

5 Secretary may, in addition to the penalties provided under 

6 subsections (a) and (b), provide for the imposition of pen7 alties for violations of this part that are comparable— 

8 ‘‘(1) in the case of health plans, to the sanc9 tions the Secretary is authorized to impose under 

10 part C or D of title XVIII in the case of a plan that 

11 violates a provision of such part; or 

12 ‘‘(2) in the case of a health care provider, to 

13 the sanctions the Secretary is authorized to impose 

14 under part A, B, or D of title XVIII in the case of 

15 a health care provider that violations a provision of 

16 such part with respect to that provider.’’. 

17 TITLE II—PROTECTIONS AND 

18 STANDARDS FOR QUALIFIED 

19 HEALTH BENEFITS PLANS 

20 Subtitle A—General Standards 

21 SEC. 201. REQUIREMENTS REFORMING HEALTH INSUR22 ANCE MARKETPLACE. 

23 (a) PURPOSE.—The purpose of this title is to estab24 lish standards to ensure that new health insurance cov25 erage and employment-based health plans that are offered 
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1 meet standards guaranteeing access to affordable cov2 erage, essential benefits, and other consumer protections. 

3 (b) REQUIREMENTS FOR QUALIFIED HEALTH BENE4 FITS PLANS.—On or after the first day of Y1, a health 

5 benefits plan shall not be a qualified health benefits plan 

6 under this division unless the plan meets the applicable 

7 requirements of the following subtitles for the type of plan 

8 and plan year involved: 

9 (1) Subtitle B (relating to affordable coverage). 

10 (2) Subtitle C (relating to essential benefits). 

11 (3) Subtitle D (relating to consumer protec12 tion). 

13 (c) TERMINOLOGY.—In this division: 

14 (1) ENROLLMENT IN EMPLOYMENT-BASED

15 HEALTH PLANS.—An individual shall be treated as 

16 being ‘‘enrolled’’ in an employment-based health 

17 plan if the individual is a participant or beneficiary 

18 (as such terms are defined in section 3(7) and 3(8), 

19 respectively, of the Employee Retirement Income Se20 curity Act of 1974) in such plan. 

21 (2) INDIVIDUAL AND GROUP HEALTH INSUR22 ANCE COVERAGE.—The terms ‘‘individual health in23 surance coverage’’ and ‘‘group health insurance cov24 erage’’ mean health insurance coverage offered in 

25 the individual market or large or small group mar-
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1 ket, respectively, as defined in section 2791 of the 

2 Public Health Service Act. 

3 (d) TREATMENT OF QUALIFIED DIRECT PRIMARY

4 CARE MEDICAL HOME PLANS.—The Commissioner may 

5 permit a qualified health benefits plan to provide coverage 

6 through a qualified direct primary care medical home plan 

7 so long as the qualified health benefits plan meets all re8 quirements that are otherwise applicable and the services 

9 covered by the medical home plan are coordinated with 

10 the QHBP offering entity. 

11 SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT 

12 COVERAGE. 

13 (a) GRANDFATHERED HEALTH INSURANCE COV14 ERAGE DEFINED.—Subject to the succeeding provisions of 

15 this section, for purposes of establishing acceptable cov16 erage under this division, the term ‘‘grandfathered health 

17 insurance coverage’’ means individual health insurance 

18 coverage that is offered and in force and effect before the 

19 first day of Y1 if the following conditions are met: 

20 (1) LIMITATION ON NEW ENROLLMENT.— 

21 (A) IN GENERAL.—Except as provided in 

22 this paragraph, the individual health insurance 

23 issuer offering such coverage does not enroll 

24 any individual in such coverage if the first ef-
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1 fective date of coverage is on or after the first 

2 day of Y1. 

3 (B) DEPENDENT COVERAGE PER4 MITTED.—Subparagraph (A) shall not affect 

5 the subsequent enrollment of a dependent of an 

6 individual who is covered as of such first day. 

7 (2) LIMITATION ON CHANGES IN TERMS OR

8 CONDITIONS.—Subject to paragraph (3) and except 

9 as required by law, the issuer does not change any 

10 of its terms or conditions, including benefits and 

11 cost-sharing, from those in effect as of the day be12 fore the first day of Y1. 

13 (3) RESTRICTIONS ON PREMIUM INCREASES.— 

14 The issuer cannot vary the percentage increase in 

15 the premium for a risk group of enrollees in specific 

16 grandfathered health insurance coverage without 

17 changing the premium for all enrollees in the same 

18 risk group at the same rate, as specified by the 

19 Commissioner. 

20 (b) GRACE PERIOD FOR CURRENT EMPLOYMENT21 BASED HEALTH PLANS.— 

22 (1) GRACE PERIOD.— 

23 (A) IN GENERAL.—The Commissioner 

24 shall establish a grace period whereby, for plan 

25 years beginning after the end of the 5-year pe-
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1 riod beginning with Y1, an employment-based 

2 health plan in operation as of the day before 

3 the first day of Y1 must meet the same require4 ments as apply to a qualified health benefits 

5 plan under section 201, including the essential 

6 benefit package requirement under section 221. 

7 (B) EXCEPTION FOR LIMITED BENEFITS

8 PLANS.—Subparagraph (A) shall not apply to 

9 an employment-based health plan in which the 

10 coverage consists only of one or more of the fol11 lowing: 

12 (i) Any coverage described in section 

13 3001(a)(1)(B)(ii)(IV) of division B of the 

14 American Recovery and Reinvestment Act 

15 of 2009 (Public Law 111–5). 

16 (ii) Excepted benefits (as defined in 

17 section 733(c) of the Employee Retirement 

18 Income Security Act of 1974), including 

19 coverage under a specified disease or ill20 ness policy described in paragraph (3)(A) 

21 of such section. 

22 (iii) Such other limited benefits as the 

23 Commissioner may specify. 

24 In no case shall an employment-based health 

25 plan in which the coverage consists only of one 
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1 or more of the coverage or benefits described in 

2 clauses (i) through (iii) be treated as acceptable 

3 coverage under this division. 

4 (2) TRANSITIONAL TREATMENT AS ACCEPT5 ABLE COVERAGE.—During the grace period specified 

6 in paragraph (1)(A), an employment-based health 

7 plan (which may be a high deducible health plan, as 

8 defined in section 223(c)(2) of the Internal Revenue 

9 Code of 1986) that is described in such paragraph 

10 shall be treated as acceptable coverage under this di11 vision. 

12 (c) LIMITATION ON INDIVIDUAL HEALTH INSURANCE

13 COVERAGE.— 

14 (1) IN GENERAL.—Individual health insurance 

15 coverage that is not grandfathered health insurance 

16 coverage under subsection (a) may only be offered 

17 on or after the first day of Y1 as an Exchange-par18 ticipating health benefits plan. 

19 (2) SEPARATE, EXCEPTED COVERAGE PER20 MITTED.—Nothing in— 

21 (A) paragraph (1) shall prevent the offer22 ing of excepted benefits described in section 

23 2791(c) of the Public Health Service Act so 

24 long as such benefits are offered outside the 
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1 Health Insurance Exchange and are priced sep2 arately from health insurance coverage; and 

3 (B) this division shall be construed— 

4 (i) to prevent the offering of a stand5 alone plan that offers coverage of excepted 

6 benefits described in section 2791(c)(2)(A) 

7 of the Public Health Service Act (relating 

8 to limited scope dental or vision benefits) 

9 for individuals and families from a State10 licensed dental and vision carrier; or 

11 (ii) as applying requirements for a 

12 qualified health benefits plan to such a 

13 stand-alone plan that is offered and priced 

14 separately from a qualified health benefits 

15 plan. 

16 Subtitle B—Standards Guaran17 teeing Access to Affordable Cov18 erage 

19 SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLU20 SIONS. 

21 A qualified health benefits plan may not impose any 

22 preexisting condition exclusion (as defined in section 

23 2701(b)(1)(A) of the Public Health Service Act) or other24 wise impose any limit or condition on the coverage under 

25 the plan with respect to an individual or dependent based 
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1 on any of the following: health status, medical condition, 

2 claims experience, receipt of health care, medical history, 

3 genetic information, evidence of insurability, disability, or 

4 source of injury (including conditions arising out of acts 

5 of domestic violence) or any similar factors. 

6 SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR IN7 SURED PLANS AND PROHIBITING RESCIS8 SIONS. 

9 The requirements of sections 2711 (other than sub10 sections (e) and (f)) and 2712 (other than paragraphs (3), 

11 and (6) of subsection (b) and subsection (e)) of the Public 

12 Health Service Act, relating to guaranteed availability and 

13 renewability of health insurance coverage, shall apply to 

14 individuals and employers in all individual and group 

15 health insurance coverage, whether offered to individuals 

16 or employers through the Health Insurance Exchange, 

17 through any employment-based health plan, or otherwise, 

18 in the same manner as such sections apply to employers 

19 and health insurance coverage offered in the small group 

20 market, except that such section 2712(b)(1) shall apply 

21 only if, before nonrenewal or discontinuation of coverage, 

22 the issuer has provided the enrollee with notice of non23 payment of premiums and there is a grace period during 

24 which the enrollee has an opportunity to correct such non25 payment. Rescissions of such coverage shall be prohibited 
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1 except in cases of fraud as defined in section 2712(b)(2) 

2 of such Act. 

3 SEC. 213. INSURANCE RATING RULES. 

4 (a) IN GENERAL.—The premium rate charged for a 

5 qualified health benefits plan that is health insurance cov6 erage may not vary except as follows: 

7 (1) LIMITED AGE VARIATION PERMITTED.—By 

8 age (within such age categories as the Commissioner 

9 shall specify) so long as the ratio of the highest such 

10 premium to the lowest such premium does not ex11 ceed the ratio of 2 to 1. 

12 (2) BY AREA.—By premium rating area (as 

13 permitted by State insurance regulators or, in the 

14 case of Exchange-participating health benefits plans, 

15 as specified by the Commissioner in consultation 

16 with such regulators). 

17 (3) BY FAMILY ENROLLMENT.—By family en18 rollment (such as variations within categories and 

19 compositions of families) so long as the ratio of the 

20 premium for family enrollment (or enrollments) to 

21 the premium for individual enrollment is uniform, as 

22 specified under State law and consistent with rules 

23 of the Commissioner. 

24 (b) STUDY AND REPORTS.— 
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1 (1) STUDY.—The Commissioner, in coordina2 tion with the Secretary of Health and Human Serv3 ices and the Secretary of Labor, shall conduct a 

4 study of the large-group-insured and self-insured 

5 employer health care markets. Such study shall ex6 amine the following: 

7 (A) The types of employers by key charac8 teristics, including size, that purchase insured 

9 products versus those that self-insure. 

10 (B) The similarities and differences be11 tween typical insured and self-insured health 

12 plans. 

13 (C) The financial solvency and capital re14 serve levels of employers that self-insure by em15 ployer size. 

16 (D) The risk of self-insured employers not 

17 being able to pay obligations or otherwise be18 coming financially insolvent. 

19 (E) The extent to which rating rules are 

20 likely to cause adverse selection in the large 

21 group market or to encourage small and 

22 midsize employers to self-insure. 

23 (2) REPORTS.—Not later than 18 months after 

24 the date of the enactment of this Act, the Commis25 sioner shall submit to Congress and the applicable 
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1 agencies a report on the study conducted under 

2 paragraph (1). Such report shall include any rec3 ommendations the Commissioner deems appropriate 

4 to ensure that the law does not provide incentives 

5 for small and midsize employers to self-insure or cre6 ate adverse selection in the risk pools of large group 

7 insurers and self-insured employers. Not later than 

8 18 months after the first day of Y1, the Commis9 sioner shall submit to Congress and the applicable 

10 agencies an updated report on such study, including 

11 updates on such recommendations. 

12 SEC. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN 

13 MENTAL HEALTH AND SUBSTANCE ABUSE 

14 DISORDER BENEFITS. 

15 (a) NONDISCRIMINATION IN BENEFITS.—A qualified 

16 health benefits plan shall comply with standards estab17 lished by the Commissioner to prohibit discrimination in 

18 health benefits or benefit structures for qualifying health 

19 benefits plans, building from section 702 of the Employee 

20 Retirement Income Security Act of 1974, section 2702 of 

21 the Public Health Service Act, and section 9802 of the 

22 Internal Revenue Code of 1986. 

23 (b) PARITY IN MENTAL HEALTH AND SUBSTANCE

24 ABUSE DISORDER BENEFITS.—To the extent such provi25 sions are not superceded by or inconsistent with subtitle 
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1 C, the provisions of section 2705 (other than subsections 

2 (a)(1), (a)(2), and (c)) of the Public Health Service Act 

3 shall apply to a qualified health benefits plan, regardless 

4 of whether it is offered in the individual or group market, 

5 in the same manner as such provisions apply to health 

6 insurance coverage offered in the large group market. 

7 SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS. 

8 (a) IN GENERAL.—A qualified health benefits plan 

9 that uses a provider network for items and services shall 

10 meet such standards respecting provider networks as the 

11 Commissioner may establish to assure the adequacy of 

12 such networks in ensuring enrollee access to such items 

13 and services and transparency in the cost-sharing differen14 tials among providers participating in the network and 

15 policies for accessing out-of-network providers. 

16 (b) INTERNET ACCESS TO INFORMATION.—A quali17 fied health benefits plan that uses a provider network shall 

18 provide a current listing of all providers in its network 

19 on its Website and such data shall be available on the 

20 Health Insurance Exchange Website as a part of the basic 

21 information on that plan. The Commissioner shall also es22 tablish an on-line system whereby an individual may select 

23 by name any medical provider (as defined by the Commis24 sioner) and be informed of the plan or plans with which 

25 that provider is contracting. 
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1 (c) PROVIDER NETWORK DEFINED.—In this division, 

2 the term ‘‘provider network’’ means the providers with re3 spect to which covered benefits, treatments, and services 

4 are available under a health benefits plan. 

5 SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DE6 PENDENT COVERAGE FOR UNINSURED 

7 YOUNG ADULTS. 

8 (a) IN GENERAL.—A qualified health benefits plan 

9 shall make available, at the option of the principal enrollee 

10 under the plan, coverage for one or more qualified children 

11 (as defined in subsection (b)) of the enrollee. 

12 (b) QUALIFIED CHILD DEFINED.—In this section, 

13 the term ‘‘qualified child’’ means, with respect to a prin14 cipal enrollee in a qualified health benefits plan, an indi15 vidual who (but for age) would be treated as a dependent 

16 child of the enrollee under such plan and who— 

17 (1) is under 27 years of age; and 

18 (2) is not enrolled in a health benefits plan 

19 other than under this section. 

20 (c) PREMIUMS.—Nothing in this section shall be con21 strued as preventing a qualified health benefits plan from 

22 increasing the premiums otherwise required for coverage 

23 provided under this section consistent with standards es24 tablished by the Commissioner based upon family size 

25 under section 213(a)(3). 
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1 SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER 

2 QUALIFIED HEALTH BENEFITS PLANS DUR3 ING PLAN YEAR. 

4 In the case of health insurance coverage offered 

5 under a qualified health benefits plan, if the coverage de6 creases or the cost-sharing increases, the issuer of the cov7 erage shall notify enrollees of the change at least 90 days 

8 before the change takes effect (or such shorter period of 

9 time in cases where the change is necessary to ensure the 

10 health and safety of enrollees). 

11 Subtitle C—Standards Guaran12 teeing Access to Essential Bene13 fits 

14 SEC. 221. COVERAGE OF ESSENTIAL BENEFITS PACKAGE. 

15 (a) IN GENERAL.—A qualified health benefits plan 

16 shall provide coverage that at least meets the benefit 

17 standards adopted under section 224 for the essential ben18 efits package described in section 222 for the plan year 

19 involved. 

20 (b) CHOICE OF COVERAGE.— 

21 (1) NON-EXCHANGE-PARTICIPATING HEALTH

22 BENEFITS PLANS.—In the case of a qualified health 

23 benefits plan that is not an Exchange-participating 

24 health benefits plan, such plan may offer such cov25 erage in addition to the essential benefits package as 

26 the QHBP offering entity may specify. 
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1 (2) EXCHANGE-PARTICIPATING HEALTH BENE2 FITS PLANS.—In the case of an Exchange-partici3 pating health benefits plan, such plan is required 

4 under section 203 to provide specified levels of bene5 fits and, in the case of a plan offering a premium6 plus level of benefits, provide additional benefits. 

7 (3) CONTINUATION OF OFFERING OF SEPARATE

8 EXCEPTED BENEFITS COVERAGE.—Nothing in this 

9 division shall be construed as affecting the offering 

10 outside of the Health Insurance Exchange and 

11 under State law of health benefits in the form of ex12 cepted benefits (described in section 

13 202(b)(1)(B)(ii)) if such benefits are offered under 

14 a separate policy, contract, or certificate of insur15 ance. 

16 (c) CLINICAL APPROPRIATENESS.—Nothing in this 

17 Act shall be construed to prohibit a group health plan or 

18 health insurance issuer from using medical management 

19 practices so long as such management practices are based 

20 on valid medical evidence and are relevant to the patient 

21 whose medical treatment is under review. 

22 (d) PROVISION OF BENEFITS.—Nothing in this divi23 sion shall be construed as prohibiting a qualified health 

24 benefits plan from subcontracting with stand-alone health 
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1 insurance issuers or insurers for the provision of dental, 

2 vision, mental health, and other benefits and services. 

3 SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED. 

4 (a) IN GENERAL.—In this division, the term ‘‘essen5 tial benefits package’’ means health benefits coverage, 

6 consistent with standards adopted under section 224, to 

7 ensure the provision of quality health care and financial 

8 security, that— 

9 (1) provides payment for the items and services 

10 described in subsection (b) in accordance with gen11 erally accepted standards of medical or other appro12 priate clinical or professional practice; 

13 (2) limits cost-sharing for such covered health 

14 care items and services in accordance with such ben15 efit standards, consistent with subsection (c); 

16 (3) does not impose any annual or lifetime limit 

17 on the coverage of covered health care items and 

18 services; 

19 (4) complies with section 215(a) (relating to 

20 network adequacy); and 

21 (5) is equivalent in its scope of benefits, as cer22 tified by Office of the Actuary of the Centers for 

23 Medicare & Medicaid Services, to the average pre24 vailing employer-sponsored coverage in Y1. 
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1 In order to carry out paragraph (5), the Secretary of 

2 Labor shall conduct a survey of employer-sponsored cov3 erage to determine the benefits typically covered by em4 ployers, including multiemployer plans, and provide a re5 port on such survey to the Health Benefits Advisory Com6 mittee and to the Secretary of Health and Human Serv7 ices. 

8 (b) MINIMUM SERVICES TO BE COVERED.—Subject 

9 to subsection (d), the items and services described in this 

10 subsection are the following: 

11 (1) Hospitalization. 

12 (2) Outpatient hospital and outpatient clinic 

13 services, including emergency department services. 

14 (3) Professional services of physicians and other 

15 health professionals. 

16 (4) Such services, equipment, and supplies inci17 dent to the services of a physician’s or a health pro18 fessional’s delivery of care in institutional settings, 

19 physician offices, patients’ homes or place of resi20 dence, or other settings, as appropriate. 

21 (5) Prescription drugs. 

22 (6) Rehabilitative and habilitative services. 

23 (7) Mental health and substance use disorder 

24 services, including behavioral health treatments. 
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1 (8) Preventive services, including those services 

2 recommended with a grade of A or B by the Task 

3 Force on Clinical Preventive Services and those vac4 cines recommended for use by the Director of the 

5 Centers for Disease Control and Prevention. 

6 (9) Maternity care. 

7 (10) Well-baby and well-child care and oral 

8 health, vision, and hearing services, equipment, and 

9 supplies for children under 21 years of age. 

10 (11) Durable medical equipment, prosthetics, 

11 orthotics and related supplies. 

12 (c) REQUIREMENTS RELATING TO COST-SHARING

13 AND MINIMUM ACTUARIAL VALUE.— 

14 (1) NO COST-SHARING FOR PREVENTIVE SERV15 ICES.—There shall be no cost-sharing under the es16 sential benefits package for— 

17 (A) preventive items and services rec18 ommended with a grade of A or B by the Task 

19 Force on Clinical Preventive Services and those 

20 vaccines recommended for use by the Director 

21 of the Centers for Disease Control and Preven22 tion; or 

23 (B) well-baby and well-child care. 

24 (2) ANNUAL LIMITATION.— 
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1 (A) ANNUAL LIMITATION.—The cost-shar2 ing incurred under the essential benefits pack3 age with respect to an individual (or family) for 

4 a year does not exceed the applicable level spec5 ified in subparagraph (B). 

6 (B) APPLICABLE LEVEL.—The applicable 

7 level specified in this subparagraph for Y1 is 

8 not to exceed $5,000 for an individual and not 

9 to exceed $10,000 for a family. Such levels 

10 shall be increased (rounded to the nearest 

11 $100) for each subsequent year by the annual 

12 percentage increase in the enrollment-weighted 

13 average of premium increases for basic plans 

14 applicable to such year, except that Secretary 

15 shall adjust such increase to ensure that the ap16 plicable level specified in this subparagraph 

17 meets the minimum actuarial value required 

18 under paragraph (3). 

19 (C) USE OF COPAYMENTS.—In establishing 

20 cost-sharing levels for basic, enhanced, and pre21 mium plans under this subsection, the Sec22 retary shall, to the maximum extent possible, 

23 use only copayments and not coinsurance. 

24 (3) MINIMUM ACTUARIAL VALUE.— 
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1 (A) IN GENERAL.—The cost-sharing under 

2 the essential benefits package shall be designed 

3 to provide a level of coverage that is designed 

4 to provide benefits that are actuarially equiva5 lent to approximately 70 percent of the full ac6 tuarial value of the benefits provided under the 

7 reference benefits package described in sub8 paragraph (B). 

9 (B) REFERENCE BENEFITS PACKAGE DE10 SCRIBED.—The reference benefits package de11 scribed in this subparagraph is the essential 

12 benefits package if there were no cost-sharing 

13 imposed. 

14 (d) ASSESSMENT AND COUNSELING FOR DOMESTIC

15 VIOLENCE.—The Secretary shall support the need for an 

16 assessment and brief counseling for domestic violence as 

17 part of a behavioral health assessment or primary care 

18 visit and determine the appropriate coverage for such as19 sessment and counseling. 

20 (e) ABORTION COVERAGE PROHIBITED AS PART OF

21 MINIMUM BENEFITS PACKAGE.— 

22 (1) PROHIBITION OF REQUIRED COVERAGE.— 

23 The Health Benefits Advisory Committee may not 

24 recommend under section 223(b), and the Secretary 

25 may not adopt in standards under section 224(b), 
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1 the services described in paragraph (4)(A) or (4)(B) 

2 as part of the essential benefits package and the 

3 Commissioner may not require such services for 

4 qualified health benefits plans to participate in the 

5 Health Insurance Exchange. 

6 (2) VOLUNTARY CHOICE OF COVERAGE BY

7 PLAN.—In the case of a qualified health benefits 

8 plan, the plan is not required (or prohibited) under 

9 this Act from providing coverage of services de10 scribed in paragraph (4)(A) or (4)(B) and the 

11 QHBP offering entity shall determine whether such 

12 coverage is provided. 

13 (3) ABORTION SERVICES.— 

14 (A) ABORTIONS FOR WHICH PUBLIC FUND15 ING IS PROHIBITED.—The services described in 

16 this subparagraph are abortions for which the 

17 expenditure of Federal funds appropriated for 

18 the Department of Health and Human Services 

19 is not permitted, based on the law as in effect 

20 as of the date that is 6 months before the be21 ginning of the plan year involved. 

22 (B) ABORTIONS FOR WHICH PUBLIC FUND23 ING IS ALLOWED.—The services described in 

24 this subparagraph are abortions for which the 

25 expenditure of Federal funds appropriated for 
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1 the Department of Health and Human Services 

2 is permitted, based on the law as in effect as 

3 of the date that is 6 months before the begin4 ning of the plan year involved. 

5 (f) REPORT REGARDING INCLUSION OF ORAL

6 HEALTH CARE IN ESSENTIAL BENEFITS PACKAGE.—Not 

7 later than 1 year after the date of the enactment of this 

8 Act, the Secretary of Health and Human Services shall 

9 submit to Congress a report containing the results of a 

10 study determining the need and cost of providing acces11 sible and affordable oral health care to adults as part of 

12 the essential benefits package. 

13 SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE. 

14 (a) ESTABLISHMENT.— 

15 (1) IN GENERAL.—There is established a pri16 vate-public advisory committee which shall be a 

17 panel of medical and other experts to be known as 

18 the Health Benefits Advisory Committee to rec19 ommend covered benefits and essential, enhanced, 

20 and premium plans. 

21 (2) CHAIR.—The Surgeon General shall be a 

22 member and the chair of the Health Benefits Advi23 sory Committee. 
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1 (3) MEMBERSHIP.—The Health Benefits Advi2 sory Committee shall be composed of the following 

3 members, in addition to the Surgeon General: 

4 (A) Nine members who are not Federal 

5 employees or officers and who are appointed by 

6 the President. 

7 (B) Nine members who are not Federal 

8 employees or officers and who are appointed by 

9 the Comptroller General of the United States in 

10 a manner similar to the manner in which the 

11 Comptroller General appoints members to the 

12 Medicare Payment Advisory Commission under 

13 section 1805(c) of the Social Security Act. 

14 (C) Such even number of members (not to 

15 exceed 8) who are Federal employees and offi16 cers, as the President may appoint. 

17 Such initial appointments shall be made not later 

18 than 60 days after the date of the enactment of this 

19 Act. 

20 (4) TERMS.—Each member of the Health Bene21 fits Advisory Committee shall serve a 3-year term on 

22 the Committee, except that the terms of the initial 

23 members shall be adjusted in order to provide for a 

24 staggered term of appointment for all such mem25 bers. 
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1 (5) PARTICIPATION.—The membership of the 

2 Health Benefits Advisory Committee shall at least 

3 reflect providers, patient representatives, employers 

4 (including small employers), labor, health insurance 

5 issuers, experts in health care financing and deliv6 ery, experts in oral health care, experts in racial and 

7 ethnic disparities, experts on health care needs and 

8 disparities of individuals with disabilities, represent9 atives of relevant governmental agencies, and at 

10 least one practicing physician or other health profes11 sional and an expert in child and adolescent health 

12 and shall represent a balance among various sectors 

13 of the health care system so that no single sector 

14 unduly influences the recommendations of such 

15 Committee. 

16 (b) DUTIES.— 

17 (1) RECOMMENDATIONS ON BENEFIT STAND18 ARDS.—The Health Benefits Advisory Committee 

19 shall recommend to the Secretary of Health and 

20 Human Services (in this subtitle referred to as the 

21 ‘‘Secretary’’) benefit standards (as defined in para22 graph (5)), and periodic updates to such standards. 

23 In developing such recommendations, the Committee 

24 shall take into account innovation in health care and 
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1 consider how such standards could reduce health dis2 parities. 

3 (2) DEADLINE.—The Health Benefits Advisory 

4 Committee shall recommend initial benefit standards 

5 to the Secretary not later than 1 year after the date 

6 of the enactment of this Act. 

7 (3) STATE INPUT.—The Health Benefits Advi8 sory Committee shall examine the health coverage 

9 laws and benefits of each State in developing rec10 ommendations under this subsection and may incor11 porate such coverage and benefits as the Committee 

12 determines to be appropriate and consistent with 

13 this Act. The Health Benefits Advisory Committee 

14 shall also seek input from the States and consider 

15 recommendations on how to ensure quality of health 

16 coverage in all States. 

17 (4) PUBLIC INPUT.—The Health Benefits Advi18 sory Committee shall allow for public input as a part 

19 of developing recommendations under this sub20 section. 

21 (5) BENEFIT STANDARDS DEFINED.—In this 

22 subtitle, the term ‘‘benefit standards’’ means stand23 ards respecting— 

24 (A) the essential benefits package de25 scribed in section 222, including categories of 
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1 covered treatments, items and services within 

2 benefit classes, and cost-sharing; and 

3 (B) the cost-sharing levels for enhanced 

4 plans and premium plans (as provided under 

5 section 303(c)) consistent with paragraph (5). 

6 (6) LEVELS OF COST-SHARING FOR ENHANCED

7 AND PREMIUM PLANS.— 

8 (A) ENHANCED PLAN.—The level of cost9 sharing for enhanced plans shall be designed so 

10 that such plans have benefits that are actuari11 ally equivalent to approximately 85 percent of 

12 the actuarial value of the benefits provided 

13 under the reference benefits package described 

14 in section 222(c)(3)(B). 

15 (B) PREMIUM PLAN.—The level of cost16 sharing for premium plans shall be designed so 

17 that such plans have benefits that are actuari18 ally equivalent to approximately 95 percent of 

19 the actuarial value of the benefits provided 

20 under the reference benefits package described 

21 in section 222(c)(3)(B). 

22 (c) OPERATIONS.— 

23 (1) PER DIEM PAY.—Each member of the 

24 Health Benefits Advisory Committee shall receive 

25 travel expenses, including per diem in accordance 
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1 with applicable provisions under subchapter I of 

2 chapter 57 of title 5, United States Code, and shall 

3 otherwise serve without additional pay. 

4 (2) MEMBERS NOT TREATED AS FEDERAL EM5 PLOYEES.—Members of the Health Benefits Advi6 sory Committee shall not be considered employees of 

7 the Federal Government solely by reason of any 

8 service on the Committee, except such members shall 

9 be considered to be within the meaning of section 

10 202(a) of title 18, United States Code, for the pur11 poses of disclosure and management of conflicts of 

12 interest. 

13 (3) APPLICATION OF FACA.—The Federal Advi14 sory Committee Act (5 U.S.C. App.), other than sec15 tion 14, shall apply to the Health Benefits Advisory 

16 Committee. 

17 (d) PUBLICATION.—The Secretary shall provide for 

18 publication in the Federal Register and the posting on the 

19 Internet Website of the Department of Health and Human 

20 Services of all recommendations made by the Health Ben21 efits Advisory Committee under this section. 

22 SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDA23 TIONS; ADOPTION OF BENEFIT STANDARDS. 

24 (a) PROCESS FOR ADOPTION OF RECOMMENDA25 TIONS.— 
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1 (1) REVIEW OF RECOMMENDED STANDARDS.— 

2 Not later than 45 days after the date of receipt of 

3 benefit standards recommended under section 223 

4 (including such standards as modified under para5 graph (2)(B)), the Secretary shall review such 

6 standards and shall determine whether to propose 

7 adoption of such standards as a package. 

8 (2) DETERMINATION TO ADOPT STANDARDS.— 

9 If the Secretary determines— 

10 (A) to propose adoption of benefit stand11 ards so recommended as a package, the Sec12 retary shall, by regulation under section 553 of 

13 title 5, United States Code, propose adoption of 

14 such standards; or 

15 (B) not to propose adoption of such stand16 ards as a package, the Secretary shall notify 

17 the Health Benefits Advisory Committee in 

18 writing of such determination and the reasons 

19 for not proposing the adoption of such rec20 ommendation and provide the Committee with a 

21 further opportunity to modify its previous rec22 ommendations and submit new recommenda23 tions to the Secretary on a timely basis. 

24 (3) CONTINGENCY.—If, because of the applica25 tion of paragraph (2)(B), the Secretary would other-
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1 wise be unable to propose initial adoption of such 

2 recommended standards by the deadline specified in 

3 subsection (b)(1), the Secretary shall, by regulation 

4 under section 553 of title 5, United States Code, 

5 propose adoption of initial benefit standards by such 

6 deadline. 

7 (4) PUBLICATION.—The Secretary shall provide 

8 for publication in the Federal Register of all deter9 minations made by the Secretary under this sub10 section. 

11 (b) ADOPTION OF STANDARDS.— 

12 (1) INITIAL STANDARDS.—Not later than 18 

13 months after the date of the enactment of this Act, 

14 the Secretary shall, through the rulemaking process 

15 consistent with subsection (a), adopt an initial set of 

16 benefit standards. 

17 (2) PERIODIC UPDATING STANDARDS.—Under 

18 subsection (a), the Secretary shall provide for the 

19 periodic updating of the benefit standards previously 

20 adopted under this section. 

21 (3) REQUIREMENT.—The Secretary may not 

22 adopt any benefit standards for an essential benefits 

23 package or for level of cost-sharing that are incon24 sistent with the requirements for such a package or 

25 level under sections 222 and 223(b)(5). 
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1 Subtitle D—Additional Consumer 

2 Protections 

3 SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY 

4 HEALTH INSURERS. 

5 The Commissioner shall establish uniform marketing 

6 standards that all QHBP offering entities shall meet with 

7 respect to qualified health benefits plans that are health 

8 insurance coverage. 

9 SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS 

10 MECHANISMS. 

11 (a) IN GENERAL.—A QHBP offering entity shall pro12 vide for timely grievance and appeals mechanisms with re13 spect to qualified health benefits plans that the Commis14 sioner shall establish consistent with this section. The 

15 Commissioner shall establish time limits for each of such 

16 mechanisms and implement them in a manner that is pro17 tective to the needs of patients. 

18 (b) INTERNAL CLAIMS AND APPEALS PROCESS.— 

19 Under a qualified health benefits plan the QHBP offering 

20 entity shall provide an internal claims and appeals process 

21 that initially incorporates the claims and appeals proce22 dures (including urgent claims) set forth at section 

23 2560.503–1 of title 29, Code of Federal Regulations, as 

24 published on November 21, 2000 (65 Fed. Reg. 70246) 
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1 and shall update such process in accordance with any 

2 standards that the Commissioner may establish. 

3 (c) EXTERNAL REVIEW PROCESS.— 

4 (1) IN GENERAL.—The Commissioner shall es5 tablish an external review process (including proce6 dures for expedited reviews of urgent claims) that 

7 provides for an impartial, independent, and de novo 

8 review of denied claims under this division. 

9 (2) REQUIRING FAIR GRIEVANCE AND APPEALS

10 MECHANISMS.—A determination made, with respect 

11 to a qualified health benefits plan offered by a 

12 QHBP offering entity, under the external review 

13 process established under this subsection shall be 

14 binding on the plan and the entity. 

15 (d) TIME LIMITS.—The Commissioner shall establish 

16 time limits for each of these processes and implement 

17 them in a manner that is protective to the patient. 

18 (e) CONSTRUCTION.—Nothing in this section shall be 

19 construed as affecting the availability of judicial review 

20 under State law for adverse decisions under subsection (b) 

21 or (c), subject to section 251. 

22 SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND 

23 PLAN DISCLOSURE. 

24 (a) ACCURATE AND TIMELY DISCLOSURE.— 
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1 (1) FOR EXCHANGE-PARTICIPATING HEALTH

2 BENEFITS PLANS.—A QHBP offering entity offering 

3 an Exchange-participating health benefits plan shall 

4 comply with standards established by the Commis5 sioner for the accurate and timely disclosure to the 

6 Commissioner and the public of plan documents, 

7 plan terms and conditions, claims payment policies 

8 and practices, periodic financial disclosure, data on 

9 enrollment, data on disenrollment, data on the num10 ber of claims denials, data on rating practices, infor11 mation on cost-sharing and payments with respect to 

12 any out-of-network coverage, and other information 

13 as determined appropriate by the Commissioner. 

14 (2) EMPLOYMENT-BASED HEALTH PLANS.—The 

15 Secretary of Labor shall update and harmonize the 

16 Secretary’s rules concerning the accurate and timely 

17 disclosure to participants by group health plans of 

18 plan disclosure, plan terms and conditions, and peri19 odic financial disclosure with the standards estab20 lished by the Commissioner under paragraph (1). 

21 (3) USE OF PLAIN LANGUAGE.— 

22 (A) IN GENERAL.—The disclosures under 

23 paragraphs (1) and (2) shall be provided in 

24 plain language. 
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1 (B) DEFINITION.—In this paragraph, the 

2 term ‘‘plain language’’ means language that the 

3 intended audience, including individuals with 

4 limited English proficiency, can readily under5 stand and use because that language is concise, 

6 well-organized, and follows other best practices 

7 of plain language writing. 

8 (C) GUIDANCE.—The Commissioner and 

9 the Secretary of Labor shall jointly develop and 

10 issue guidance on best practices of plain lan11 guage writing. 

12 (4) INFORMATION ON RIGHTS.—The informa13 tion disclosed under this subsection shall include in14 formation on enrollee and participant rights under 

15 this division. 

16 (5) COST-SHARING TRANSPARENCY.—A quali17 fied health benefits plan shall allow individuals to 

18 learn the amount of cost-sharing (including 

19 deductibles, copayments, and coinsurance) under the 

20 individual’s plan or coverage that the individual 

21 would be responsible for paying with respect to the 

22 furnishing of a specific item or service by a partici23 pating provider in a timely manner upon request. At 

24 a minimum, this information shall be made available 
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1 to such individual via an Internet Website and other 

2 means for individuals without access to the Internet. 

3 (b) CONTRACTING REIMBURSEMENT.—A qualified 

4 health benefits plan shall comply with standards estab5 lished by the Commissioner to ensure transparency to each 

6 health care provider relating to reimbursement arrange7 ments between such plan and such provider. 

8 (c) PHARMACY BENEFIT MANAGERS TRANSPARENCY

9 REQUIREMENTS.— 

10 (1) IN GENERAL.—If a QHBP offering entity 

11 contracts with a pharmacy benefit manager or other 

12 entity (in this subsection referred to as a ‘‘PBM’’) 

13 to manage prescription drug coverage or otherwise 

14 control prescription drug costs under a qualified 

15 health benefits plan, the PBM shall provide at least 

16 annually to the Commissioner and to the QHBP of17 fering entity offering such plan the following infor18 mation, in a form and manner to be determined by 

19 the Commissioner: 

20 (A) Information on the number and total 

21 cost of prescriptions under the contract that are 

22 filled via mail order and at retail pharmacies. 

23 (B) An estimate of aggregate average pay24 ments under the contract, per prescription 

25 (weighted by prescription volume), made to mail 
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1 order and retail pharmacies, and the average 

2 amount, per prescription, that the PBM was 

3 paid by the plan for prescriptions filled at mail 

4 order and retail pharmacists. 

5 (C) An estimate of the aggregate average 

6 payment per prescription (weighted by prescrip7 tion volume) under the contract received from 

8 pharmaceutical manufacturers, including all re9 bates, discounts, prices concessions, or adminis10 trative, and other payments from pharma11 ceutical manufacturers, and a description of the 

12 types of payments, and the amount of these 

13 payments that were shared with the plan, and 

14 a description of the percentage of prescriptions 

15 for which the PBM received such payments. 

16 (D) Information on the overall percentage 

17 of generic drugs dispensed under the contract 

18 at retail and mail order pharmacies, and the 

19 percentage of cases in which a generic drug is 

20 dispensed when available. 

21 (E) Information on the percentage and 

22 number of cases under the contract in which in23 dividuals were switched because of PBM poli24 cies or at the direct or indirect control of the 

25 PBM from a prescribed drug that had a lower 
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1 cost for the QHBP offering entity to a drug 

2 that had a higher cost for the QHBP offering 

3 entity, the rationale for these switches, and a 

4 description of the PBM policies governing such 

5 switches. 

6 (2) CONFIDENTIALITY OF INFORMATION.—In7 formation disclosed by a PBM to the Commissioner 

8 or a QHBP offering entity under this subsection is 

9 confidential and shall not be disclosed by the Com10 missioner or the QHBP offering entity in a form 

11 which discloses the identity of a specific PBM or 

12 prices charged by such PBM or a specific retailer, 

13 manufacturer, or wholesaler, except only by the 

14 Commissioner— 

15 (A) to permit State or Federal law enforce16 ment authorities to use the information pro17 vided for program compliance purposes and for 

18 the purpose of combating waste, fraud, and 

19 abuse; 

20 (B) to permit the Comptroller General, the 

21 Medicare Payment Advisory Commission, or the 

22 Secretary of Health and Human Services to re23 view the information provided; and 
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1 (C) to permit the Director of the Congres2 sional Budget Office to review the information 

3 provided. 

4 (3) ANNUAL PUBLIC REPORT.—On an annual 

5 basis, the Commissioner shall prepare a public re6 port providing industrywide aggregate or average in7 formation to be used in assessing the overall impact 

8 of PBMs on prescription drug prices and spending. 

9 Such report shall not disclose the identity of a spe10 cific PBM, or prices charged by such PBM, or a 

11 specific retailer, manufacturer, or wholesaler, or any 

12 other confidential or trade secret information. 

13 (4) PENALTIES.—The provisions of subsection 

14 (b)(3)(C) of section 1927 shall apply to a PBM that 

15 fails to provide information required under sub16 section (a) or that knowingly provides false informa17 tion in the same manner as such provisions apply to 

18 a manufacturer with an agreement under such sec19 tion that fails to provide information under sub20 section (b)(3)(A) of such section or knowingly pro21 vides false information under such section, respec22 tively. 
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1 SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS 

2 PLANS NOT OFFERED THROUGH THE 

3 HEALTH INSURANCE EXCHANGE. 

4 The requirements of the previous provisions of this 

5 subtitle shall apply to qualified health benefits plans that 

6 are not being offered through the Health Insurance Ex7 change only to the extent specified by the Commissioner. 

8 SEC. 235. TIMELY PAYMENT OF CLAIMS. 

9 A QHBP offering entity shall comply with the re10 quirements of section 1857(f) of the Social Security Act 

11 with respect to a qualified health benefits plan it offers 

12 in the same manner as a Medicare Advantage organization 

13 is required to comply with such requirements with respect 

14 to a Medicare Advantage plan it offers under part C of 

15 Medicare. 

16 SEC. 236. STANDARDIZED RULES FOR COORDINATION AND 

17 SUBROGATION OF BENEFITS. 

18 The Commissioner shall establish standards for the 

19 coordination and subrogation of benefits and reimburse20 ment of payments in cases of qualified health benefits 

21 plans involving individuals and multiple plan coverage. 

22 SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICA23 TION. 

24 A QHBP offering entity is required to comply with 

25 administrative simplification provisions under part C of 
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1 title XI of the Social Security Act with respect to qualified 

2 health benefits plans it offers. 

3 SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION 

4 AGAINST HEALTH CARE PROVIDERS. 

5 This Act (and the amendments made by this Act) 

6 shall not be construed as superseding laws, as they now 

7 or hereinafter exist, of any State or jurisdiction designed 

8 to prohibit a qualified health benefits plan from discrimi9 nating with respect to participation, reimbursement, cov10 ered services, indemnification, or related requirements 

11 under such plan against a health care provider that is act12 ing within the scope of that provider’s license or certifi13 cation under applicable State law. 

14 SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFOR15 MATION. 

16 (a) STUDY.—The Secretary of Health and Human 

17 Services shall conduct a study on the use of physician pre18 scriber information in sales and marketing practices of 

19 pharmaceutical manufacturers. 

20 (b) REPORT.—Based on the study conducted under 

21 subsection (a), the Secretary shall submit to Congress a 

22 report on actions needed to be taken by the Congress or 

23 the Secretary to protect providers from biased marketing 

24 and sales practices. 
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1 SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING 

2 INFORMATION. 

3 (a) IN GENERAL.—The QHBP offering entity — 

4 (1) shall provide for the dissemination of infor5 mation related to end-of-life planning to individuals 

6 seeking enrollment in Exchange-participating health 

7 benefits plans offered through the Exchange; 

8 (2) shall present such individuals with— 

9 (A) the option to establish advanced direc10 tives and physician’s orders for life sustaining 

11 treatment according to the laws of the State in 

12 which the individual resides; and 

13 (B) information related to other planning 

14 tools; and 

15 (3) shall not promote suicide, assisted suicide, 

16 euthanasia, or mercy killing. 

17 The information presented under paragraph (2) shall not 

18 presume the withdrawal of treatment and shall include 

19 end-of-life planning information that includes options to 

20 maintain all or most medical interventions. 

21 (b) CONSTRUCTION.— Nothing in this section shall 

22 be construed— 

23 (1) to require an individual to complete an ad24 vanced directive or a physician’s order for life sus25 taining treatment or other end-of-life planning docu26 ment; 
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1 (2) to require an individual to consent to re2 strictions on the amount, duration, or scope of med3 ical benefits otherwise covered under a qualified 

4 health benefits plan; or 

5 (3) to promote suicide, assisted suicide, eutha6 nasia, or mercy killing. 

7 (c) ADVANCED DIRECTIVE DEFINED.—In this sec8 tion, the term ‘‘advanced directive’’ includes a living will, 

9 a comfort care order, or a durable power of attorney for 

10 health care. 

11 (d) PROHIBITION ON THE PROMOTION OF ASSISTED

12 SUICIDE.— 

13 (1) IN GENERAL.—Subject to paragraph (3), 

14 information provided to meet the requirements of 

15 subsection (a)(2) shall not include advanced direc16 tives or other planning tools that list or describe as 

17 an option suicide, assisted suicide, euthanasia, or 

18 mercy killing, regardless of legality. 

19 (2) CONSTRUCTION.—Nothing in paragraph (1) 

20 shall be construed to apply to or affect any option 

21 to— 

22 (A) withhold or withdraw of medical treat23 ment or medical care; 

24 (B) withhold or withdraw of nutrition or 

25 hydration; and 
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1 (C) provide palliative or hospice care or 

2 use an item, good, benefit, or service furnished 

3 for the purpose of alleviating pain or discom4 fort, even if such use may increase the risk of 

5 death, so long as such item, good, benefit, or 

6 service is not also furnished for the purpose of 

7 causing, or the purpose of assisting in causing, 

8 death, for any reason. 

9 (3) NO PREEMPTION OF STATE LAW.—Nothing 

10 in this section shall be construed to preempt or oth11 erwise have any effect on State laws regarding ad12 vance care planning, palliative care, or end-of-life de13 cision-making. 

14 Subtitle E—Governance 

15 SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH 

16 CHOICES COMMISSIONER. 

17 (a) IN GENERAL.—There is hereby established, as an 

18 independent agency in the executive branch of the Govern19 ment, a Health Choices Administration (in this division 

20 referred to as the ‘‘Administration’’). 

21 (b) COMMISSIONER.— 

22 (1) IN GENERAL.—The Administration shall be 

23 headed by a Health Choices Commissioner (in this 

24 division referred to as the ‘‘Commissioner’’) who 
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1 shall be appointed by the President, by and with the 

2 advice and consent of the Senate. 

3 (2) COMPENSATION; ETC.—The provisions of 

4 paragraphs (2), (5), and (7) of subsection (a) (relat5 ing to compensation, terms, general powers, rule6 making, and delegation) of section 702 of the Social 

7 Security Act (42 U.S.C. 902) shall apply to the 

8 Commissioner and the Administration in the same 

9 manner as such provisions apply to the Commis10 sioner of Social Security and the Social Security Ad11 ministration. 

12 (c) INSPECTOR GENERAL.—For provision estab13 lishing an Office of the Inspector General for the Health 

14 Choices Administration, see section 1647. 

15 SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER. 

16 (a) DUTIES.—The Commissioner is responsible for 

17 carrying out the following functions under this division: 

18 (1) QUALIFIED PLAN STANDARDS.—The estab19 lishment of qualified health benefits plan standards 

20 under this title, including the enforcement of such 

21 standards in coordination with State insurance regu22 lators and the Secretaries of Labor and the Treas23 ury. 
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1 (2) HEALTH INSURANCE EXCHANGE.—The es2 tablishment and operation of a Health Insurance 

3 Exchange under subtitle A of title III. 

4 (3) INDIVIDUAL AFFORDABILITY CREDITS.— 

5 The administration of individual affordability credits 

6 under subtitle C of title III, including determination 

7 of eligibility for such credits. 

8 (4) ADDITIONAL FUNCTIONS.—Such additional 

9 functions as may be specified in this division. 

10 (b) PROMOTING ACCOUNTABILITY.— 

11 (1) IN GENERAL.—The Commissioner shall un12 dertake activities in accordance with this subtitle to 

13 promote accountability of QHBP offering entities in 

14 meeting Federal health insurance requirements, re15 gardless of whether such accountability is with re16 spect to qualified health benefits plans offered 

17 through the Health Insurance Exchange or outside 

18 of such Exchange. 

19 (2) COMPLIANCE EXAMINATION AND AUDITS.— 

20 (A) IN GENERAL.—The Commissioner 

21 shall, in coordination with States, conduct au22 dits of qualified health benefits plan compliance 

23 with Federal requirements. Such audits may 

24 include random compliance audits and targeted 
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1 audits in response to complaints or other sus2 pected noncompliance. 

3 (B) RECOUPMENT OF COSTS IN CONNEC4 TION WITH EXAMINATION AND AUDITS.—The 

5 Commissioner is authorized to recoup from 

6 qualified health benefits plans reimbursement 

7 for the costs of such examinations and audit of 

8 such QHBP offering entities. 

9 (c) DATA COLLECTION.—The Commissioner shall 

10 collect data for purposes of carrying out the Commis11 sioner’s duties, including for purposes of promoting qual12 ity and value, protecting consumers, and addressing dis13 parities in health and health care and may share such data 

14 with the Secretary of Health and Human Services. 

15 (d) SANCTIONS AUTHORITY.— 

16 (1) IN GENERAL.—In the case that the Com17 missioner determines that a QHBP offering entity 

18 violates a requirement of this title, the Commis19 sioner may, in coordination with State insurance 

20 regulators and the Secretary of Labor, provide, in 

21 addition to any other remedies authorized by law, 

22 for any of the remedies described in paragraph (2). 

23 (2) REMEDIES.—The remedies described in this 

24 paragraph, with respect to a qualified health benefits 

25 plan offered by a QHBP offering entity, are— 
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1 (A) civil money penalties of not more than 

2 the amount that would be applicable under 

3 similar circumstances for similar violations 

4 under section 1857(g) of the Social Security 

5 Act; 

6 (B) suspension of enrollment of individuals 

7 under such plan after the date the Commis8 sioner notifies the entity of a determination 

9 under paragraph (1) and until the Commis10 sioner is satisfied that the basis for such deter11 mination has been corrected and is not likely to 

12 recur; 

13 (C) in the case of an Exchange-partici14 pating health benefits plan, suspension of pay15 ment to the entity under the Health Insurance 

16 Exchange for individuals enrolled in such plan 

17 after the date the Commissioner notifies the en18 tity of a determination under paragraph (1) 

19 and until the Secretary is satisfied that the 

20 basis for such determination has been corrected 

21 and is not likely to recur; or 

22 (D) working with State insurance regu23 lators to terminate plans for repeated failure by 

24 the offering entity to meet the requirements of 

25 this title. 
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1 (e) STANDARD DEFINITIONS OF INSURANCE AND

2 MEDICAL TERMS.—The Commissioner shall provide for 

3 the development of standards for the definitions of terms 

4 used in health insurance coverage, including insurance-re5 lated terms. 

6 (f) EFFICIENCY IN ADMINISTRATION.—The Commis7 sioner shall issue regulations for the effective and efficient 

8 administration of the Health Insurance Exchange and af9 fordability credits under subtitle C, including, with respect 

10 to the determination of eligibility for affordability credits, 

11 the use of personnel who are employed in accordance with 

12 the requirements of title 5, United States Code, to carry 

13 out the duties of the Commissioner or, in the case of sec14 tions 308 and 341(b)(2), the use of State personnel who 

15 are employed in accordance with standards prescribed by 

16 the Office of Personnel Management pursuant to section 

17 208 of the Intergovernmental Personnel Act of 1970 (42 

18 U.S.C. 4728). 

19 SEC. 243. CONSULTATION AND COORDINATION. 

20 (a) CONSULTATION.—In carrying out the Commis21 sioner’s duties under this division, the Commissioner, as 

22 appropriate, shall consult at least with the following: 

23 (1) State attorneys general and State insurance 

24 regulators, including concerning the standards for 

25 health insurance coverage that is a qualified health 
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1 benefits plan under this title and enforcement of 

2 such standards. 

3 (2) The National Association of Insurance 

4 Commissioners, including for purposes of using 

5 model guidelines established by such association for 

6 purposes of subtitles B and D. 

7 (3) Appropriate State agencies, specifically con8 cerning the administration of individual affordability 

9 credits under subtitle C of title III and the offering 

10 of Exchange-participating health benefits plans, to 

11 Medicaid eligible individuals under subtitle A of such 

12 title. 

13 (4) The Federal Trade Commission, specifically 

14 concerning the development and issuance of guid15 ance, rules, or standards regarding fair marketing 

16 practices under section 231 or otherwise, or any con17 sumer disclosure requirements under section 233 or 

18 otherwise. 

19 (5) Other appropriate Federal agencies. 

20 (6) Indian tribes and tribal organizations. 

21 (b) COORDINATION.— 

22 (1) IN GENERAL.—In carrying out the func23 tions of the Commissioner, including with respect to 

24 the enforcement of the provisions of this division, 

25 the Commissioner shall work in coordination with 
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1 existing Federal and State entities to the maximum 

2 extent feasible consistent with this division and in a 

3 manner that prevents conflicts of interest in duties 

4 and ensures effective enforcement. 

5 (2) UNIFORM STANDARDS.—The Commissioner, 

6 in coordination with such entities, shall seek to 

7 achieve uniform standards that adequately protect 

8 consumers in a manner that does not unreasonably 

9 affect employers and insurers. 

10 SEC. 244. HEALTH INSURANCE OMBUDSMAN. 

11 (a) IN GENERAL.—The Commissioner shall appoint 

12 within the Health Choices Administration a Qualified 

13 Health Benefits Plan Ombudsman who shall have exper14 tise and experience in the fields of health care and edu15 cation of (and assistance to) individuals. 

16 (b) DUTIES.—The Qualified Health Benefits Plan 

17 Ombudsman shall, in a linguistically appropriate man18 ner— 

19 (1) receive complaints, grievances, and requests 

20 for information submitted by individuals through 

21 means such as the mail, by telephone, electronically, 

22 and in person; 

23 (2) provide assistance with respect to com24 plaints, grievances, and requests referred to in para25 graph (1), including— 
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1 (A) helping individuals determine the rel2 evant information needed to seek an appeal of 

3 a decision or determination; 

4 (B) assistance to such individuals in choos5 ing a qualified health benefits plan in which to 

6 enroll; 

7 (C) assistance to such individuals with any 

8 problems arising from disenrollment from such 

9 a plan; and 

10 (D) assistance to such individuals in pre11 senting information under subtitle C (relating 

12 to affordability credits); and 

13 (3) submit annual reports to Congress and the 

14 Commissioner that describe the activities of the Om15 budsman and that include such recommendations for 

16 improvement in the administration of this division as 

17 the Ombudsman determines appropriate. The Om18 budsman shall not serve as an advocate for any in19 creases in payments or new coverage of services, but 

20 may identify issues and problems in payment or cov21 erage policies. 
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1 Subtitle F—Relation to Other 

2 Requirements; Miscellaneous 

3 SEC. 251. RELATION TO OTHER REQUIREMENTS. 

4 (a) COVERAGE NOT OFFERED THROUGH EX5 CHANGE.— 

6 (1) IN GENERAL.—In the case of health insur7 ance coverage not offered through the Health Insur8 ance Exchange (whether or not offered in connection 

9 with an employment-based health plan), and in the 

10 case of employment-based health plans, the require11 ments of this title do not supercede any require12 ments applicable under titles XXII and XXVII of 

13 the Public Health Service Act, parts 6 and 7 of sub14 title B of title I of the Employee Retirement Income 

15 Security Act of 1974, or State law, except insofar as 

16 such requirements prevent the application of a re17 quirement of this division, as determined by the 

18 Commissioner. 

19 (2) CONSTRUCTION.—Nothing in paragraphs 

20 (1) or (2) shall be construed as affecting the appli21 cation of section 514 of the Employee Retirement 

22 Income Security Act of 1974. 

23 (b) COVERAGE OFFERED THROUGH EXCHANGE.— 
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1 (1) IN GENERAL.—In the case of health insur2 ance coverage offered through the Health Insurance 

3 Exchange— 

4 (A) the requirements of this title do not 

5 supercede any requirements (including require6 ments relating to genetic information non7 discrimination and mental health parity) appli8 cable under title XXVII of the Public Health 

9 Service Act or under State law, except insofar 

10 as such requirements prevent the application of 

11 a requirement of this division, as determined by 

12 the Commissioner; and 

13 (B) individual rights and remedies under 

14 State laws shall apply. 

15 (2) CONSTRUCTION.—In the case of coverage 

16 described in paragraph (1), nothing in such para17 graph shall be construed as preventing the applica18 tion of rights and remedies under State laws to 

19 health insurance issuers generally with respect to 

20 any requirement referred to in paragraph (1)(A). 

21 The previous sentence shall not be construed as pro22 viding for the applicability of rights or remedies 

23 under State laws with respect to requirements appli24 cable to employers or other plan sponsors in connec25 tion with arrangements which are treated as group 
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1 health plans under section 802(a)(1) of the Em2 ployee Retirement Income Security Act of 1974. 

3 SEC. 252. PROHIBITING DISCRIMINATION IN HEALTH CARE. 

4 (a) IN GENERAL.—Except as otherwise explicitly per5 mitted by this Act and by subsequent regulations con6 sistent with this Act, all health care and related services 

7 (including insurance coverage and public health activities) 

8 covered by this Act shall be provided without regard to 

9 personal characteristics extraneous to the provision of 

10 high quality health care or related services. 

11 (b) IMPLEMENTATION.—To implement the require12 ment set forth in subsection (a), the Secretary of Health 

13 and Human Services shall, not later than 18 months after 

14 the date of the enactment of this Act, promulgate such 

15 regulations as are necessary or appropriate to insure that 

16 all health care and related services (including insurance 

17 coverage and public health activities) covered by this Act 

18 are provided (whether directly or through contractual, li19 censing, or other arrangements) without regard to per20 sonal characteristics extraneous to the provision of high 

21 quality health care or related services. 

22 SEC. 253. WHISTLEBLOWER PROTECTION. 

23 (a) RETALIATION PROHIBITED.—No employer may 

24 discharge any employee or otherwise discriminate against 

25 any employee with respect to his compensation, terms, 
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1 conditions, or other privileges of employment because the 

2 employee (or any person acting pursuant to a request of 

3 the employee)— 

4 (1) provided, caused to be provided, or is about 

5 to provide or cause to be provided to the employer, 

6 the Federal Government, or the attorney general of 

7 a State information relating to any violation of, or 

8 any act or omission the employee reasonably believes 

9 to be a violation of any provision of this Act or any 

10 order, rule, or regulation promulgated under this 

11 Act; 

12 (2) testified or is about to testify in a pro13 ceeding concerning such violation; 

14 (3) assisted or participated or is about to assist 

15 or participate in such a proceeding; or 

16 (4) objected to, or refused to participate in, any 

17 activity, policy, practice, or assigned task that the 

18 employee (or other such person) reasonably believed 

19 to be in violation of any provision of this Act or any 

20 order, rule, or regulation promulgated under this 

21 Act. 

22 (b) ENFORCEMENT ACTION.—An employee covered 

23 by this section who alleges discrimination by an employer 

24 in violation of subsection (a) may bring an action governed 

25 by the rules, procedures, legal burdens of proof, and rem-
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1 edies set forth in section 40(b) of the Consumer Product 

2 Safety Act (15 U.S.C. 2087(b)). 

3 (c) EMPLOYER DEFINED.—As used in this section, 

4 the term ‘‘employer’’ means any person (including one or 

5 more individuals, partnerships, associations, corporations, 

6 trusts, professional membership organization including a 

7 certification, disciplinary, or other professional body, unin8 corporated organizations, nongovernmental organizations, 

9 or trustees) engaged in profit or nonprofit business or in10 dustry whose activities are governed by this Act, and any 

11 agent, contractor, subcontractor, grantee, or consultant of 

12 such person. 

13 (d) RULE OF CONSTRUCTION.—The rule of construc14 tion set forth in section 20109(h) of title 49, United 

15 States Code, shall also apply to this section. 

16 SEC. 254. CONSTRUCTION REGARDING COLLECTIVE BAR17 GAINING. 

18 Nothing in this division shall be construed to alter 

19 or supersede any statutory or other obligation to engage 

20 in collective bargaining over the terms or conditions of em21 ployment related to health care. Any plan amendment 

22 made pursuant to a collective bargaining agreement relat23 ing to the plan which amends the plan solely to conform 

24 to any requirement added by this division shall not be 
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1 treated as a termination of such collective bargaining 

2 agreement. 

3 SEC. 255. SEVERABILITY. 

4 If any provision of this Act, or any application of such 

5 provision to any person or circumstance, is held to be un6 constitutional, the remainder of the provisions of this Act 

7 and the application of the provision to any other person 

8 or circumstance shall not be affected. 

9 SEC. 256. TREATMENT OF HAWAII PREPAID HEALTH CARE 

10 ACT. 

11 (a) IN GENERAL.—Subject to this section— 

12 (1) nothing in this division (or an amendment 

13 made by this division) shall be construed to modify 

14 or limit the application of the exemption for the Ha15 waii Prepaid Health Care Act (Haw. Rev. Stat. §§ 

16 393–1 et seq.) as provided for under section 

17 514(b)(5) of the Employee Retirement Income Secu18 rity Act of 1974 (29 U.S.C. 1144(b)(5)), and such 

19 exemption shall also apply with respect to the provi20 sions of this division; and 

21 (2) for purposes of this division (and the 

22 amendments made by this division), coverage pro23 vided pursuant to the Hawaii Prepaid Health Care 

24 Act shall be treated as a qualified health benefits 

25 plan providing acceptable coverage so long as the 
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1 Secretary of Labor determines that such coverage 

2 for employees (taking into account the benefits and 

3 the cost to employees for such benefits) is substan4 tially equivalent to or greater than the coverage pro5 vided for employees pursuant to the essential bene6 fits package. 

7 (b) COORDINATION WITH STATE LAW OF HAWAII.— 

8 The Commissioner shall, based on ongoing consultation 

9 with the appropriate officials of the State of Hawaii, make 

10 adjustments to rules and regulations of the Commissioner 

11 under this division as may be necessary, as determined 

12 by the Commissioner, to most effectively coordinate the 

13 provisions of this division with the provisions of the Ha14 waii Prepaid Health Care Act, taking into account any 

15 changes made from time to time to the Hawaii Prepaid 

16 Health Care Act and related laws of such State. 

17 SEC. 257. ACTIONS BY STATE ATTORNEYS GENERAL. 

18 Any State attorney general may bring a civil action 

19 in the name of such State as parens patriae on behalf of 

20 natural persons residing in such State, in any district 

21 court of the United States or State court having jurisdic22 tion of the defendant to secure monetary or equitable relief 

23 for violation of any provisions of this title or regulations 

24 issued thereunder. Nothing in this section shall be con-
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1 strued as affecting the application of section 514 of the 

2 Employee Retirement Income Security Act of 1974. 

3 SEC. 258. APPLICATION OF STATE AND FEDERAL LAWS RE4 GARDING ABORTION. 

5 (a) NO PREEMPTION OF STATE LAWS REGARDING

6 ABORTION.—Nothing in this Act shall be construed to 

7 preempt or otherwise have any effect on State laws regard8 ing the prohibition of (or requirement of) coverage, fund9 ing, or procedural requirements on abortions, including 

10 parental notification or consent for the performance of an 

11 abortion on a minor. 

12 (b) NO EFFECT ON FEDERAL LAWS REGARDING

13 ABORTION.— 

14 (1) IN GENERAL.—Nothing in this Act shall be 

15 construed to have any effect on Federal laws regard16 ing— 

17 (A) conscience protection; 

18 (B) willingness or refusal to provide abor19 tion; and 

20 (C) discrimination on the basis of the will21 ingness or refusal to provide, pay for, cover, or 

22 refer for abortion or to provide or participate in 

23 training to provide abortion. 

24 (c) NO EFFECT ON FEDERAL CIVIL RIGHTS LAW.— 

25 Nothing in this section shall alter the rights and obliga-
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1 tions of employees and employers under title VII of the 

2 Civil Rights Act of 1964. 

3 SEC. 259. NONDISCRIMINATION ON ABORTION AND RE4 SPECT FOR RIGHTS OF CONSCIENCE. 

5 (a) NONDISCRIMINATION.—A Federal agency or pro6 gram, and any State or local government that receives 

7 Federal financial assistance under this Act (or an amend8 ment made by this Act), may not— 

9 (1) subject any individual or institutional health 

10 care entity to discrimination; or 

11 (2) require any health plan created or regulated 

12 under this Act (or an amendment made by this Act) 

13 to subject any individual or institutional health care 

14 entity to discrimination, 

15 on the basis that the health care entity does not provide, 

16 pay for, provide coverage of, or refer for abortions. 

17 (b) DEFINITION.—In this section, the term ‘‘health 

18 care entity’’ includes an individual physician or other 

19 health care professional, a hospital, a provider-sponsored 

20 organization, a health maintenance organization, a health 

21 insurance plan, or any other kind of health care facility, 

22 organization, or plan. 

23 (c) ADMINISTRATION.—The Office for Civil Rights of 

24 the Department of Health and Human Services is des25 ignated to receive complaints of discrimination based on 
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1 this section, and coordinate the investigation of such com2 plaints. 

3 SEC. 260. AUTHORITY OF FEDERAL TRADE COMMISSION. 

4 Section 6 of the Federal Trade Commission Act (15 

5 U.S.C. 46) is amended by striking ‘‘and prepare reports’’ 

6 and all that follows and inserting the following: ‘‘and pre7 pare reports, and to share information under clauses (f) 

8 and (k), relating to insurance. Notwithstanding section 4, 

9 the Commission’s authority shall include the authority to 

10 conduct studies and prepare reports, and to share infor11 mation under clauses (f) and (k), relating to insurance, 

12 without regard to whether the subject of such studies, re13 ports, or information is for-profit or not-for-profit.’’. 

14 SEC. 261. CONSTRUCTION REGARDING STANDARD OF 

15 CARE. 

16 (a) IN GENERAL.—The development, recognition, or 

17 implementation of any guideline or other standard under 

18 a provision described in subsection (b) shall not be con19 strued to establish the standard of care or duty of care 

20 owed by health care providers to their patients in any med21 ical malpractice action or claim (as defined in section 

22 431(7) of the Health Care Quality Improvement Act of 

23 1986 (42 U.S.C. 11151(7)). 

24 (b) PROVISIONS DESCRIBED.—The provisions de25 scribed in this subsection are the following: 
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1 (1) Section 324 (relating to modernized pay2 ment initiatives and delivery system reform under 

3 the public health option). 

4 (2) The amendments made by section 1151 (re5 lating to reducing potentially preventable hospital re6 admissions). 

7 (3) The amendments made by section 1751 (re8 lating to health care acquired conditions). 

9 (4) Section 3131 of the Public Health Service 

10 Act (relating to the Task Force on Clinical Preven11 tive Services), added by section 2301. 

12 (5) Part D of title IX of the Public Health 

13 Service Act (relating to implementation of best prac14 tices in the delivery of health care), added by section 

15 2401. 

16 (c) SAVINGS CLAUSE FOR STATE MEDICAL MAL17 PRACTICE LAWS.—Nothing in this Act or the amendments 

18 made by this Act shall be construed to modify or impair 

19 State law governing legal standards or procedures used 

20 in medical malpractice cases, including the authority of 

21 a State to make or implement such law. 

22 SEC. 262. RESTORING APPLICATION OF ANTITRUST LAWS 

23 TO HEALTH SECTOR INSURERS. 

24 (a) AMENDMENT TO MCCARRAN-FERGUSON ACT.— 

25 Section 3 of the Act of March 9, 1945 (15 U.S.C. 1013), 
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1 commonly known as the McCarran-Ferguson Act, is 

2 amended by adding at the end the following: 

3 ‘‘(c)(1) Except as provided in paragraph (2), nothing 

4 contained in this Act shall modify, impair, or supersede 

5 the operation of any of the antitrust laws with respect to 

6 the business of health insurance or the business of medical 

7 malpractice insurance. 

8 ‘‘(2) Paragraph (1) shall not apply to— 

9 ‘‘(A) collecting, compiling, classifying, or dis10 seminating historical loss data; 

11 ‘‘(B) determining a loss development factor ap12 plicable to historical loss data; or 

13 ‘‘(C) performing actuarial services if doing so 

14 does not involve a restraint of trade. 

15 ‘‘(3) For purposes of this subsection— 

16 ‘‘(A) the term ‘antitrust laws’ has the meaning 

17 given it in subsection (a) of the first section of the 

18 Clayton Act, except that such term includes section 

19 5 of the Federal Trade Commission Act to the ex20 tent that such section 5 applies to unfair methods of 

21 competition; 

22 ‘‘(B) the term ‘historical loss data’ means infor23 mation respecting claims paid, or reserves held for 

24 claims reported, by any person engaged in the busi25 ness of insurance; and 
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1 ‘‘(C) the term ‘loss development factor’ means 

2 an adjustment to be made to the aggregate of losses 

3 incurred during a prior period of time that have 

4 been paid, or for which claims have been received 

5 and reserves are being held, in order to estimate the 

6 aggregate of the losses incurred during such period 

7 that will ultimately be paid.’’. 

8 (b) RELATED PROVISION.—For purposes of section 

9 5 of the Federal Trade Commission Act (15 U.S.C. 45) 

10 to the extent such section applies to unfair methods of 

11 competition, section 3(c) of the McCarran-Ferguson Act 

12 shall apply with respect to the business of health insur13 ance, and with respect to the business of medical mal14 practice insurance, without regard to whether such busi15 ness is carried on for profit, notwithstanding the definition 

16 of ‘‘Corporation’’ contained in section 4 of the Federal 

17 Trade Commission Act. 

18 (c) RELATED PRESERVATION OF ANTITRUST

19 LAWS.—Except as provided in subsections (a) and (b), 

20 nothing in this Act, or in the amendments made by this 

21 Act, shall be construed to modify, impair, or supersede 

22 the operation of any of the antitrust laws. For purposes 

23 of the preceding sentence, the term ‘‘antitrust laws’’ has 

24 the meaning given it in subsection (a) of the first section 

25 of the Clayton Act, except that it includes section 5 of 
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1 the Federal Trade Commission Act to the extent that such 

2 section 5 applies to unfair methods of competition. 

3 SEC. 263. STUDY AND REPORT ON METHODS TO INCREASE 

4 EHR USE BY SMALL HEALTH CARE PRO5 VIDERS. 

6 (a) STUDY.—The Secretary of Health and Human 

7 Services shall conduct a study of potential methods to in8 crease the use of qualified electronic health records (as 

9 defined in section 3000(13) of the Public Health Service 

10 Act) by small health care providers. Such study shall con11 sider at least the following methods: 

12 (1) Providing for higher rates of reimbursement 

13 or other incentives for such health care providers to 

14 use electronic health records (taking into consider15 ation initiatives by private health insurance compa16 nies and incentives provided under Medicare under 

17 title XVIII of the Social Security Act, Medicaid 

18 under title XIX of such Act, and other programs). 

19 (2) Promoting low-cost electronic health record 

20 software packages that are available for use by such 

21 health care providers, including software packages 

22 that are available to health care providers through 

23 the Veterans Administration and other sources. 

24 (3) Training and education of such health care 

25 providers on the use of electronic health records. 
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1 (4) Providing assistance to such health care 

2 providers on the implementation of electronic health 

3 records. 

4 (b) REPORT.—Not later than December 31, 2013, 

5 the Secretary of Health and Human Services shall submit 

6 to Congress a report containing the results of the study 

7 conducted under subsection (a), including recommenda8 tions for legislation or administrative action to increase 

9 the use of electronic health records by small health care 

10 providers that include the use of both public and private 

11 funding sources. 

12 SEC. 264. PERFORMANCE ASSESSMENT AND ACCOUNT13 ABILITY: APPLICATION OF GPRA. 

14 (a) APPLICATION OF GPRA.—Section 306 of title 5, 

15 United States Code, and sections 1115, 1116, 1117, and 

16 9703 of title 31 of such Code (originally enacted by the 

17 Government Performance and Results Act of 1993, Public 

18 Law 103–62) apply to the executive agencies established 

19 by this Act, including the Health Choices Administration. 

20 Under such section 306, each such executive agency is re21 quired to provide for a strategic plan every 3 years. 

22 (b) IMPROVING CONSUMER SERVICE AND STREAM23 LINING PROCEDURES.—Every 3 years each such executive 

24 agency shall— 
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1 (1)(A) assess the quality of customer service 

2 provided, (B) develop a strategy for improving such 

3 service, and (C) establish standards for high-quality 

4 customer service; and 

5 (2)(A) identify redundant rules, regulations, 

6 and procedures, and (B) develop and implement a 

7 plan for eliminating or streamlining such 

8 redundancies. 

9 SEC. 265. LIMITATION ON ABORTION FUNDING. 

10 (a) IN GENERAL.—No funds authorized or appro11 priated by this Act (or an amendment made by this Act) 

12 may be used to pay for any abortion or to cover any part 

13 of the costs of any health plan that includes coverage of 

14 abortion, except in the case where a woman suffers from 

15 a physical disorder, physical injury, or physical illness that 

16 would, as certified by a physician, place the woman in dan17 ger of death unless an abortion is performed, including 

18 a life-endangering physical condition caused by or arising 

19 from the pregnancy itself, or unless the pregnancy is the 

20 result of an act of rape or incest. 

21 (b) OPTION TO PURCHASE SEPARATE SUPPLE22 MENTAL COVERAGE OR PLAN.—Nothing in this section 

23 shall be construed as prohibiting any nonfederal entity (in24 cluding an individual or a State or local government) from 

25 purchasing separate supplemental coverage for abortions 
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1 for which funding is prohibited under this section, or a 

2 plan that includes such abortions, so long as— 

3 (1) such coverage or plan is paid for entirely 

4 using only funds not authorized or appropriated by 

5 this Act; and 

6 (2) such coverage or plan is not purchased 

7 using— 

8 (A) individual premium payments required 

9 for a Exchange-participating health benefits 

10 plan towards which an affordability credit is ap11 plied; or 

12 (B) other nonfederal funds required to re13 ceive a federal payment, including a State’s or 

14 locality’s contribution of Medicaid matching 

15 funds. 

16 (c) OPTION TO OFFER SEPARATE SUPPLEMENTAL

17 COVERAGE OR PLAN.—Notwithstanding section 303(b), 

18 nothing in this section shall restrict any nonfederal QHBP 

19 offering entity from offering separate supplemental cov20 erage for abortions for which funding is prohibited under 

21 this section, or a plan that includes such abortions, so long 

22 as— 

23 (1) premiums for such separate supplemental 

24 coverage or plan are paid for entirely with funds not 

25 authorized or appropriated by this Act; 
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1 (2) administrative costs and all services offered 

2 through such supplemental coverage or plan are paid 

3 for using only premiums collected for such coverage 

4 or plan; and 

5 (3) any nonfederal QHBP offering entity that 

6 offers an Exchange-participating health benefits 

7 plan that includes coverage for abortions for which 

8 funding is prohibited under this section also offers 

9 an Exchange-participating health benefits plan that 

10 is identical in every respect except that it does not 

11 cover abortions for which funding is prohibited 

12 under this section. 

13 TITLE III—HEALTH INSURANCE 

14 EXCHANGE AND RELATED 

15 PROVISIONS 

16 Subtitle A—Health Insurance 

17 Exchange 

18 SEC. 301. ESTABLISHMENT OF HEALTH INSURANCE EX19 CHANGE; OUTLINE OF DUTIES; DEFINITIONS. 

20 (a) ESTABLISHMENT.—There is established within 

21 the Health Choices Administration and under the direc22 tion of the Commissioner a Health Insurance Exchange 

23 in order to facilitate access of individuals and employers, 

24 through a transparent process, to a variety of choices of 
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1 affordable, quality health insurance coverage, including a 

2 public health insurance option. 

3 (b) OUTLINE OF DUTIES OF COMMISSIONER.—In ac4 cordance with this subtitle and in coordination with appro5 priate Federal and State officials as provided under sec6 tion 243(b), the Commissioner shall— 

7 (1) under section 304 establish standards for, 

8 accept bids from, and negotiate and enter into con9 tracts with, QHBP offering entities for the offering 

10 of health benefits plans through the Health Insur11 ance Exchange, with different levels of benefits re12 quired under section 303, and including with respect 

13 to oversight and enforcement; 

14 (2) under section 305 facilitate outreach and 

15 enrollment in such plans of Exchange-eligible indi16 viduals and employers described in section 302; and 

17 (3) conduct such activities related to the Health 

18 Insurance Exchange as required, including establish19 ment of a risk pooling mechanism under section 306 

20 and consumer protections under subtitle D of title 

21 II. 

22 SEC. 302. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOY23 ERS. 

24 (a) ACCESS TO COVERAGE.—In accordance with this 

25 section, all individuals are eligible to obtain coverage 
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1 through enrollment in an Exchange-participating health 

2 benefits plan offered through the Health Insurance Ex3 change unless such individuals are enrolled in another 

4 qualified health benefits plan or certain other acceptable 

5 coverage. 

6 (b) DEFINITIONS.—In this division: 

7 (1) EXCHANGE-ELIGIBLE INDIVIDUAL.—The 

8 term ‘‘Exchange-eligible individual’’ means an indi9 vidual who is eligible under this section to be en10 rolled through the Health Insurance Exchange in an 

11 Exchange-participating health benefits plan and, 

12 with respect to family coverage, includes dependents 

13 of such individual. 

14 (2) EXCHANGE-ELIGIBLE EMPLOYER.—The 

15 term ‘‘Exchange-eligible employer’’ means an em16 ployer that is eligible under this section to enroll 

17 through the Health Insurance Exchange employees 

18 of the employer (and their dependents) in Exchange19 eligible health benefits plans. 

20 (3) EMPLOYMENT-RELATED DEFINITIONS.— 

21 The terms ‘‘employer’’, ‘‘employee’’, ‘‘full-time em22 ployee’’, and ‘‘part-time employee’’ have the mean23 ings given such terms by the Commissioner for pur24 poses of this division. 
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1 (c) TRANSITION.—Individuals and employers shall 

2 only be eligible to enroll or participate in the Health Insur3 ance Exchange in accordance with the following transition 

4 schedule: 

5 (1) FIRST YEAR.—In Y1 (as defined in section 

6 100(c))— 

7 (A) individuals described in subsection 

8 (d)(1), including individuals described in sub9 section (d)(3); and 

10 (B) smallest employers described in sub11 section (e)(1). 

12 (2) SECOND YEAR.—In Y2— 

13 (A) individuals and employers described in 

14 paragraph (1); and 

15 (B) smaller employers described in sub16 section (e)(2). 

17 (3) THIRD AND SUBSEQUENT YEARS.—In Y3— 

18 (A) individuals and employers described in 

19 paragraph (2); 

20 (B) small employers described in sub21 section (e)(3); and 

22 (C) larger employers as permitted by the 

23 Commissioner under subsection (e)(4). 

24 (d) INDIVIDUALS.— 
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1 (1) INDIVIDUAL DESCRIBED.—Subject to the 

2 succeeding provisions of this subsection, an indi3 vidual described in this paragraph is an individual 

4 who— 

5 (A) is not enrolled in coverage described in 

6 subparagraph (C) or (D) of paragraph (2); and 

7 (B) is not enrolled in coverage as a full8 time employee (or as a dependent of such an 

9 employee) under a group health plan if the cov10 erage and an employer contribution under the 

11 plan meet the requirements of section 412. 

12 For purposes of subparagraph (B), in the case of an 

13 individual who is self-employed, who has at least 1 

14 employee, and who meets the requirements of section 

15 412, such individual shall be deemed a full-time em16 ployee described in such subparagraph. 

17 (2) ACCEPTABLE COVERAGE.—For purposes of 

18 this division, the term ‘‘acceptable coverage’’ means 

19 any of the following: 

20 (A) QUALIFIED HEALTH BENEFITS PLAN

21 COVERAGE.—Coverage under a qualified health 

22 benefits plan. 

23 (B) GRANDFATHERED HEALTH INSURANCE

24 COVERAGE; COVERAGE UNDER CURRENT GROUP

25 HEALTH PLAN.—Coverage under a grand-
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1 fathered health insurance coverage (as defined 

2 in subsection (a) of section 202) or under a 

3 current group health plan (described in sub4 section (b) of such section). 

5 (C) MEDICARE.—Coverage under part A of 

6 title XVIII of the Social Security Act. 

7 (D) MEDICAID.—Coverage for medical as8 sistance under title XIX of the Social Security 

9 Act, excluding such coverage that is only avail10 able because of the application of subsection 

11 (u), (z), (aa), or (hh) of section 1902 of such 

12 Act. 

13 (E) MEMBERS OF THE ARMED FORCES

14 AND DEPENDENTS (INCLUDING TRICARE).— 

15 Coverage under chapter 55 of title 10, United 

16 States Code, including similar coverage fur17 nished under section 1781 of title 38 of such 

18 Code. 

19 (F) VA.—Coverage under the veteran’s 

20 health care program under chapter 17 of title 

21 38, United States Code. 

22 (G) OTHER COVERAGE.—Such other health 

23 benefits coverage, such as a State health bene24 fits risk pool, as the Commissioner, in coordina-
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1 tion with the Secretary of the Treasury, recog2 nizes for purposes of this paragraph. 

3 The Commissioner shall make determinations under 

4 this paragraph in coordination with the Secretary of 

5 the Treasury. 

6 (3) CONTINUING ELIGIBILITY PERMITTED.— 

7 (A) IN GENERAL.—Except as provided in 

8 subparagraph (B), once an individual qualifies 

9 as an Exchange-eligible individual under this 

10 subsection (including as an employee or depend11 ent of an employee of an Exchange-eligible em12 ployer) and enrolls under an Exchange-partici13 pating health benefits plan through the Health 

14 Insurance Exchange, the individual shall con15 tinue to be treated as an Exchange-eligible indi16 vidual until the individual is no longer enrolled 

17 with an Exchange-participating health benefits 

18 plan. 

19 (B) EXCEPTIONS.— 

20 (i) IN GENERAL.—Subparagraph (A) 

21 shall not apply to an individual once the 

22 individual becomes eligible for coverage— 

23 (I) under part A of the Medicare 

24 program; 
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1 (II) under the Medicaid program 

2 as a Medicaid-eligible individual, ex3 cept as permitted under clause (ii); or 

4 (III) in such other circumstances 

5 as the Commissioner may provide. 

6 (ii) TRANSITION PERIOD.—In the case 

7 described in clause (i)(II), the Commis8 sioner shall permit the individual to con9 tinue treatment under subparagraph (A) 

10 until such limited time as the Commis11 sioner determines it is administratively fea12 sible, consistent with minimizing disruption 

13 in the individual’s access to health care. 

14 (4) TRANSITION FOR CHIP ELIGIBLES.—An in15 dividual who is eligible for child health assistance 

16 under title XXI of the Social Security Act for a pe17 riod during Y1 shall not be an Exchange-eligible in18 dividual during such period. 

19 (e) EMPLOYERS.— 

20 (1) SMALLEST EMPLOYER.—Subject to para21 graph (5), smallest employers described in this para22 graph are employers with 25 or fewer employees. 

23 (2) SMALLER EMPLOYERS.—Subject to para24 graph (5), smaller employers described in this para25 graph are employers that are not smallest employers 
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1 described in paragraph (1) and have 50 or fewer em2 ployees. 

3 (3) SMALL EMPLOYERS.—Subject to paragraph 

4 (5), small employers described in this paragraph are 

5 employers that are not described in paragraph (1) or 

6 (2) and have 100 or fewer employees. 

7 (4) LARGER EMPLOYERS.— 

8 (A) IN GENERAL.—Beginning with Y3, the 

9 Commissioner may permit employers not de10 scribed in paragraph (1), (2), or (3) to be Ex11 change-eligible employers. 

12 (B) PHASE-IN.—In applying subparagraph 

13 (A), the Commissioner may phase-in the appli14 cation of such subparagraph based on the num15 ber of full-time employees of an employer and 

16 such other considerations as the Commissioner 

17 deems appropriate. 

18 (5) CONTINUING ELIGIBILITY.—Once an em19 ployer is permitted to be an Exchange-eligible em20 ployer under this subsection and enrolls employees 

21 through the Health Insurance Exchange, the em22 ployer shall continue to be treated as an Exchange23 eligible employer for each subsequent plan year re24 gardless of the number of employees involved unless 

25 and until the employer meets the requirement of sec-
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1 tion 411(a) through paragraph (1) of such section 

2 by offering a group health plan and not through of3 fering an Exchange-participating health benefits 

4 plan. 

5 (6) EMPLOYER PARTICIPATION AND CONTRIBU6 TIONS.— 

7 (A) SATISFACTION OF EMPLOYER RESPON8 SIBILITY.—For any year in which an employer 

9 is an Exchange-eligible employer, such employer 

10 may meet the requirements of section 412 with 

11 respect to employees of such employer by offer12 ing such employees the option of enrolling with 

13 Exchange-participating health benefits plans 

14 through the Health Insurance Exchange con15 sistent with the provisions of subtitle B of title 

16 IV. 

17 (B) EMPLOYEE CHOICE.—Any employee 

18 offered Exchange-participating health benefits 

19 plans by the employer of such employee under 

20 subparagraph (A) may choose coverage under 

21 any such plan. That choice includes, with re22 spect to family coverage, coverage of the de23 pendents of such employee. 

24 (7) AFFILIATED GROUPS.—Any employer which 

25 is part of a group of employers who are treated as 
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1 a single employer under subsection (b), (c), (m), or 

2 (o) of section 414 of the Internal Revenue Code of 

3 1986 shall be treated, for purposes of this subtitle, 

4 as a single employer. 

5 (8) TREATMENT OF MULTI-EMPLOYER

6 PLANS.—The plan sponsor of a group health plan 

7 (as defined in section 773(a) of the Employee Re8 tirement Income Security Act of 1974) that is a 

9 multi-employer plan (as defined in section 3(37) of 

10 such Act) may obtain health insurance coverage with 

11 respect to participants in the plan through the Ex12 change to the same extent that an employer not de13 scribed in paragraph (1) or (2) is permitted by the 

14 Commissioner to obtain health insurance coverage 

15 through the Exchange as an Exchange-eligible em16 ployer. 

17 (9) OTHER COUNTING RULES.—The Commis18 sioner shall establish rules relating to how employees 

19 are counted for purposes of carrying out this sub20 section. 

21 (f) SPECIAL SITUATION AUTHORITY.—The Commis22 sioner shall have the authority to establish such rules as 

23 may be necessary to deal with special situations with re24 gard to uninsured individuals and employers participating 

25 as Exchange-eligible individuals and employers, such as 
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1 transition periods for individuals and employers who gain, 

2 or lose, Exchange-eligible participation status, and to es3 tablish grace periods for premium payment. 

4 (g) SURVEYS OF INDIVIDUALS AND EMPLOYERS.— 

5 The Commissioner shall provide for periodic surveys of 

6 Exchange-eligible individuals and employers concerning 

7 satisfaction of such individuals and employers with the 

8 Health Insurance Exchange and Exchange-participating 

9 health benefits plans. 

10 (h) EXCHANGE ACCESS STUDY.— 

11 (1) IN GENERAL.—The Commissioner shall con12 duct a study of access to the Health Insurance Ex13 change for individuals and for employers, including 

14 individuals and employers who are not eligible and 

15 enrolled in Exchange-participating health benefits 

16 plans. The goal of the study is to determine if there 

17 are significant groups and types of individuals and 

18 employers who are not Exchange-eligible individuals 

19 or employers, but who would have improved benefits 

20 and affordability if made eligible for coverage in the 

21 Exchange. 

22 (2) ITEMS INCLUDED IN STUDY.—Such study 

23 also shall examine— 

24 (A) the terms, conditions, and affordability 

25 of group health coverage offered by employers 
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1 and QHBP offering entities outside of the Ex2 change compared to Exchange-participating 

3 health benefits plans; and 

4 (B) the affordability-test standard for ac5 cess of certain employed individuals to coverage 

6 in the Health Insurance Exchange. 

7 (3) REPORT.—Not later than January 1 of Y3, 

8 in Y6, and thereafter, the Commissioner shall sub9 mit to Congress a report on the study conducted 

10 under this subsection and shall include in such re11 port recommendations regarding changes in stand12 ards for Exchange eligibility for individuals and em13 ployers. 

14 SEC. 303. BENEFITS PACKAGE LEVELS. 

15 (a) IN GENERAL.—The Commissioner shall specify 

16 the benefits to be made available under Exchange-partici17 pating health benefits plans during each plan year, con18 sistent with subtitle C of title II and this section. 

19 (b) LIMITATION ON HEALTH BENEFITS PLANS OF20 FERED BY OFFERING ENTITIES.—The Commissioner may 

21 not enter into a contract with a QHBP offering entity 

22 under section 304(c) for the offering of an Exchange-par23 ticipating health benefits plan in a service area unless the 

24 following requirements are met: 
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1 (1) REQUIRED OFFERING OF BASIC PLAN.—The 

2 entity offers only one basic plan for such service 

3 area. 

4 (2) OPTIONAL OFFERING OF ENHANCED

5 PLAN.—If and only if the entity offers a basic plan 

6 for such service area, the entity may offer one en7 hanced plan for such area. 

8 (3) OPTIONAL OFFERING OF PREMIUM PLAN.— 

9 If and only if the entity offers an enhanced plan for 

10 such service area, the entity may offer one premium 

11 plan for such area. 

12 (4) OPTIONAL OFFERING OF PREMIUM-PLUS

13 PLANS.—If and only if the entity offers a premium 

14 plan for such service area, the entity may offer one 

15 or more premium-plus plans for such area. 

16 All such plans may be offered under a single contract with 

17 the Commissioner. 

18 (c) SPECIFICATION OF BENEFIT LEVELS FOR

19 PLANS.— 

20 (1) IN GENERAL.—The Commissioner shall es21 tablish the following standards consistent with this 

22 subsection and title II: 

23 (A) BASIC, ENHANCED, AND PREMIUM

24 PLANS.—Standards for 3 levels of Exchange25 participating health benefits plans: basic, en-
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1 hanced, and premium (in this division referred 

2 to as a ‘‘basic plan’’, ‘‘enhanced plan’’, and 

3 ‘‘premium plan’’, respectively). 

4 (B) PREMIUM-PLUS PLAN BENEFITS.— 

5 Standards for additional benefits that may be 

6 offered, consistent with this subsection and sub7 title C of title II, under a premium plan (such 

8 a plan with additional benefits referred to in 

9 this division as a ‘‘premium-plus plan’’) . 

10 (2) BASIC PLAN.— 

11 (A) IN GENERAL.—A basic plan shall offer 

12 the essential benefits package required under 

13 title II for a qualified health benefits plan with 

14 an actuarial value of 70 percent of the full ac15 tuarial value of the benefits provided under the 

16 reference benefits package. 

17 (B) TIERED COST-SHARING FOR AFFORD18 ABLE CREDIT ELIGIBLE INDIVIDUALS.—In the 

19 case of an affordable credit eligible individual 

20 (as defined in section 342(a)(1)) enrolled in an 

21 Exchange-participating health benefits plan, the 

22 benefits under a basic plan are modified to pro23 vide for the reduced cost-sharing for the income 

24 tier applicable to the individual under section 

25 324(c). 
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1 (3) ENHANCED PLAN.—An enhanced plan shall 

2 offer, in addition to the level of benefits under the 

3 basic plan, a lower level of cost-sharing as provided 

4 under title II consistent with section 223(b)(5)(A). 

5 (4) PREMIUM PLAN.—A premium plan shall 

6 offer, in addition to the level of benefits under the 

7 basic plan, a lower level of cost-sharing as provided 

8 under title II consistent with section 223(b)(5)(B). 

9 (5) PREMIUM-PLUS PLAN.—A premium-plus 

10 plan is a premium plan that also provides additional 

11 benefits, such as adult oral health and vision care, 

12 approved by the Commissioner. The portion of the 

13 premium that is attributable to such additional ben14 efits shall be separately specified. 

15 (6) RANGE OF PERMISSIBLE VARIATION IN

16 COST-SHARING.—The Commissioner shall establish a 

17 permissible range of variation of cost-sharing for 

18 each basic, enhanced, and premium plan, except with 

19 respect to any benefit for which there is no cost20 sharing permitted under the essential benefits pack21 age. Such variation shall permit a variation of not 

22 more than plus (or minus) 10 percent in cost-shar23 ing with respect to each benefit category specified 

24 under section 222. Nothing in this subtitle shall be 

25 construed as prohibiting tiering in cost-sharing, in-
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1 cluding through preferred and participating pro2 viders and prescription drugs. In applying this para3 graph, a health benefits plan may increase the cost4 sharing by 10 percent within each category or tier, 

5 as applicable, and may decrease or eliminate cost6 sharing in any category or tier as compared to the 

7 essential benefits package. 

8 (d) TREATMENT OF STATE BENEFIT MANDATES.— 

9 Insofar as a State requires a health insurance issuer offer10 ing health insurance coverage to include benefits beyond 

11 the essential benefits package, such requirement shall con12 tinue to apply to an Exchange-participating health bene13 fits plan, if the State has entered into an arrangement 

14 satisfactory to the Commissioner to reimburse the Com15 missioner for the amount of any net increase in afford16 ability premium credits under subtitle C as a result of an 

17 increase in premium in basic plans as a result of applica18 tion of such requirement. 

19 SEC. 304. CONTRACTS FOR THE OFFERING OF EXCHANGE20 PARTICIPATING HEALTH BENEFITS PLANS. 

21 (a) CONTRACTING DUTIES.—In carrying out section 

22 301(b)(1) and consistent with this subtitle: 

23 (1) OFFERING ENTITY AND PLAN STAND24 ARDS.—The Commissioner shall— 
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1 (A) establish standards necessary to imple2 ment the requirements of this title and title II 

3 for— 

4 (i) QHBP offering entities for the of5 fering of an Exchange-participating health 

6 benefits plan; and 

7 (ii) Exchange-participating health 

8 benefits plans; and 

9 (B) certify QHBP offering entities and 

10 qualified health benefits plans as meeting such 

11 standards and requirements of this title and 

12 title II for purposes of this subtitle. 

13 (2) SOLICITING AND NEGOTIATING BIDS; CON14 TRACTS.— 

15 (A) BID SOLICITATION.—The Commis16 sioner shall solicit bids from QHBP offering en17 tities for the offering of Exchange-participating 

18 health benefits plans. Such bids shall include 

19 justification for proposed premiums. 

20 (B) BID REVIEW AND NEGOTIATION.—The 

21 Commissioner shall, based upon a review of 

22 such bids including the premiums and their af23 fordability, negotiate with such entities for the 

24 offering of such plans. 
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1 (C) DENIAL OF EXCESSIVE PREMIUMS.— 

2 The Commissioner shall deny excessive pre3 miums and premium increases. 

4 (D) CONTRACTS.—The Commissioner shall 

5 enter into contracts with such entities for the 

6 offering of such plans through the Health In7 surance Exchange under terms (consistent with 

8 this title) negotiated between the Commissioner 

9 and such entities. 

10 (3) FEDERAL ACQUISITION REGULATION.—In 

11 carrying out this subtitle, the Commissioner may 

12 waive such provisions of the Federal Acquisition 

13 Regulation that the Commissioner determines to be 

14 inconsistent with the furtherance of this subtitle, 

15 other than provisions relating to confidentiality of 

16 information. Competitive procedures shall be used in 

17 awarding contracts under this subtitle to the extent 

18 that such procedures are consistent with this sub19 title. 

20 (b) STANDARDS FOR QHBP OFFERING ENTITIES TO

21 OFFER EXCHANGE-PARTICIPATING HEALTH BENEFITS

22 PLANS.—The standards established under subsection 

23 (a)(1)(A) shall require that, in order for a QHBP offering 

24 entity to offer an Exchange-participating health benefits 

25 plan, the entity must meet the following requirements: 
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1 (1) LICENSED.—The entity shall be licensed to 

2 offer health insurance coverage under State law for 

3 each State in which it is offering such coverage. 

4 (2) DATA REPORTING.—The entity shall pro5 vide for the reporting of such information as the 

6 Commissioner may specify, including information 

7 necessary to administer the risk pooling mechanism 

8 described in section 306(b) and information to ad9 dress disparities in health and health care. 

10 (3) AFFORDABILITY.—The entity shall provide 

11 for affordable premiums. 

12 (4) IMPLEMENTING AFFORDABILITY CRED13 ITS.—The entity shall provide for implementation of 

14 the affordability credits provided for enrollees under 

15 subtitle C, including the reduction in cost-sharing 

16 under section 344(c). 

17 (5) ENROLLMENT.—The entity shall accept all 

18 enrollments under this subtitle, subject to such ex19 ceptions (such as capacity limitations) in accordance 

20 with the requirements under title II for a qualified 

21 health benefits plan. The entity shall notify the 

22 Commissioner if the entity projects or anticipates 

23 reaching such a capacity limitation that would result 

24 in a limitation in enrollment. 
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1 (6) RISK POOLING PARTICIPATION.—The entity 

2 shall participate in such risk pooling mechanism as 

3 the Commissioner establishes under section 306(b). 

4 (7) ESSENTIAL COMMUNITY PROVIDERS.—With 

5 respect to the basic plan offered by the entity, the 

6 entity shall include within the plan network those es7 sential community providers, where available, that 

8 serve predominantly low-income, medically-under9 served individuals, such as health care providers de10 fined in section 340B(a)(4) of the Public Health 

11 Service Act and providers described in section 

12 1927(c)(1)(D)(i)(IV) of the Social Security Act (as 

13 amended by section 221 of Public Law 111–8). The 

14 Commissioner shall specify the extent to which and 

15 manner in which the previous sentence shall apply in 

16 the case of a basic plan with respect to which the 

17 Commissioner determines provides substantially all 

18 benefits through a health maintenance organization, 

19 as defined in section 2791(b)(3) of the Public 

20 Health Service Act. This paragraph shall not be con21 strued to require a basic plan to contract with a pro22 vider if such provider refuses to accept the generally 

23 applicable payment rates of such plan. 

24 (8) CULTURALLY AND LINGUISTICALLY APPRO25 PRIATE SERVICES AND COMMUNICATIONS.—The en-
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1 tity shall provide for culturally and linguistically ap2 propriate communication and health services. 

3 (9) SPECIAL RULES WITH RESPECT TO INDIAN

4 ENROLLEES AND INDIAN HEALTH CARE PRO5 VIDERS.— 

6 (A) CHOICE OF PROVIDERS.—The entity 

7 shall— 

8 (i) demonstrate to the satisfaction of 

9 the Commissioner that it has contracted 

10 with a sufficient number of Indian health 

11 care providers to ensure timely access to 

12 covered services furnished by such pro13 viders to individual Indians through the 

14 entity’s Exchange-participating health ben15 efits plan; and 

16 (ii) agree to pay Indian health care 

17 providers, whether such providers are par18 ticipating or nonparticipating providers 

19 with respect to the entity, for covered serv20 ices provided to those enrollees who are eli21 gible to receive services from such pro22 viders at a rate that is not less than the 

23 level and amount of payment which the en24 tity would make for the services of a par-
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1 ticipating provider which is not an Indian 

2 health care provider. 

3 (B) SPECIAL RULE RELATING TO INDIAN

4 HEALTH CARE PROVIDERS.—Provision of serv5 ices by an Indian health care provider exclu6 sively to Indians and their dependents shall not 

7 constitute discrimination under this Act. 

8 (10) PROGRAM INTEGRITY STANDARDS.—The 

9 entity shall establish and operate a program to pro10 tect and promote the integrity of Exchange-partici11 pating health benefits plans it offers, in accordance 

12 with standards and functions established by the 

13 Commissioner. 

14 (11) ADDITIONAL REQUIREMENTS.—The entity 

15 shall comply with other applicable requirements of 

16 this title, as specified by the Commissioner, which 

17 shall include standards regarding billing and collec18 tion practices for premiums and related grace peri19 ods and which may include standards to ensure that 

20 the entity does not use coercive practices to force 

21 providers not to contract with other entities offering 

22 coverage through the Health Insurance Exchange. 

23 (c) CONTRACTS.— 

24 (1) BID APPLICATION.—To be eligible to enter 

25 into a contract under this section, a QHBP offering 
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1 entity shall submit to the Commissioner a bid at 

2 such time, in such manner, and containing such in3 formation as the Commissioner may require. 

4 (2) TERM.—Each contract with a QHBP offer5 ing entity under this section shall be for a term of 

6 not less than one year, but may be made automati7 cally renewable from term to term in the absence of 

8 notice of termination by either party. 

9 (3) ENFORCEMENT OF NETWORK ADEQUACY.— 

10 In the case of a health benefits plan of a QHBP of11 fering entity that uses a provider network, the con12 tract under this section with the entity shall provide 

13 that if— 

14 (A) the Commissioner determines that 

15 such provider network does not meet such 

16 standards as the Commissioner shall establish 

17 under section 215; and 

18 (B) an individual enrolled in such plan re19 ceives an item or service from a provider that 

20 is not within such network; 

21 then any cost-sharing for such item or service shall 

22 be equal to the amount of such cost-sharing that 

23 would be imposed if such item or service was fur24 nished by a provider within such network. 
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1 (4) OVERSIGHT AND ENFORCEMENT RESPON2 SIBILITIES.—The Commissioner shall establish proc3 esses, in coordination with State insurance regu4 lators, to oversee, monitor, and enforce applicable re5 quirements of this title with respect to QHBP offer6 ing entities offering Exchange-participating health 

7 benefits plans, including the marketing of such 

8 plans. Such processes shall include the following: 

9 (A) GRIEVANCE AND COMPLAINT MECHA10 NISMS.—The Commissioner shall establish, in 

11 coordination with State insurance regulators, a 

12 process under which Exchange-eligible individ13 uals and employers may file complaints con14 cerning violations of such standards. 

15 (B) ENFORCEMENT.—In carrying out au16 thorities under this division relating to the 

17 Health Insurance Exchange, the Commissioner 

18 may impose one or more of the intermediate 

19 sanctions described in section 242(d). 

20 (C) TERMINATION.— 

21 (i) IN GENERAL.—The Commissioner 

22 may terminate a contract with a QHBP of23 fering entity under this section for the of24 fering of an Exchange-participating health 

25 benefits plan if such entity fails to comply 
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1 with the applicable requirements of this 

2 title. Any determination by the Commis3 sioner to terminate a contract shall be 

4 made in accordance with formal investiga5 tion and compliance procedures established 

6 by the Commissioner under which— 

7 (I) the Commissioner provides 

8 the entity with the reasonable oppor9 tunity to develop and implement a 

10 corrective action plan to correct the 

11 deficiencies that were the basis of the 

12 Commissioner’s determination; and 

13 (II) the Commissioner provides 

14 the entity with reasonable notice and 

15 opportunity for hearing (including the 

16 right to appeal an initial decision) be17 fore terminating the contract. 

18 (ii) EXCEPTION FOR IMMINENT AND

19 SERIOUS RISK TO HEALTH.—Clause (i) 

20 shall not apply if the Commissioner deter21 mines that a delay in termination, result22 ing from compliance with the procedures 

23 specified in such clause prior to termi24 nation, would pose an imminent and seri25 ous risk to the health of individuals en-
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1 rolled under the qualified health benefits 

2 plan of the QHBP offering entity. 

3 (D) CONSTRUCTION.—Nothing in this sub4 section shall be construed as preventing the ap5 plication of other sanctions under subtitle E of 

6 title II with respect to an entity for a violation 

7 of such a requirement. 

8 (5) SPECIAL RULE RELATED TO COST-SHARING

9 AND INDIAN HEALTH CARE PROVIDERS.—The con10 tract under this section with a QHBP offering entity 

11 for a health benefits plan shall provide that if an in12 dividual who is an Indian is enrolled in such a plan 

13 and such individual receives a covered item or serv14 ice from an Indian health care provider (regardless 

15 of whether such provider is in the plan’s provider 

16 network), the cost-sharing for such item or service 

17 shall be equal to the amount of cost-sharing that 

18 would be imposed if such item or service— 

19 (A) had been furnished by another pro20 vider in the plan’s provider network; or 

21 (B) in the case that the plan has no such 

22 network, was furnished by a non-Indian pro23 vider. 

24 (6) NATIONAL PLAN.—Nothing in this section 

25 shall be construed as preventing the Commissioner 
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1 from entering into a contract under this subsection 

2 with a QHBP offering entity for the offering of a 

3 health benefits plan with the same benefits in every 

4 State so long as such entity is licensed to offer such 

5 plan in each State and the benefits meet the applica6 ble requirements in each such State. 

7 (d) NO DISCRIMINATION ON THE BASIS OF PROVI8 SION OF ABORTION.—No Exchange participating health 

9 benefits plan may discriminate against any individual 

10 health care provider or health care facility because of its 

11 unwillingness to provide, pay for, provide coverage of, or 

12 refer for abortions. 

13 SEC. 305. OUTREACH AND ENROLLMENT OF EXCHANGE-EL14 IGIBLE INDIVIDUALS AND EMPLOYERS IN EX15 CHANGE-PARTICIPATING HEALTH BENEFITS 

16 PLAN. 

17 (a) IN GENERAL.— 

18 (1) OUTREACH.—The Commissioner shall con19 duct outreach activities consistent with subsection 

20 (c), including through use of appropriate entities as 

21 described in paragraph (3) of such subsection, to in22 form and educate individuals and employers about 

23 the Health Insurance Exchange and Exchange-par24 ticipating health benefits plan options. Such out25 reach shall include outreach specific to vulnerable 
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1 populations, such as children, individuals with dis2 abilities, individuals with mental illness, and individ3 uals with other cognitive impairments. 

4 (2) ELIGIBILITY.—The Commissioner shall 

5 make timely determinations of whether individuals 

6 and employers are Exchange-eligible individuals and 

7 employers (as defined in section 302). 

8 (3) ENROLLMENT.—The Commissioner shall es9 tablish and carry out an enrollment process for Ex10 change-eligible individuals and employers, including 

11 at community locations, in accordance with sub12 section (b). 

13 (b) ENROLLMENT PROCESS.— 

14 (1) IN GENERAL.—The Commissioner shall es15 tablish a process consistent with this title for enroll16 ments in Exchange-participating health benefits 

17 plans. Such process shall provide for enrollment 

18 through means such as the mail, by telephone, elec19 tronically, and in person. 

20 (2) ENROLLMENT PERIODS.— 

21 (A) OPEN ENROLLMENT PERIOD.—The 

22 Commissioner shall establish an annual open 

23 enrollment period during which an Exchange-el24 igible individual or employer may elect to enroll 

25 in an Exchange-participating health benefits 
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1 plan for the following plan year and an enroll2 ment period for affordability credits under sub3 title C. Such periods shall be during September 

4 through November of each year, or such other 

5 time that would maximize timeliness of income 

6 verification for purposes of such subtitle. The 

7 open enrollment period shall not be less than 30 

8 days. 

9 (B) SPECIAL ENROLLMENT.—The Com10 missioner shall also provide for special enroll11 ment periods to take into account special cir12 cumstances of individuals and employers, such 

13 as an individual who— 

14 (i) loses acceptable coverage; 

15 (ii) experiences a change in marital or 

16 other dependent status; 

17 (iii) moves outside the service area of 

18 the Exchange-participating health benefits 

19 plan in which the individual is enrolled; or 

20 (iv) experiences a significant change 

21 in income. 

22 (C) ENROLLMENT INFORMATION.—The 

23 Commissioner shall provide for the broad dis24 semination of information to prospective enroll25 ees on the enrollment process, including before 
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1 each open enrollment period. In carrying out 

2 the previous sentence, the Commissioner may 

3 work with other appropriate entities to facilitate 

4 such provision of information. 

5 (3) AUTOMATIC ENROLLMENT FOR NON-MED6 ICAID ELIGIBLE INDIVIDUALS.— 

7 (A) IN GENERAL.—The Commissioner 

8 shall provide for a process under which individ9 uals who are Exchange-eligible individuals de10 scribed in subparagraph (B) are automatically 

11 enrolled under an appropriate Exchange-partici12 pating health benefits plan. Such process may 

13 involve a random assignment or some other 

14 form of assignment that takes into account the 

15 health care providers used by the individual in16 volved or such other relevant factors as the 

17 Commissioner may specify. 

18 (B) SUBSIDIZED INDIVIDUALS DE19 SCRIBED.—An individual described in this sub20 paragraph is an Exchange-eligible individual 

21 who is either of the following: 

22 (i) AFFORDABILITY CREDIT ELIGIBLE

23 INDIVIDUALS.—The individual— 
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1 (I) has applied for, and been de2 termined eligible for, affordability 

3 credits under subtitle C; 

4 (II) has not opted out from re5 ceiving such affordability credit; and 

6 (III) does not otherwise enroll in 

7 another Exchange-participating health 

8 benefits plan. 

9 (ii) INDIVIDUALS ENROLLED IN A

10 TERMINATED PLAN.—The individual who 

11 is enrolled in an Exchange-participating 

12 health benefits plan that is terminated 

13 (during or at the end of a plan year) and 

14 who does not otherwise enroll in another 

15 Exchange-participating health benefits 

16 plan. 

17 (4) DIRECT PAYMENT OF PREMIUMS TO

18 PLANS.—Under the enrollment process, individuals 

19 enrolled in an Exchange-participating health benefits 

20 plan shall pay such plans directly, and not through 

21 the Commissioner or the Health Insurance Ex22 change. 

23 (c) COVERAGE INFORMATION AND ASSISTANCE.— 

24 (1) COVERAGE INFORMATION.—The Commis25 sioner shall provide for the broad dissemination of 
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1 information on Exchange-participating health bene2 fits plans offered under this title. Such information 

3 shall be provided in a comparative manner, and shall 

4 include information on benefits, premiums, cost5 sharing, quality, provider networks, and consumer 

6 satisfaction. 

7 (2) CONSUMER ASSISTANCE WITH CHOICE.—To 

8 provide assistance to Exchange-eligible individuals 

9 and employers, the Commissioner shall— 

10 (A) provide for the operation of a toll-free 

11 telephone hotline to respond to requests for as12 sistance and maintain an Internet Web site 

13 through which individuals may obtain informa14 tion on coverage under Exchange-participating 

15 health benefits plans and file complaints; 

16 (B) develop and disseminate information to 

17 Exchange-eligible enrollees on their rights and 

18 responsibilities; 

19 (C) assist Exchange-eligible individuals in 

20 selecting Exchange-participating health benefits 

21 plans and obtaining benefits through such 

22 plans; and 

23 (D) ensure that the Internet Web site de24 scribed in subparagraph (A) and the informa25 tion described in subparagraph (B) is developed 
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1 using plain language (as defined in section 

2 233(a)(2)). 

3 (3) USE OF OTHER ENTITIES.—In carrying out 

4 this subsection, the Commissioner may work with 

5 other appropriate entities to facilitate the dissemina6 tion of information under this subsection and to pro7 vide assistance as described in paragraph (2). 

8 (d) COVERAGE FOR CERTAIN NEWBORNS UNDER

9 MEDICAID.— 

10 (1) IN GENERAL.—In the case of a child born 

11 in the United States who at the time of birth is not 

12 otherwise covered under acceptable coverage, for the 

13 period of time beginning on the date of birth and 

14 ending on the date the child otherwise is covered 

15 under acceptable coverage (or, if earlier, the end of 

16 the month in which the 60-day period, beginning on 

17 the date of birth, ends), the child shall be deemed— 

18 (A) to be a Medicaid eligible individual for 

19 purposes of this division and Medicaid; and 

20 (B) to be automatically enrolled in Med21 icaid as a traditional Medicaid eligible indi22 vidual (as defined in section 1943(c) of the So23 cial Security Act). 

24 (2) EXTENDED TREATMENT AS MEDICAID ELI25 GIBLE INDIVIDUAL.—In the case of a child described 
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1 in paragraph (1) who at the end of the period re2 ferred to in such paragraph is not otherwise covered 

3 under acceptable coverage, the child shall be deemed 

4 (until such time as the child obtains such coverage 

5 or the State otherwise makes a determination of the 

6 child’s eligibility for medical assistance under its 

7 Medicaid plan pursuant to section 1943(b)(1) of the 

8 Social Security Act) to be a Medicaid eligible indi9 vidual described in section 1902(l)(1)(B) of such 

10 Act. 

11 (e) MEDICAID COVERAGE FOR MEDICAID ELIGIBLE

12 INDIVIDUALS.— 

13 (1) MEDICAID ENROLLMENT OBLIGATION.—An 

14 individual may apply, in the manner described in 

15 section 341(b)(1), for a determination of whether 

16 the individual is a Medicaid-eligible individual. If the 

17 individual is determined to be so eligible, the Com18 missioner, through the Medicaid memorandum of 

19 understanding under paragraph (2), shall provide 

20 for the enrollment of the individual under the State 

21 Medicaid plan in accordance with such memorandum 

22 of understanding. In the case of such an enrollment, 

23 the State shall provide for the same periodic redeter24 mination of eligibility under Medicaid as would oth-
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1 erwise apply if the individual had directly applied for 

2 medical assistance to the State Medicaid agency. 

3 (2) COORDINATED ENROLLMENT WITH STATE

4 THROUGH MEMORANDUM OF UNDERSTANDING.— 

5 The Commissioner, in consultation with the Sec6 retary of Health and Human Services, shall enter 

7 into a memorandum of understanding with each 

8 State with respect to coordinating enrollment of in9 dividuals in Exchange-participating health benefits 

10 plans and under the State’s Medicaid program con11 sistent with this section and to otherwise coordinate 

12 the implementation of the provisions of this division 

13 with respect to the Medicaid program. Such memo14 randum shall permit the exchange of information 

15 consistent with the limitations described in section 

16 1902(a)(7) of the Social Security Act. Nothing in 

17 this section shall be construed as permitting such 

18 memorandum to modify or vitiate any requirement 

19 of a State Medicaid plan. 

20 (f) EFFECTIVE CULTURALLY AND LINGUISTICALLY

21 APPROPRIATE COMMUNICATION.—In carrying out this 

22 section, the Commissioner shall establish effective methods 

23 for communicating in plain language and a culturally and 

24 linguistically appropriate manner. 
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1 (g) ROLE FOR ENROLLMENT AGENTS AND BRO2 KERS.—Nothing in this division shall be construed to af3 fect the role of enrollment agents and brokers under State 

4 law, including with regard to the enrollment of individuals 

5 and employers in qualified health benefits plans including 

6 the public health insurance option. 

7 (h) ASSISTANCE FOR SMALL EMPLOYERS.— 

8 (1) IN GENERAL.—The Commissioner, in con9 sultation with the Small Business Administration, 

10 shall establish and carry out a program to provide 

11 to small employers counseling and technical assist12 ance with respect to the provision of health insur13 ance to employees of such employers through the 

14 Health Insurance Exchange. 

15 (2) DUTIES.—The program established under 

16 paragraph (1) shall include the following services: 

17 (A) Educational activities to increase 

18 awareness of the Health Insurance Exchange 

19 and available small employer health plan op20 tions. 

21 (B) Distribution of information to small 

22 employers with respect to the enrollment and 

23 selection process for health plans available 

24 under the Health Insurance Exchange, includ25 ing standardized comparative information on 
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1 the health plans available under the Health In2 surance Exchange. 

3 (C) Distribution of information to small 

4 employers with respect to available affordability 

5 credits or other financial assistance. 

6 (D) Referrals to appropriate entities of 

7 complaints and questions relating to the Health 

8 Insurance Exchange. 

9 (E) Enrollment and plan selection assist10 ance for employers with respect to the Health 

11 Insurance Exchange. 

12 (F) Responses to questions relating to the 

13 Health Insurance Exchange and the program 

14 established under paragraph (1). 

15 (3) AUTHORITY TO PROVIDE SERVICES DI16 RECTLY OR BY CONTRACT.—The Commissioner may 

17 provide services under paragraph (2) directly or by 

18 contract with nonprofit entities that the Commis19 sioner determines capable of carrying out such serv20 ices. 

21 (4) SMALL EMPLOYER DEFINED.—In this sub22 section, the term ‘‘small employer’’ means an em23 ployer with less than 100 employees. 

24 (i) PARTICIPATION OF SMALL EMPLOYER BENEFIT

25 ARRANGEMENTS.— 
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1 (1) IN GENERAL.—The Commissioner may 

2 enter into contracts with small employer benefit ar3 rangements to provide consumer information, out4 reach, and assistance in the enrollment of small em5 ployers (and their employees) who are members of 

6 such an arrangement under Exchange participating 

7 health benefits plans. 

8 (2) SMALL EMPLOYER BENEFIT ARRANGEMENT

9 DEFINED.—In this subsection, the term ‘‘small em10 ployer benefit arrangement’’ means a not-for-profit 

11 agricultural or other cooperative that— 

12 (A) consists solely of its members and is 

13 operated for the primary purpose of providing 

14 affordable employee benefits to its members; 

15 (B) only has as members small employers 

16 in the same industry or line of business; 

17 (C) has no member that has more than a 

18 5 percent voting interest in the cooperative; and 

19 (D) is governed by a board of directors 

20 elected by its members. 

21 SEC. 306. OTHER FUNCTIONS. 

22 (a) COORDINATION OF AFFORDABILITY CREDITS.— 

23 The Commissioner shall coordinate the distribution of af24 fordability premium and cost-sharing credits under sub-
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1 title C to QHBP offering entities offering Exchange-par2 ticipating health benefits plans. 

3 (b) COORDINATION OF RISK POOLING.—The Com4 missioner shall establish a mechanism whereby there is an 

5 adjustment made of the premium amounts payable among 

6 QHBP offering entities offering Exchange-participating 

7 health benefits plans of premiums collected for such plans 

8 that takes into account (in a manner specified by the Com9 missioner) the differences in the risk characteristics of in10 dividuals and employees enrolled under the different Ex11 change-participating health benefits plans offered by such 

12 entities so as to minimize the impact of adverse selection 

13 of enrollees among the plans offered by such entities. For 

14 purposes of the previous sentence, the Commissioner may 

15 utilize data regarding enrollee demographics, inpatient 

16 and outpatient diagnoses (in a similar manner as such 

17 data are used under parts C and D of title XVIII of the 

18 Social Security Act), and such other information as the 

19 Secretary determines may be necessary, such as the actual 

20 medical costs of enrollees during the previous year. 

21 SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND. 

22 (a) ESTABLISHMENT OF HEALTH INSURANCE EX23 CHANGE TRUST FUND.—There is created within the 

24 Treasury of the United States a trust fund to be known 

25 as the ‘‘Health Insurance Exchange Trust Fund’’ (in this 
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1 section referred to as the ‘‘Trust Fund’’), consisting of 

2 such amounts as may be appropriated or credited to the 

3 Trust Fund under this section or any other provision of 

4 law. 

5 (b) PAYMENTS FROM TRUST FUND.—The Commis6 sioner shall pay from time to time from the Trust Fund 

7 such amounts as the Commissioner determines are nec8 essary to make payments to operate the Health Insurance 

9 Exchange, including payments under subtitle C (relating 

10 to affordability credits). 

11 (c) TRANSFERS TO TRUST FUND.— 

12 (1) DEDICATED PAYMENTS.—There are hereby 

13 appropriated to the Trust Fund amounts equivalent 

14 to the following: 

15 (A) TAXES ON INDIVIDUALS NOT OBTAIN16 ING ACCEPTABLE COVERAGE.—The amounts re17 ceived in the Treasury under section 59B of the 

18 Internal Revenue Code of 1986 (relating to re19 quirement of health insurance coverage for indi20 viduals). 

21 (B) EMPLOYMENT TAXES ON EMPLOYERS

22 NOT PROVIDING ACCEPTABLE COVERAGE.—The 

23 amounts received in the Treasury under sec24 tions 3111(c) and 3221(c) of the Internal Rev-
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1 enue Code of 1986 (relating to employers elect2 ing to not provide health benefits). 

3 (C) EXCISE TAX ON FAILURES TO MEET

4 CERTAIN HEALTH COVERAGE REQUIRE5 MENTS.—The amounts received in the Treasury 

6 under section 4980H(b) (relating to excise tax 

7 with respect to failure to meet health coverage 

8 participation requirements). 

9 (2) APPROPRIATIONS TO COVER GOVERNMENT

10 CONTRIBUTIONS.—There are hereby appropriated, 

11 out of any moneys in the Treasury not otherwise ap12 propriated, to the Trust Fund, an amount equivalent 

13 to the amount of payments made from the Trust 

14 Fund under subsection (b) plus such amounts as are 

15 necessary reduced by the amounts deposited under 

16 paragraph (1). 

17 (d) APPLICATION OF CERTAIN RULES.—Rules simi18 lar to the rules of subchapter B of chapter 98 of the Inter19 nal Revenue Code of 1986 shall apply with respect to the 

20 Trust Fund. 

21 SEC. 308. OPTIONAL OPERATION OF STATE-BASED HEALTH 

22 INSURANCE EXCHANGES. 

23 (a) IN GENERAL.—If— 

24 (1) a State (or group of States, subject to the 

25 approval of the Commissioner) applies to the Com-
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1 missioner for approval of a State-based Health In2 surance Exchange to operate in the State (or group 

3 of States); and 

4 (2) the Commissioner approves such State5 based Health Insurance Exchange, 

6 then, subject to subsections (c) and (d), the State-based 

7 Health Insurance Exchange shall operate, instead of the 

8 Health Insurance Exchange, with respect to such State 

9 (or group of States). The Commissioner shall approve a 

10 State-based Health Insurance Exchange if it meets the re11 quirements for approval under subsection (b). 

12 (b) REQUIREMENTS FOR APPROVAL.— 

13 (1) IN GENERAL.—The Commissioner may not 

14 approve a State-based Health Insurance Exchange 

15 under this section unless the following requirements 

16 are met: 

17 (A) The State-based Health Insurance Ex18 change must demonstrate the capacity to and 

19 provide assurances satisfactory to the Commis20 sioner that the State-based Health Insurance 

21 Exchange will carry out the functions specified 

22 for the Health Insurance Exchange in the State 

23 (or States) involved, including— 

24 (i) negotiating and contracting with 

25 QHBP offering entities for the offering of 
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1 Exchange-participating health benefits 

2 plans, which satisfy the standards and re3 quirements of this title and title II; 

4 (ii) enrolling Exchange-eligible indi5 viduals and employers in such State in 

6 such plans; 

7 (iii) the establishment of sufficient 

8 local offices to meet the needs of Ex9 change-eligible individuals and employers; 

10 (iv) administering affordability credits 

11 under subtitle B using the same meth12 odologies (and at least the same income 

13 verification methods) as would otherwise 

14 apply under such subtitle and at a cost to 

15 the Federal Government which does exceed 

16 the cost to the Federal Government if this 

17 section did not apply; and 

18 (v) enforcement activities consistent 

19 with Federal requirements. 

20 (B) There is no more than one Health In21 surance Exchange operating with respect to any 

22 one State. 

23 (C) The State provides assurances satisfac24 tory to the Commissioner that approval of such 
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1 an Exchange will not result in any net increase 

2 in expenditures to the Federal Government. 

3 (D) The State provides for reporting of 

4 such information as the Commissioner deter5 mines and assurances satisfactory to the Com6 missioner that it will vigorously enforce viola7 tions of applicable requirements. 

8 (E) Such other requirements as the Com9 missioner may specify. 

10 (2) PRESUMPTION FOR CERTAIN STATE-OPER11 ATED EXCHANGES.— 

12 (A) IN GENERAL.—In the case of a State 

13 operating an Exchange prior to January 1, 

14 2010, that seeks to operate the State-based 

15 Health Insurance Exchange under this section, 

16 the Commissioner shall presume that such Ex17 change meets the standards under this section 

18 unless the Commissioner determines, after com19 pletion of the process established under sub20 paragraph (B), that the Exchange does not 

21 comply with such standards. 

22 (B) PROCESS.—The Commissioner shall 

23 establish a process to work with a State de24 scribed in subparagraph (A) to provide assist25 ance necessary to assure that the State’s Ex-
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1 change comes into compliance with the stand2 ards for approval under this section. 

3 (c) CEASING OPERATION.— 

4 (1) IN GENERAL.—A State-based Health Insur5 ance Exchange may, at the option of each State in6 volved, and only after providing timely and reason7 able notice to the Commissioner, cease operation as 

8 such an Exchange, in which case the Health Insur9 ance Exchange shall operate, instead of such State10 based Health Insurance Exchange, with respect to 

11 such State (or States). 

12 (2) TERMINATION; HEALTH INSURANCE EX13 CHANGE RESUMPTION OF FUNCTIONS.—The Com14 missioner may terminate the approval (for some or 

15 all functions) of a State-based Health Insurance Ex16 change under this section if the Commissioner deter17 mines that such Exchange no longer meets the re18 quirements of subsection (b) or is no longer capable 

19 of carrying out such functions in accordance with 

20 the requirements of this subtitle. In lieu of termi21 nating such approval, the Commissioner may tempo22 rarily assume some or all functions of the State23 based Health Insurance Exchange until such time as 

24 the Commissioner determines the State-based 

25 Health Insurance Exchange meets such require-
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1 ments of subsection (b) and is capable of carrying 

2 out such functions in accordance with the require3 ments of this subtitle. 

4 (3) EFFECTIVENESS.—The ceasing or termi5 nation of a State-based Health Insurance Exchange 

6 under this subsection shall be effective in such time 

7 and manner as the Commissioner shall specify. 

8 (d) RETENTION OF AUTHORITY.— 

9 (1) AUTHORITY RETAINED.—Enforcement au10 thorities of the Commissioner shall be retained by 

11 the Commissioner. 

12 (2) DISCRETION TO RETAIN ADDITIONAL AU13 THORITY.—The Commissioner may specify functions 

14 of the Health Insurance Exchange that— 

15 (A) may not be performed by a State16 based Health Insurance Exchange under this 

17 section; or 

18 (B) may be performed by the Commis19 sioner and by such a State-based Health Insur20 ance Exchange. 

21 (e) REFERENCES.—In the case of a State-based 

22 Health Insurance Exchange, except as the Commissioner 

23 may otherwise specify under subsection (d), any references 

24 in this subtitle to the Health Insurance Exchange or to 

25 the Commissioner in the area in which the State-based 
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1 Health Insurance Exchange operates shall be deemed a 

2 reference to the State-based Health Insurance Exchange 

3 and the head of such Exchange, respectively. 

4 (f) FUNDING.—In the case of a State-based Health 

5 Insurance Exchange, there shall be assistance provided for 

6 the operation of such Exchange in the form of a matching 

7 grant with a State share of expenditures required. 

8 SEC. 309. INTERSTATE HEALTH INSURANCE COMPACTS. 

9 (a) IN GENERAL.—Effective January 1, 2015, 2 or 

10 more States may form Health Care Choice Compacts (in 

11 this section referred to as ‘‘compacts’’) to facilitate the 

12 purchase of individual health insurance coverage across 

13 State lines. 

14 (b) MODEL GUIDELINES.—The Secretary of Health 

15 and Human Services (in this section referred to as the 

16 ‘‘Secretary’’) shall consult with the National Association 

17 of Insurance Commissioners (in this section referred to as 

18 ‘‘NAIC’’) to develop not later than January 1, 2014, 

19 model guidelines for the creation of compacts. In devel20 oping such guidelines, the Secretary shall consult with 

21 consumers, health insurance issuers, and other interested 

22 parties. Such guidelines shall— 

23 (1) provide for the sale of health insurance cov24 erage to residents of all compacting States subject to 
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1 the laws and regulations of a primary State des2 ignated by the compacting States; 

3 (2) require health insurance issuers issuing 

4 health insurance coverage in secondary States to 

5 maintain licensure in every such State; 

6 (3) preserve the authority of the State of an in7 dividual’s residence to enforce law relating to— 

8 (A) market conduct; 

9 (B) unfair trade practices; 

10 (C) network adequacy; 

11 (D) consumer protection standards; 

12 (E) grievance and appeals; 

13 (F) fair claims payment requirements; 

14 (G) prompt payment of claims; 

15 (H) rate review; and 

16 (I) fraud. 

17 (4) permit State insurance commissioners and 

18 other State agencies in secondary States access to 

19 the records of a health insurance issuer to the same 

20 extent as if the policy were written in that State; 

21 and 

22 (5) provide for clear and conspicuous disclosure 

23 to consumers that the policy may not be subject to 

24 all the laws and regulations of the State in which 

25 the purchaser resides. 
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1 (c) NO REQUIREMENT TO COMPACT.—Nothing in 

2 this section shall be construed to require a State to join 

3 a compact. 

4 (d) STATE AUTHORITY.—A State may not enter into 

5 a compact under this subsection unless the State enacts 

6 a law after the date of enactment of this Act that specifi7 cally authorizes the State to enter into such compact. 

8 (e) CONSUMER PROTECTIONS.—If a State enters into 

9 a compact it must retain responsibility for the consumer 

10 protections of its residents and its residents retain the 

11 right to bring a claim in a State court in the State in 

12 which the resident resides. 

13 (f) ASSISTANCE TO COMPACTING STATES.— 

14 (1) IN GENERAL.—Beginning January 1, 2015, 

15 the Secretary shall make awards, from amounts ap16 propriated under paragraph (5), to States in the 

17 amount specified in paragraph (2) for the uses de18 scribed in paragraph (3). 

19 (2) AMOUNT SPECIFIED.— 

20 (A) IN GENERAL.—For each fiscal year, 

21 the Secretary shall determine the total amount 

22 that the Secretary will make available for 

23 grants under this subsection. 

24 (B) STATE AMOUNT.—For each State that 

25 is awarded a grant under paragraph (1), the 
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1 amount of such grants shall be based on a for2 mula established by the Secretary, not to exceed 

3 $1 million per State, under which States shall 

4 receive an award in the amount that is based 

5 on the following two components: 

6 (i) A minimum amount for each 

7 State. 

8 (ii) An additional amount based on 

9 population of the State. 

10 (3) USE OF FUNDS.—A State shall use 

11 amounts awarded under this subsection for activities 

12 (including planning activities) related regulating 

13 health insurance coverage sold in secondary States. 

14 (4) RENEWABILITY OF GRANT.—The Secretary 

15 may renew a grant award under paragraph (1) if the 

16 State receiving the grant continues to be a member 

17 of a compact. 

18 (5) AUTHORIZATION OF APPROPRIATIONS.— 

19 There are authorized to be appropriated such sums 

20 as may be necessary to carry out this subsection in 

21 each of fiscal years 2015 through 2020. 

22 SEC. 310. HEALTH INSURANCE COOPERATIVES. 

23 (a) ESTABLISHMENT.—Not later than 6 months after 

24 the date of the enactment of this Act, the Commissioner, 

25 in consultation with the Secretary of the Treasury, shall 
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1 establish a Consumer Operated and Oriented Plan pro2 gram (in this section referred to as the ‘‘CO–OP pro3 gram’’) under which the Commissioner may make grants 

4 and loans for the establishment and initial operation of 

5 not-for-profit, member–run health insurance cooperatives 

6 (in this section individually referred to as a ‘‘cooperative’’) 

7 that provide insurance through the Health Insurance Ex8 change or a State-based Health Insurance Exchange 

9 under section 308. Nothing in this section shall be con10 strued as requiring a State to establish such a cooperative. 

11 (b) START-UP AND SOLVENCY GRANTS AND

12 LOANS.— 

13 (1) IN GENERAL.—Not later than 36 months 

14 after the date of the enactment of this Act, the 

15 Commissioner, acting through the CO–OP program, 

16 may make— 

17 (A) loans (of such period and with such 

18 terms as the Secretary may specify) to coopera19 tives to assist such cooperatives with start-up 

20 costs; and 

21 (B) grants to cooperatives to assist such 

22 cooperatives in meeting State solvency require23 ments in the States in which such cooperative 

24 offers or issues insurance coverage. 
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1 (2) CONDITIONS.—A grant or loan may not be 

2 awarded under this subsection with respect to a co3 operative unless the following conditions are met: 

4 (A) The cooperative is structured as a not5 for-profit, member organization under the law 

6 of each State in which such cooperative offers, 

7 intends to offer, or issues insurance coverage, 

8 with the membership of the cooperative being 

9 made up entirely of beneficiaries of the insur10 ance coverage offered by such cooperative. 

11 (B) The cooperative did not offer insur12 ance on or before July 16, 2009, and the coop13 erative is not an affiliate or successor to an in14 surance company offering insurance on or be15 fore such date. 

16 (C) The governing documents of the coop17 erative incorporate ethical and conflict of inter18 est standards designed to protect against insur19 ance industry involvement and interference in 

20 the governance of the cooperative. 

21 (D) The cooperative is not sponsored by a 

22 State government. 

23 (E) Substantially all of the activities of the 

24 cooperative consist of the issuance of qualified 

25 health benefits plans through the Health Insur-
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1 ance Exchange or a State-based health insur2 ance exchange. 

3 (F) The cooperative is licensed to offer in4 surance in each State in which it offers insur5 ance. 

6 (G) The governance of the cooperative 

7 must be subject to a majority vote of its mem8 bers. 

9 (H) As provided in guidance issued by the 

10 Secretary of Health and Human Services, the 

11 cooperative operates with a strong consumer 

12 focus, including timeliness, responsiveness, and 

13 accountability to members. 

14 (I) Any profits made by the cooperative 

15 are used to lower premiums, improve benefits, 

16 or to otherwise improve the quality of health 

17 care delivered to members. 

18 (3) PRIORITY.—The Commissioner, in making 

19 grants and loans under this subsection, shall give 

20 priority to cooperatives that— 

21 (A) operate on a statewide basis; 

22 (B) use an integrated delivery system; or 

23 (C) have a significant level of financial 

24 support from nongovernmental sources. 
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1 (4) RULES OF CONSTRUCTION.—Nothing in 

2 this section shall be construed to prevent a coopera3 tive established in one State from integrating with a 

4 cooperative established in another State the adminis5 tration, issuance of coverage, or other activities re6 lated to acting as a QHBP offering entity. Nothing 

7 in this section shall be construed as preventing State 

8 governments from taking actions to permit such in9 tegration. 

10 (5) AMORTIZATION OF GRANTS AND LOANS.— 

11 The Secretary shall provide for the repayment of 

12 grants or loans provided under this subsection to the 

13 Treasury in an amortized manner over a 10-year pe14 riod. 

15 (6) REPAYMENT FOR VIOLATIONS OF TERMS OF

16 PROGRAM.—If a cooperative violates the terms of the 

17 CO–OP program and fails to correct the violation 

18 within a reasonable period of time, as determined by 

19 the Commissioner, the cooperative shall repay the 

20 total amount of any loan or grant received by such 

21 cooperative under this section, plus interest (at a 

22 rate determined by the Secretary). 

23 (7) AUTHORIZATION OF APPROPRIATIONS.— 

24 There is authorized to be appropriated 

25 $5,000,000,000 for the period of fiscal years 2010 
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1 through 2014 to provide for grants and loans under 

2 this subsection. 

3 (c) DEFINITIONS.—For purposes of this section: 

4 (1) STATE.—The term ‘‘State’’ means each of 

5 the 50 States and the District of Columbia. 

6 (2) MEMBER.—The term ‘‘member’’, with re7 spect to a cooperative, means an individual who, 

8 after the cooperative offers health insurance cov9 erage, is enrolled in such coverage. 

10 SEC. 311. RETENTION OF DOD AND VA AUTHORITY. 

11 Nothing in this subtitle shall be construed as affect12 ing any authority under title 38, United States Code, or 

13 chapter 55 of title 10, United States Code. 

14 Subtitle B—Public Health 

15 Insurance Option 

16 SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A 

17 PUBLIC HEALTH INSURANCE OPTION AS AN 

18 EXCHANGE-QUALIFIED HEALTH BENEFITS 

19 PLAN. 

20 (a) ESTABLISHMENT.—For years beginning with Y1, 

21 the Secretary of Health and Human Services (in this sub22 title referred to as the ‘‘Secretary’’) shall provide for the 

23 offering of an Exchange-participating health benefits plan 

24 (in this division referred to as the ‘‘public health insurance 

25 option’’) that ensures choice, competition, and stability of 
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1 affordable, high quality coverage throughout the United 

2 States in accordance with this subtitle. In designing the 

3 option, the Secretary’s primary responsibility is to create 

4 a low-cost plan without compromising quality or access to 

5 care. 

6 (b) OFFERING AS AN EXCHANGE-PARTICIPATING

7 HEALTH BENEFITS PLAN.— 

8 (1) EXCLUSIVE TO THE EXCHANGE.—The pub9 lic health insurance option shall only be made avail10 able through the Health Insurance Exchange. 

11 (2) ENSURING A LEVEL PLAYING FIELD.—Con12 sistent with this subtitle, the public health insurance 

13 option shall comply with requirements that are ap14 plicable under this title to an Exchange-participating 

15 health benefits plan, including requirements related 

16 to benefits, benefit levels, provider networks, notices, 

17 consumer protections, and cost-sharing. 

18 (3) PROVISION OF BENEFIT LEVELS.—The pub19 lic health insurance option— 

20 (A) shall offer basic, enhanced, and pre21 mium plans; and 

22 (B) may offer premium-plus plans. 

23 (c) ADMINISTRATIVE CONTRACTING.—The Secretary 

24 may enter into contracts for the purpose of performing 

25 administrative functions (including functions described in 
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1 subsection (a)(4) of section 1874A of the Social Security 

2 Act) with respect to the public health insurance option in 

3 the same manner as the Secretary may enter into con4 tracts under subsection (a)(1) of such section. The Sec5 retary has the same authority with respect to the public 

6 health insurance option as the Secretary has under sub7 sections (a)(1) and (b) of section 1874A of the Social Se8 curity Act with respect to title XVIII of such Act. Con9 tracts under this subsection shall not involve the transfer 

10 of insurance risk to such entity. 

11 (d) OMBUDSMAN.—The Secretary shall establish an 

12 office of the ombudsman for the public health insurance 

13 option which shall have duties with respect to the public 

14 health insurance option similar to the duties of the Medi15 care Beneficiary Ombudsman under section 1808(c)(2) of 

16 the Social Security Act. 

17 (e) DATA COLLECTION.—The Secretary shall collect 

18 such data as may be required to establish premiums and 

19 payment rates for the public health insurance option and 

20 for other purposes under this subtitle, including to im21 prove quality and to reduce racial, ethnic, and other dis22 parities in health and health care. Nothing in this subtitle 

23 may be construed as authorizing the Secretary (or any em24 ployee or contractor) to create or maintain lists of non25 medical personal property. 
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1 (f) TREATMENT OF PUBLIC HEALTH INSURANCE OP2 TION.—With respect to the public health insurance option, 

3 the Secretary shall be treated as a QHBP offering entity 

4 offering an Exchange-participating health benefits plan. 

5 (g) ACCESS TO FEDERAL COURTS.—The provisions 

6 of Medicare (and related provisions of title II of the Social 

7 Security Act) relating to access of Medicare beneficiaries 

8 to Federal courts for the enforcement of rights under 

9 Medicare, including with respect to amounts in con10 troversy, shall apply to the public health insurance option 

11 and individuals enrolled under such option under this title 

12 in the same manner as such provisions apply to Medicare 

13 and Medicare beneficiaries. 

14 SEC. 322. PREMIUMS AND FINANCING. 

15 (a) ESTABLISHMENT OF PREMIUMS.— 

16 (1) IN GENERAL.—The Secretary shall establish 

17 geographically adjusted premium rates for the public 

18 health insurance option— 

19 (A) in a manner that complies with the 

20 premium rules established by the Commissioner 

21 under section 213 for Exchange-participating 

22 health benefits plans; and 

23 (B) at a level sufficient to fully finance the 

24 costs of— 
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1 (i) health benefits provided by the 

2 public health insurance option; and 

3 (ii) administrative costs related to op4 erating the public health insurance option. 

5 (2) CONTINGENCY MARGIN.—In establishing 

6 premium rates under paragraph (1), the Secretary 

7 shall include an appropriate amount for a contin8 gency margin (which shall be not less than 90 days 

9 of estimated claims). Before setting such appropriate 

10 amount for years starting with Y3, the Secretary 

11 shall solicit a recommendation on such amount from 

12 the American Academy of Actuaries. 

13 (b) ACCOUNT.— 

14 (1) ESTABLISHMENT.—There is established in 

15 the Treasury of the United States an Account for 

16 the receipts and disbursements attributable to the 

17 operation of the public health insurance option, in18 cluding the start-up funding under paragraph (2). 

19 Section 1854(g) of the Social Security Act shall 

20 apply to receipts described in the previous sentence 

21 in the same manner as such section applies to pay22 ments or premiums described in such section. 

23 (2) START-UP FUNDING.— 

24 (A) IN GENERAL.—In order to provide for 

25 the establishment of the public health insurance 
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1 option, there is hereby appropriated to the Sec2 retary, out of any funds in the Treasury not 

3 otherwise appropriated, $2,000,000,000. In 

4 order to provide for initial claims reserves be5 fore the collection of premiums, there are here6 by appropriated to the Secretary, out of any 

7 funds in the Treasury not otherwise appro8 priated, such sums as necessary to cover 90 

9 days worth of claims reserves based on pro10 jected enrollment. 

11 (B) AMORTIZATION OF START-UP FUND12 ING.—The Secretary shall provide for the re13 payment of the startup funding provided under 

14 subparagraph (A) to the Treasury in an amor15 tized manner over the 10-year period beginning 

16 with Y1. 

17 (C) LIMITATION ON FUNDING.—Nothing in 

18 this section shall be construed as authorizing 

19 any additional appropriations to the Account, 

20 other than such amounts as are otherwise pro21 vided with respect to other Exchange-partici22 pating health benefits plans. 

23 (3) NO BAILOUTS.—In no case shall the public 

24 health insurance option receive any Federal funds 

25 for purposes of insolvency in any manner similar to 
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1 the manner in which entities receive Federal funding 

2 under the Troubled Assets Relief Program of the 

3 Secretary of the Treasury. 

4 SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES. 

5 (a) NEGOTIATION OF PAYMENT RATES.— 

6 (1) IN GENERAL.—The Secretary shall nego7 tiate payment for the public health insurance option 

8 for health care providers and items and services, in9 cluding prescription drugs, consistent with this sec10 tion and section 324. 

11 (2) MANNER OF NEGOTIATION.—The Secretary 

12 shall negotiate such rates in a manner that results 

13 in payment rates that are not lower, in the aggre14 gate, than rates under title XVIII of the Social Se15 curity Act, and not higher, in the aggregate, than 

16 the average rates paid by other QHBP offering enti17 ties for services and health care providers. 

18 (3) INNOVATIVE PAYMENT METHODS.—Nothing 

19 in this subsection shall be construed as preventing 

20 the use of innovative payment methods such as those 

21 described in section 324 in connection with the nego22 tiation of payment rates under this subsection. 

23 (4) TREATMENT OF CERTAIN STATE WAIV24 ERS.—In the case of any State operating a cost-con25 tainment waiver for health care providers in accord-
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1 ance with section 1814(b)(3) of the Social Security 

2 Act, the Secretary shall provide for payment to such 

3 providers under the public health insurance option 

4 consistent with the provisions and requirements of 

5 that waiver. 

6 (b) ESTABLISHMENT OF A PROVIDER NETWORK.— 

7 (1) IN GENERAL.—Health care providers (in8 cluding physicians and hospitals) participating in 

9 Medicare are participating providers in the public 

10 health insurance option unless they opt out in a 

11 process established by the Secretary consistent with 

12 this subsection. 

13 (2) REQUIREMENTS FOR OPT-OUT PROCESS.— 

14 Under the process established under paragraph 

15 (1)— 

16 (A) providers described in such paragraph 

17 shall be provided at least a 1-year period prior 

18 to the first day of Y1 to opt out of participating 

19 in the public health insurance option; 

20 (B) no provider shall be subject to a pen21 alty for not participating in the public health 

22 insurance option; 

23 (C) the Secretary shall include information 

24 on how providers participating in Medicare who 
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1 chose to opt out of participating in the public 

2 health insurance option may opt back in; and 

3 (D) there shall be an annual enrollment 

4 period in which providers may decide whether 

5 to participate in the public health insurance op6 tion. 

7 (3) RULEMAKING.—Not later than 18 months 

8 before the first day of Y1, the Secretary shall pro9 mulgate rules (pursuant to notice and comment) for 

10 the process described in paragraph (1). 

11 (c) LIMITATIONS ON REVIEW.—There shall be no ad12 ministrative or judicial review of a payment rate or meth13 odology established under this section or under section 

14 324. 

15 SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIV16 ERY SYSTEM REFORM. 

17 (a) IN GENERAL.—For plan years beginning with Y1, 

18 the Secretary may utilize innovative payment mechanisms 

19 and policies to determine payments for items and services 

20 under the public health insurance option. The payment 

21 mechanisms and policies under this section may include 

22 patient-centered medical home and other care manage23 ment payments, accountable care organizations, value24 based purchasing, bundling of services, differential pay-
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1 ment rates, performance or utilization based payments, 

2 partial capitation, and direct contracting with providers. 

3 (b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.— 

4 The Secretary shall design and implement the payment 

5 mechanisms and policies under this section in a manner 

6 that— 

7 (1) seeks to— 

8 (A) improve health outcomes; 

9 (B) reduce health disparities (including ra10 cial, ethnic, and other disparities); 

11 (C) provide efficient and affordable care; 

12 (D) address geographic variation in the 

13 provision of health services; or 

14 (E) prevent or manage chronic illness; and 

15 (2) promotes care that is integrated, patient16 centered, quality, and efficient. 

17 (c) ENCOURAGING THE USE OF HIGH VALUE SERV18 ICES.—To the extent allowed by the benefit standards ap19 plied to all Exchange-participating health benefits plans, 

20 the public health insurance option may modify cost-shar21 ing and payment rates to encourage the use of services 

22 that promote health and value. 

23 (d) PROMOTION OF DELIVERY SYSTEM REFORM.— 

24 The Secretary shall monitor and evaluate the progress of 

25 payment and delivery system reforms under this Act and 
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1 shall seek to implement such reforms subject to the fol2 lowing: 

3 (1) To the extent that the Secretary finds a 

4 payment and delivery system reform successful in 

5 improving quality and reducing costs, the Secretary 

6 shall implement such reform on as large a geo7 graphic scale as practical and economical. 

8 (2) The Secretary may delay the implementa9 tion of such a reform in geographic areas in which 

10 such implementation would place the public health 

11 insurance option at a competitive disadvantage. 

12 (3) The Secretary may prioritize implementa13 tion of such a reform in high cost geographic areas 

14 or otherwise in order to reduce total program costs 

15 or to promote high value care. 

16 (e) NON-UNIFORMITY PERMITTED.—Nothing in this 

17 subtitle shall prevent the Secretary from varying payments 

18 based on different payment structure models (such as ac19 countable care organizations and medical homes) under 

20 the public health insurance option for different geographic 

21 areas. 

22 SEC. 325. PROVIDER PARTICIPATION. 

23 (a) IN GENERAL.—The Secretary shall establish con24 ditions of participation for health care providers under the 

25 public health insurance option. 
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1 (b) LICENSURE OR CERTIFICATION.— 

2 (1) IN GENERAL.—Except as provided in para3 graph (2), the Secretary shall not allow a health 

4 care provider to participate in the public health in5 surance option unless such provider is appropriately 

6 licensed, certified, or otherwise permitted to practice 

7 under State law. 

8 (2) SPECIAL RULE FOR IHS FACILITIES AND

9 PROVIDERS.—The requirements under paragraph (1) 

10 shall not apply to— 

11 (A) a facility that is operated by the In12 dian Health Service; 

13 (B) a facility operated by an Indian Tribe 

14 or tribal organization under the Indian Self-De15 termination Act (Public Law 93–638); 

16 (C) a health care professional employed by 

17 the Indian Health Service; or 

18 (D) a health care professional— 

19 (i) who is employed to provide health 

20 care services in a facility operated by an 

21 Indian Tribe or tribal organization under 

22 the Indian Self-Determination Act; and 

23 (ii) who is licensed or certified in any 

24 State. 

25 (c) PAYMENT TERMS FOR PROVIDERS.— 
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1 (1) PHYSICIANS.—The Secretary shall provide 

2 for the annual participation of physicians under the 

3 public health insurance option, for which payment 

4 may be made for services furnished during the year, 

5 in one of 2 classes: 

6 (A) PREFERRED PHYSICIANS.—Those phy7 sicians who agree to accept the payment under 

8 section 323 (without regard to cost-sharing) as 

9 the payment in full. 

10 (B) PARTICIPATING, NON-PREFERRED

11 PHYSICIANS.—Those physicians who agree not 

12 to impose charges (in relation to the payment 

13 described in section 323 for such physicians) 

14 that exceed the sum of the in-network cost15 sharing plus 15 percent of the total payment 

16 for each item and service. The Secretary shall 

17 reduce the payment described in section 323 for 

18 such physicians. 

19 (2) OTHER PROVIDERS.—The Secretary shall 

20 provide for the participation (on an annual or other 

21 basis specified by the Secretary) of health care pro22 viders (other than physicians) under the public 

23 health insurance option under which payment shall 

24 only be available if the provider agrees to accept the 
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1 payment under section 323 (without regard to cost2 sharing) as the payment in full. 

3 (d) EXCLUSION OF CERTAIN PROVIDERS.—The Sec4 retary shall exclude from participation under the public 

5 health insurance option a health care provider that is ex6 cluded from participation in a Federal health care pro7 gram (as defined in section 1128B(f) of the Social Secu8 rity Act). 

9 SEC. 326. APPLICATION OF FRAUD AND ABUSE PROVI10 SIONS. 

11 Provisions of civil law identified by the Secretary by 

12 regulation, in consultation with the Inspector General of 

13 the Department of Health and Human Services, that im14 pose sanctions with respect to waste, fraud, and abuse 

15 under Medicare, such as sections 3729 through 3733 of 

16 title 31, United States Code (commonly known as the 

17 False Claims Act), shall also apply to the public health 

18 insurance option. 

19 SEC. 327. APPLICATION OF HIPAA INSURANCE REQUIRE20 MENTS. 

21 The requirements of sections 2701 through 2792 of 

22 the Public Health Service Act shall apply to the public 

23 health insurance option in the same manner as they apply 

24 to health insurance coverage offered by a health insurance 

25 issuer in the individual market. 
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1 SEC. 328. APPLICATION OF HEALTH INFORMATION PRI2 VACY, SECURITY, AND ELECTRONIC TRANS3 ACTION REQUIREMENTS. 

4 Part C of title XI of the Social Security Act, relating 

5 to standards for protections against the wrongful disclo6 sure of individually identifiable health information, health 

7 information security, and the electronic exchange of health 

8 care information, shall apply to the public health insur9 ance option in the same manner as such part applies to 

10 other health plans (as defined in section 1171(5) of such 

11 Act). 

12 SEC. 329. ENROLLMENT IN PUBLIC HEALTH INSURANCE 

13 OPTION IS VOLUNTARY. 

14 Nothing in this division shall be construed as requir15 ing anyone to enroll in the public health insurance option. 

16 Enrollment in such option is voluntary. 

17 SEC. 330. ENROLLMENT IN PUBLIC HEALTH INSURANCE 

18 OPTION BY MEMBERS OF CONGRESS. 

19 Notwithstanding any other provision of this Act, 

20 Members of Congress may enroll in the public health in21 surance option. 

22 SEC. 331. REIMBURSEMENT OF SECRETARY OF VETERANS 

23 AFFAIRS. 

24 The Secretary of Health and Human Services shall 

25 seek to enter into a memorandum of understanding with 

26 the Secretary of Veterans Affairs regarding the recovery 
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1 of costs related to non-service-connected care or services 

2 provided by the Secretary of Veterans Affairs to an indi3 vidual covered under the public health insurance option 

4 in a manner consistent with recovery of costs related to 

5 non-service-connected care from private health insurance 

6 plans. 

7 Subtitle C—Individual 

8 Affordability Credits 

9 SEC. 341. AVAILABILITY THROUGH HEALTH INSURANCE EX10 CHANGE. 

11 (a) IN GENERAL.—Subject to the succeeding provi12 sions of this subtitle, in the case of an affordable credit 

13 eligible individual enrolled in an Exchange-participating 

14 health benefits plan— 

15 (1) the individual shall be eligible for, in accord16 ance with this subtitle, affordability credits con17 sisting of— 

18 (A) an affordability premium credit under 

19 section 343 to be applied against the premium 

20 for the Exchange-participating health benefits 

21 plan in which the individual is enrolled; and 

22 (B) an affordability cost-sharing credit 

23 under section 344 to be applied as a reduction 

24 of the cost-sharing otherwise applicable to such 

25 plan; and 
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1 (2) the Commissioner shall pay the QHBP of2 fering entity that offers such plan from the Health 

3 Insurance Exchange Trust Fund the aggregate 

4 amount of affordability credits for all affordable 

5 credit eligible individuals enrolled in such plan. 

6 (b) APPLICATION.— 

7 (1) IN GENERAL.—An Exchange eligible indi8 vidual may apply to the Commissioner through the 

9 Health Insurance Exchange or through another enti10 ty under an arrangement made with the Commis11 sioner, in a form and manner specified by the Com12 missioner. The Commissioner through the Health 

13 Insurance Exchange or through another public enti14 ty under an arrangement made with the Commis15 sioner shall make a determination as to eligibility of 

16 an individual for affordability credits under this sub17 title. The Commissioner shall establish a process 

18 whereby, on the basis of information otherwise avail19 able, individuals may be deemed to be affordable 

20 credit eligible individuals. In carrying this subtitle, 

21 the Commissioner shall establish effective methods 

22 that ensure that individuals with limited English 

23 proficiency are able to apply for affordability credits. 

24 (2) USE OF STATE MEDICAID AGENCIES.—If 

25 the Commissioner determines that a State Medicaid 
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1 agency has the capacity to make a determination of 

2 eligibility for affordability credits under this subtitle 

3 and under the same standards as used by the Com4 missioner, under the Medicaid memorandum of un5 derstanding under section 305(e)(2)— 

6 (A) the State Medicaid agency is author7 ized to conduct such determinations for any Ex8 change-eligible individual who requests such a 

9 determination; and 

10 (B) the Commissioner shall reimburse the 

11 State Medicaid agency for the costs of con12 ducting such determinations. 

13 (3) MEDICAID SCREEN AND ENROLL OBLIGA14 TION.—In the case of an application made under 

15 paragraph (1), there shall be a determination of 

16 whether the individual is a Medicaid-eligible indi17 vidual. If the individual is determined to be so eligi18 ble, the Commissioner, through the Medicaid memo19 randum of understanding under section 305(e)(2), 

20 shall provide for the enrollment of the individual 

21 under the State Medicaid plan in accordance with 

22 such Medicaid memorandum of understanding. In 

23 the case of such an enrollment, the State shall pro24 vide for the same periodic redetermination of eligi25 bility under Medicaid as would otherwise apply if the 
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1 individual had directly applied for medical assistance 

2 to the State Medicaid agency. 

3 (4) APPLICATION AND VERIFICATION OF RE4 QUIREMENT OF CITIZENSHIP OR LAWFUL PRESENCE

5 IN THE UNITED STATES.— 

6 (A) REQUIREMENT.—No individual shall 

7 be an affordable credit eligible individual (as 

8 defined in section 342(a)(1)) unless the indi9 vidual is a citizen or national of the United 

10 States or is lawfully present in a State in the 

11 United States (other than as a nonimmigrant 

12 described in a subparagraph (excluding sub13 paragraphs (K), (T), (U), and (V)) of section 

14 101(a)(15) of the Immigration and Nationality 

15 Act). 

16 (B) DECLARATION OF CITIZENSHIP OR

17 LAWFUL IMMIGRATION STATUS.—No individual 

18 shall be an affordable credit eligible individual 

19 unless there has been a declaration made, in a 

20 form and manner specified by the Health 

21 Choices Commissioner similar to the manner re22 quired under section 1137(d)(1) of the Social 

23 Security Act and under penalty of perjury, that 

24 the individual— 
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1 (i) is a citizen or national of the 

2 United States; or 

3 (ii) is not such a citizen or national 

4 but is lawfully present in a State in the 

5 United States (other than as a non6 immigrant described in a subparagraph 

7 (excluding subparagraphs (K), (T), (U), 

8 and (V)) of section 101(a)(15) of the Im9 migration and Nationality Act). 

10 Such declaration shall be verified in accordance 

11 with subparagraph (C) or (D), as the case may 

12 be. 

13 (C) VERIFICATION PROCESS FOR CITI14 ZENS.— 

15 (i) IN GENERAL.—In the case of an 

16 individual making the declaration described 

17 in subparagraph (B)(i), subject to clause 

18 (ii), section 1902(ee) of the Social Security 

19 Act shall apply to such declaration in the 

20 same manner as such section applies to a 

21 declaration described in paragraph (1) of 

22 such section. 

23 (ii) SPECIAL RULES.—In applying sec24 tion 1902(ee) of such Act under clause 

25 (i)— 
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1 (I) any reference in such section 

2 to a State is deemed a reference to 

3 the Commissioner (or other public en4 tity making the eligibility determina5 tion); 

6 (II) any reference to medical as7 sistance or enrollment under a State 

8 plan is deemed a reference to provi9 sion of affordability credits under this 

10 subtitle; 

11 (III) a reference to a newly en12 rolled individual under paragraph 

13 (2)(A) of such section is deemed a ref14 erence to an individual newly in re15 ceipt of an affordability credit under 

16 this subtitle; 

17 (IV) approval by the Secretary 

18 shall not be required in applying para19 graph (2)(B)(ii) of such section; 

20 (V) paragraph (3) of such section 

21 shall not apply; and 

22 (VI) before the end of Y2, the 

23 Health Choices Commissioner, in con24 sultation with the Commissioner of 

25 Social Security, may extend the peri-
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1 ods specified in paragraph (1)(B)(ii) 

2 of such section. 

3 (D) VERIFICATION PROCESS FOR NONCITI4 ZENS.— 

5 (i) IN GENERAL.—In the case of an 

6 individual making the declaration described 

7 in subparagraph (B)(ii), subject to clause 

8 (ii), the verification procedures of para9 graphs (2) through (5) of section 1137(d) 

10 of the Social Security Act shall apply to 

11 such declaration in the same manner as 

12 such procedures apply to a declaration de13 scribed in paragraph (1) of such section. 

14 (ii) SPECIAL RULES.—In applying 

15 such paragraphs of section 1137(d) of such 

16 Act under clause (i)— 

17 (I) any reference in such para18 graphs to a State is deemed a ref19 erence to the Health Choices Commis20 sioner; and 

21 (II) any reference to benefits 

22 under a program is deemed a ref23 erence to affordability credits under 

24 this subtitle. 
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1 (iii) APPLICATION TO STATE-BASED

2 EXCHANGES.—In the case of the applica3 tion of the verification process under this 

4 subparagraph to a State-based Health In5 surance Exchange approved under section 

6 308, section 1137(e) of such Act shall 

7 apply to the Health Choices Commissioner 

8 in relation to the State. 

9 (E) ANNUAL REPORTS.—The Health 

10 Choices Commissioner shall report to Congress 

11 annually on the number of applicants for af12 fordability credits under this subtitle, their citi13 zenship or immigration status, and the disposi14 tion of their applications. Such report shall be 

15 made publicly available and shall include infor16 mation on— 

17 (i) the number of applicants whose 

18 declaration of citizenship or immigration 

19 status, name, or social security account 

20 number was not consistent with records 

21 maintained by the Commissioner of Social 

22 Security or the Department of Homeland 

23 Security and, of such applicants, the num24 ber who contested the inconsistency and 

25 sought to document their citizenship or im-
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1 migration status, name, or social security 

2 account number or to correct the informa3 tion maintained in such records and, of 

4 those, the results of such contestations; 

5 and 

6 (ii) the administrative costs of con7 ducting the status verification under this 

8 paragraph. 

9 (F) GAO REPORT.—Not later than the end 

10 of Y2, the Comptroller General of the United 

11 States shall submit to the Committee on Ways 

12 and Means, the Committee on Energy and 

13 Commerce, the Committee on Education and 

14 Labor, and the Committee on the Judiciary of 

15 the House of Representatives and the Com16 mittee on Finance, the Committee on Health, 

17 Education, Labor, and Pensions, and the Com18 mittee on the Judiciary of the Senate a report 

19 examining the effectiveness of the citizenship 

20 and immigration verification systems applied 

21 under this paragraph. Such report shall include 

22 an analysis of the following: 

23 (i) The causes of erroneous deter24 minations under such systems. 
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1 (ii) The effectiveness of the processes 

2 used in remedying such erroneous deter3 minations. 

4 (iii) The impact of such systems on 

5 individuals, health care providers, and Fed6 eral and State agencies, including the ef7 fect of erroneous determinations under 

8 such systems. 

9 (iv) The effectiveness of such systems 

10 in preventing ineligible individuals from re11 ceiving for affordability credits. 

12 (v) The characteristics of applicants 

13 described in subparagraph (E)(i). 

14 (G) PROHIBITION OF DATABASE.—Nothing 

15 in this paragraph or the amendments made by 

16 paragraph (6) shall be construed as authorizing 

17 the Health Choices Commissioner or the Com18 missioner of Social Security to establish a data19 base of information on citizenship or immigra20 tion status. 

21 (H) INITIAL FUNDING.— 

22 (i) IN GENERAL.—Out of any funds in 

23 the Treasury not otherwise appropriated, 

24 there is appropriated to the Commissioner 

25 of Social Security $30,000,000, to be avail-
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1 able without fiscal year limit to carry out 

2 this paragraph and section 205(v) of the 

3 Social Security Act. 

4 (ii) FUNDING LIMITATION.—In no 

5 case shall funds from the Social Security 

6 Administration’s Limitation on Adminis7 trative Expenses be used to carry out ac8 tivities related to this paragraph or section 

9 205(v) of the Social Security Act. 

10 (5) AGREEMENT WITH SOCIAL SECURITY COM11 MISSIONER.— 

12 (A) IN GENERAL.—The Health Choices 

13 Commissioner shall enter into and maintain an 

14 agreement described in section 205(v)(2) of the 

15 Social Security Act with the Commissioner of 

16 Social Security. 

17 (B) FUNDING.—The agreement entered 

18 into under subparagraph (A) shall, for each fis19 cal year (beginning with fiscal year 2013)— 

20 (i) provide funds to the Commissioner 

21 of Social Security for the full costs of the 

22 responsibilities of the Commissioner of So23 cial Security under paragraph (4), includ24 ing— 
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1 (I) acquiring, installing, and 

2 maintaining technological equipment 

3 and systems necessary for the fulfill4 ment of the responsibilities of the 

5 Commissioner of Social Security 

6 under paragraph (4), but only that 

7 portion of such costs that are attrib8 utable to such responsibilities; and 

9 (II) responding to individuals 

10 who contest with the Commissioner of 

11 Social Security a reported inconsist12 ency with records maintained by the 

13 Commissioner of Social Security or 

14 the Department of Homeland Security 

15 relating to citizenship or immigration 

16 status, name, or social security ac17 count number under paragraph (4); 

18 (ii) based on an estimating method19 ology agreed to by the Commissioner of 

20 Social Security and the Health Choices 

21 Commissioner, provide such funds, within 

22 10 calendar days of the beginning of the 

23 fiscal year for the first quarter and in ad24 vance for all subsequent quarters in that 

25 fiscal year; and 
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1 (iii) provide for an annual accounting 

2 and reconciliation of the actual costs in3 curred and the funds provided under the 

4 agreement. 

5 (C) REVIEW OF ACCOUNTING.—The an6 nual accounting and reconciliation conducted 

7 pursuant to subparagraph (B)(iii) shall be re8 viewed by the Inspectors General of the Social 

9 Security Administration and the Health Choices 

10 Administration, including an analysis of consist11 ency with the requirements of paragraph (4). 

12 (D) CONTINGENCY.—In any case in which 

13 agreement with respect to the provisions re14 quired under subparagraph (B) for any fiscal 

15 year has not been reached as of the first day 

16 of such fiscal year, the latest agreement with 

17 respect to such provisions shall be deemed in ef18 fect on an interim basis for such fiscal year 

19 until such time as an agreement relating to 

20 such provisions is subsequently reached. In any 

21 case in which an interim agreement applies for 

22 any fiscal year under this subparagraph, the 

23 Commissioner of Social Security shall, not later 

24 than the first day of such fiscal year, notify the 

25 appropriate Committees of the Congress of the 
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1 failure to reach the agreement with respect to 

2 such provisions for such fiscal year. Until such 

3 time as the agreement with respect to such pro4 visions has been reached for such fiscal year, 

5 the Commissioner of Social Security shall, not 

6 later than the end of each 90-day period after 

7 October 1 of such fiscal year, notify such Com8 mittees of the status of negotiations between 

9 such Commissioner and the Health Choices 

10 Commissioner in order to reach such an agree11 ment. 

12 (E) APPLICATION TO PUBLIC ENTITIES

13 ADMINISTERING AFFORDABILITY CREDITS.—If 

14 the Health Choices Commissioner provides for 

15 the conduct of verifications under paragraph 

16 (4) through a public entity, the Health Choices 

17 Commissioner shall require the public entity to 

18 enter into an agreement with the Commissioner 

19 of Social Security which provides the same 

20 terms as the agreement described in this para21 graph (and section 205(v) of the Social Security 

22 Act) between the Health Choices Commissioner 

23 and the Commissioner of Social Security, except 

24 that the Health Choices Commissioner shall be 

25 responsible for providing funds for the Commis-
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1 sioner of Social Security in accordance with 

2 subparagraphs (B) through (D). 

3 (6) AMENDMENTS TO SOCIAL SECURITY ACT.— 

4 (A) COORDINATION OF INFORMATION BE5 TWEEN SOCIAL SECURITY ADMINISTRATION AND

6 HEALTH CHOICES ADMINISTRATION.— 

7 (i) IN GENERAL.—Section 205 of the 

8 Social Security Act (42 U.S.C. 405) is 

9 amended by adding at the end the fol10 lowing new subsection: 

11 ‘‘Coordination of Information With Health Choices 

12 Administration 

13 ‘‘(v)(1) The Health Choices Commissioner may col14 lect and use the names and social security account num15 bers of individuals as required to provide for verification 

16 of citizenship under subsection (b)(4)(C) of section 341 

17 of the Affordable Health Care for America Act in connec18 tion with determinations of eligibility for affordability 

19 credits under such section. 

20 ‘‘(2)(A) The Commissioner of Social Security shall 

21 enter into and maintain an agreement with the Health 

22 Choices Commissioner for the purpose of establishing, in 

23 compliance with the requirements of section 1902(ee) as 

24 applied pursuant to section 341(b)(4)(C) of the Affordable 

25 Health Care for America Act, a program for verifying in-
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1 formation required to be collected by the Health Choices 

2 Commissioner under such section 341(b)(4)(C). 

3 ‘‘(B) The agreement entered into pursuant to sub4 paragraph (A) shall include such safeguards as are nec5 essary to ensure the maintenance of confidentiality of any 

6 information disclosed for purposes of verifying information 

7 described in subparagraph (A) and to provide procedures 

8 for permitting the Health Choices Commissioner to use 

9 the information for purposes of maintaining the records 

10 of the Health Choices Administration. 

11 ‘‘(C) The agreement entered into pursuant to sub12 paragraph (A) shall provide that information provided by 

13 the Commissioner of Social Security to the Health Choices 

14 Commissioner pursuant to the agreement shall be provided 

15 at such time, at such place, and in such manner as the 

16 Commissioner of Social Security determines appropriate. 

17 ‘‘(D) Information provided by the Commissioner of 

18 Social Security to the Health Choices Commissioner pur19 suant to an agreement entered into pursuant to subpara20 graph (A) shall be considered as strictly confidential and 

21 shall be used only for the purposes described in this para22 graph and for carrying out such agreement. Any officer 

23 or employee or former officer or employee of the Health 

24 Choices Commissioner, or any officer or employee or 

25 former officer or employee of a contractor of the Health 
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1 Choices Commissioner, who, without the written authority 

2 of the Commissioner of Social Security, publishes or com3 municates any information in such individual’s possession 

4 by reason of such employment or position as such an offi5 cer shall be guilty of a felony and, upon conviction thereof, 

6 shall be fined or imprisoned, or both, as described in sec7 tion 208. 

8 ‘‘(3) The agreement entered into under paragraph (2) 

9 shall provide for funding to the Commissioner of Social 

10 Security consistent with section 341(b)(5) of Affordable 

11 Health Care for America Act. 

12 ‘‘(4) This subsection shall apply in the case of a pub13 lic entity that conducts verifications under section 

14 341(b)(4) of the Affordable Health Care for America Act 

15 and the obligations of this subsection shall apply to such 

16 an entity in the same manner as such obligations apply 

17 to the Health Choices Commissioner when such Commis18 sioner is conducting such verifications.’’. 

19 (ii) CONFORMING AMENDMENT.—Sec20 tion 205(c)(2)(C) of such Act (42 U.S.C. 

21 405(c)(2)(C)) is amended by adding at the 

22 end the following new clause: 

23 ‘‘(x) For purposes of the administration of the 

24 verification procedures described in section 341(b)(4) of 

25 the Affordable Health Care for America Act, the Health 
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1 Choices Commissioner may collect and use social security 

2 account numbers as provided for in section 205(v)(1).’’. 

3 (B) IMPROVING THE INTEGRITY OF DATA

4 AND EFFECTIVENESS OF SAVE PROGRAM.—Sec5 tion 1137(d) of the Social Security Act (42 

6 U.S.C. 1320b–7(d)) is amended by adding at 

7 the end the following new paragraphs: 

8 ‘‘(6)(A) With respect to the use by any agency of the 

9 system described in subsection (b) by programs specified 

10 in subsection (b) or any other use of such system, the 

11 United States Citizenship and Immigration Services and 

12 any other agency charged with the management of the sys13 tem shall establish appropriate safeguards necessary to 

14 protect and improve the integrity and accuracy of data 

15 relating to individuals by— 

16 ‘‘(i) establishing a process through which such 

17 individuals are provided access to, and the ability to 

18 amend, correct, and update, their own personally 

19 identifiable information contained within the system; 

20 ‘‘(ii) providing a written response, without 

21 undue delay, to any individual who has made such 

22 a request to amend, correct, or update such individ23 ual’s own personally identifiable information con24 tained within the system; and 
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1 ‘‘(iii) developing a written notice for user agen2 cies to provide to individuals who are denied a ben3 efit due to a determination of ineligibility based on 

4 a final verification determination under the system. 

5 ‘‘(B) The notice described in subparagraph (A)(ii) 

6 shall include— 

7 ‘‘(i) information about the reason for such no8 tice; 

9 ‘‘(ii) a description of the right of the recipient 

10 of the notice under subparagraph (A)(i) to contest 

11 such notice; 

12 ‘‘(iii) a description of the right of the recipient 

13 under subparagraph (A)(i) to access and attempt to 

14 amend, correct, and update the recipient’s own per15 sonally identifiable information contained within 

16 records of the system described in paragraph (3); 

17 and 

18 ‘‘(iv) instructions on how to contest such notice 

19 and attempt to correct records of such system relat20 ing to the recipient, including contact information 

21 for relevant agencies.’’. 

22 (C) STREAMLINING ADMINISTRATION OF

23 VERIFICATION PROCESS FOR UNITED STATES

24 CITIZENS.—Section 1902(ee)(2) of the Social 
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1 Security Act (42 U.S.C. 1396a(ee)(2)) is 

2 amended by adding at the end the following: 

3 ‘‘(D) In carrying out the verification procedures 

4 under this subsection with respect to a State, if the Com5 missioner of Social Security determines that the records 

6 maintained by such Commissioner are not consistent with 

7 an individual’s allegation of United States citizenship, 

8 pursuant to procedures which shall be established by the 

9 State in coordination with the Commissioner of Social Se10 curity, the Secretary of Homeland Security, and the Sec11 retary of Health and Human Services— 

12 ‘‘(i) the Commissioner of Social Security shall 

13 inform the State of the inconsistency; 

14 ‘‘(ii) upon being so informed of the inconsist15 ency, the State shall submit the information on the 

16 individual to the Secretary of Homeland Security for 

17 a determination of whether the records of the De18 partment of Homeland Security indicate that the in19 dividual is a citizen; 

20 ‘‘(iii) upon making such determination, the De21 partment of Homeland Security shall inform the 

22 State of such determination; and 

23 ‘‘(iv) information provided by the Commissioner 

24 of Social Security shall be considered as strictly con25 fidential and shall only be used by the State and the 
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1 Secretary of Homeland Security for the purposes of 

2 such verification procedures. 

3 ‘‘(E) Verification of status eligibility pursuant to the 

4 procedures established under this subsection shall be 

5 deemed a verification of status eligibility for purposes of 

6 this title, title XXI, and affordability credits under section 

7 341(b)(4) of the Affordable Health Care for America Act, 

8 regardless of the program in which the individual is apply9 ing for benefits.’’. 

10 (c) USE OF AFFORDABILITY CREDITS.— 

11 (1) IN GENERAL.—In Y1 and Y2 an affordable 

12 credit eligible individual may use an affordability 

13 credit only with respect to a basic plan. 

14 (2) FLEXIBILITY IN PLAN ENROLLMENT AU15 THORIZED.—Beginning with Y3, the Commissioner 

16 shall establish a process to allow an affordability 

17 premium credit under section 343, but not the af18 fordability cost-sharing credit under section 344, to 

19 be used for enrollees in enhanced or premium plans. 

20 In the case of an affordable credit eligible individual 

21 who enrolls in an enhanced or premium plan, the in22 dividual shall be responsible for any difference be23 tween the premium for such plan and the afford24 ability credit amount otherwise applicable if the indi25 vidual had enrolled in a basic plan. 
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1 (d) ACCESS TO DATA.—In carrying out this subtitle, 

2 the Commissioner shall request from the Secretary of the 

3 Treasury consistent with section 6103 of the Internal Rev4 enue Code of 1986 such information as may be required 

5 to carry out this subtitle. 

6 (e) NO CASH REBATES.—In no case shall an afford7 able credit eligible individual receive any cash payment as 

8 a result of the application of this subtitle. 

9 SEC. 342. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL. 

10 (a) DEFINITION.— 

11 (1) IN GENERAL.—For purposes of this divi12 sion, the term ‘‘affordable credit eligible individual’’ 

13 means, subject to subsection (b) and section 346, an 

14 individual who is lawfully present in a State in the 

15 United States (other than as a nonimmigrant de16 scribed in a subparagraph (excluding subparagraphs 

17 (K), (T), (U), and (V)) of section 101(a)(15) of the 

18 Immigration and Nationality Act)— 

19 (A) who is enrolled under an Exchange20 participating health benefits plan and is not en21 rolled under such plan as an employee (or de22 pendent of an employee) through an employer 

23 qualified health benefits plan that meets the re24 quirements of section 412; 
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1 (B) with modified adjusted gross income 

2 below 400 percent of the Federal poverty level 

3 for a family of the size involved; 

4 (C) who is not a Medicaid eligible indi5 vidual, other than an individual during a transi6 tion period under section 302(d)(3)(B)(ii); and 

7 (D) subject to paragraph (3), who is not 

8 enrolled in acceptable coverage (other than an 

9 Exchange-participating health benefits plan). 

10 (2) TREATMENT OF FAMILY.—Except as the 

11 Commissioner may otherwise provide, members of 

12 the same family who are affordable credit eligible in13 dividuals shall be treated as a single affordable cred14 it individual eligible for the applicable credit for such 

15 a family under this subtitle. 

16 (3) SPECIAL RULE FOR INDIANS.—Subpara17 graph (D) of paragraph (1) shall not apply to an in18 dividual who has coverage that is treated as accept19 able coverage for purposes of section 59B(d)(2) of 

20 the Internal Revenue Code of 1986 but is not treat21 ed as acceptable coverage for purposes of this divi22 sion. 

23 (b) LIMITATIONS ON EMPLOYEE AND DEPENDENT

24 DISQUALIFICATION.— 
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1 (1) IN GENERAL.—Subject to paragraph (2), 

2 the term ‘‘affordable credit eligible individual’’ does 

3 not include a full-time employee of an employer if 

4 the employer offers the employee coverage (for the 

5 employee and dependents) as a full-time employee 

6 under a group health plan if the coverage and em7 ployer contribution under the plan meet the require8 ments of section 412. 

9 (2) EXCEPTIONS.— 

10 (A) FOR CERTAIN FAMILY CIR11 CUMSTANCES.—The Commissioner shall estab12 lish such exceptions and special rules in the 

13 case described in paragraph (1) as may be ap14 propriate in the case of a divorced or separated 

15 individual or such a dependent of an employee 

16 who would otherwise be an affordable credit eli17 gible individual. 

18 (B) FOR UNAFFORDABLE EMPLOYER COV19 ERAGE.—Beginning in Y2, in the case of full20 time employees for which the cost of the em21 ployee premium for coverage under a group 

22 health plan would exceed 12 percent of current 

23 modified adjusted gross income (determined by 

24 the Commissioner on the basis of verifiable doc25 umentation), paragraph (1) shall not apply. 
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1 (c) INCOME DEFINED.— 

2 (1) IN GENERAL.—In this title, the term ‘‘in3 come’’ means modified adjusted gross income (as de4 fined in section 59B of the Internal Revenue Code 

5 of 1986). 

6 (2) STUDY OF INCOME DISREGARDS.—The 

7 Commissioner shall conduct a study that examines 

8 the application of income disregards for purposes of 

9 this subtitle. Not later than the first day of Y2, the 

10 Commissioner shall submit to Congress a report on 

11 such study and shall include such recommendations 

12 as the Commissioner determines appropriate. 

13 (d) CLARIFICATION OF TREATMENT OF AFFORD14 ABILITY CREDITS.—Affordability credits under this sub15 title shall not be treated, for purposes of title IV of the 

16 Personal Responsibility and Work Opportunity Reconcili17 ation Act of 1996, to be a benefit provided under section 

18 403 of such title. 

19 SEC. 343. AFFORDABILITY PREMIUM CREDIT. 

20 (a) IN GENERAL.—The affordability premium credit 

21 under this section for an affordable credit eligible indi22 vidual enrolled in an Exchange-participating health bene23 fits plan is in an amount equal to the amount (if any) 

24 by which the reference premium amount specified in sub25 section (c), exceeds the affordable premium amount speci-
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1 fied in subsection (b) for the individual, except that in no 

2 case shall the affordable premium credit exceed the pre3 mium for the plan. 

4 (b) AFFORDABLE PREMIUM AMOUNT.— 

5 (1) IN GENERAL.—The affordable premium 

6 amount specified in this subsection for an individual 

7 for the annual premium in a plan year shall be equal 

8 to the product of— 

9 (A) the premium percentage limit specified 

10 in paragraph (2) for the individual based upon 

11 the individual’s modified adjusted gross income 

12 for the plan year; and 

13 (B) the individual’s modified adjusted 

14 gross income for such plan year. 

15 (2) PREMIUM PERCENTAGE LIMITS BASED ON

16 TABLE.—The Commissioner shall establish premium 

17 percentage limits so that for individuals whose modi18 fied adjusted gross income is within an income tier 

19 specified in the table in subsection (d) such percent20 age limits shall increase, on a sliding scale in a lin21 ear manner, from the initial premium percentage to 

22 the final premium percentage specified in such table 

23 for such income tier. 

24 (c) REFERENCE PREMIUM AMOUNT.—The reference 

25 premium amount specified in this subsection for a plan 
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1 year for an individual in a premium rating area is equal 

2 to the average premium for the 3 basic plans in the area 

3 for the plan year with the lowest premium levels. In com4 puting such amount the Commissioner may exclude plans 

5 with extremely limited enrollments. 

6 (d) TABLE OF PREMIUM PERCENTAGE LIMITS, AC7 TUARIAL VALUE PERCENTAGES, AND OUT-OF-POCKET

8 LIMITS FOR Y1 BASED ON INCOME TIER.— 

9 (1) IN GENERAL.—For purposes of this sub10 title, subject to paragraph (3) and section 346, the 

11 table specified in this subsection is as follows: 

In the case of 

modified adjusted 

gross income (expressed as a percent of FPL) within the following income tier: 

The initial 

premium 

percentage 

is— 

The final 

premium 

percentage 

is— 

The actuarial value 

percentage 

is— 

The out-ofpocket limit 

for Y1 is— 

133% through 

150% 

1.5% 3.0% 97% $500 

150% through 

200% 

3.0% 5.5% 93% $1,000 

200% through 

250% 

5.5% 8.0% 85% $2,000 

250% through 

300% 

8.0% 10.0% 78% $4,000 

300% through 

350% 

10.0% 11.0% 72% $4,500 

350% through 

400% 

11.0% 12.0% 70% $5,000 

12 (2) SPECIAL RULES.—For purposes of applying 

13 the table under paragraph (1): 

14 (A) FOR LOWEST LEVEL OF INCOME.—In 

15 the case of an individual with income that does 

16 not exceed 133 percent of FPL, the individual 
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1 shall be considered to have income that is 133 

2 percent of FPL. 

3 (B) APPLICATION OF HIGHER ACTUARIAL

4 VALUE PERCENTAGE AT TIER TRANSITION

5 POINTS.—If two actuarial value percentages 

6 may be determined with respect to an indi7 vidual, the actuarial value percentage shall be 

8 the higher of such percentages. 

9 (3) INDEXING.—For years after Y1, the Com10 missioner shall adjust the initial and final premium 

11 percentages to maintain the ratio of governmental to 

12 enrollee shares of premiums over time, for each in13 come tier identified in the table in paragraph (1). 

14 SEC. 344. AFFORDABILITY COST-SHARING CREDIT. 

15 (a) IN GENERAL.—The affordability cost-sharing 

16 credit under this section for an affordable credit eligible 

17 individual enrolled in an Exchange-participating health 

18 benefits plan is in the form of the cost-sharing reduction 

19 described in subsection (b) provided under this section for 

20 the income tier in which the individual is classified based 

21 on the individual’s modified adjusted gross income. 

22 (b) COST-SHARING REDUCTIONS.—The Commis23 sioner shall specify a reduction in cost-sharing amounts 

24 and the annual limitation on cost-sharing specified in sec25 tion 222(c)(2)(B) under a basic plan for each income tier 
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1 specified in the table under section 343(d), with respect 

2 to a year, in a manner so that, as estimated by the Com3 missioner— 

4 (1) the actuarial value of the coverage with 

5 such reduced cost-sharing amounts (and the reduced 

6 annual cost-sharing limit) is equal to the actuarial 

7 value percentage (specified in the table under section 

8 343(d) for the income tier involved) of the full actu9 arial value if there were no cost-sharing imposed 

10 under the plan; and 

11 (2) the annual limitation on cost-sharing speci12 fied in section 222(c)(2)(B) is reduced to a level 

13 that does not exceed the maximum out-of-pocket 

14 limit specified in subsection (c). 

15 (c) MAXIMUM OUT-OF-POCKET LIMIT.— 

16 (1) IN GENERAL.—Subject to paragraph (2), 

17 the maximum out-of-pocket limit specified in this 

18 subsection for an individual within an income tier— 

19 (A) for individual coverage— 

20 (i) for Y1 is the out-of-pocket limit 

21 for Y1 specified in subsection (c) in the 

22 table under section 343(d) for the income 

23 tier involved; or 

24 (ii) for a subsequent year is such out25 of-pocket limit for the previous year under 
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1 this subparagraph increased (rounded to 

2 the nearest $10) for each subsequent year 

3 by the percentage increase in the enroll4 ment-weighted average of premium in5 creases for basic plans applicable to such 

6 year; or 

7 (B) for family coverage is twice the max8 imum out-of-pocket limit under subparagraph 

9 (A) for the year involved. 

10 (2) ADJUSTMENT.—The Commissioner shall ad11 just the maximum out-of-pocket limits under para12 graph (1) to ensure that such limits meet the actu13 arial value percentage specified in the table under 

14 section 343(d) for the income tier involved. 

15 (d) DETERMINATION AND PAYMENT OF COST-SHAR16 ING AFFORDABILITY CREDIT.—In the case of an afford17 able credit eligible individual in a tier enrolled in an Ex18 change-participating health benefits plan offered by a 

19 QHBP offering entity, the Commissioner shall provide for 

20 payment to the offering entity of an amount equivalent 

21 to the increased actuarial value of the benefits under the 

22 plan provided under section 303(c)(2)(B) resulting from 

23 the reduction in cost-sharing described in subsections (b) 

24 and (c). 
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1 SEC. 345. INCOME DETERMINATIONS. 

2 (a) IN GENERAL.—In applying this subtitle for an 

3 affordability credit for an individual for a plan year, the 

4 individual’s income shall be the income (as defined in sec5 tion 342(c)) for the individual for the most recent taxable 

6 year (as determined in accordance with rules of the Com7 missioner). The Federal poverty level applied shall be such 

8 level in effect as of the date of the application. 

9 (b) PROGRAM INTEGRITY; INCOME VERIFICATION

10 PROCEDURES.— 

11 (1) PROGRAM INTEGRITY.—The Commissioner 

12 shall take such steps as may be appropriate to en13 sure the accuracy of determinations and redeter14 minations under this subtitle. 

15 (2) INCOME VERIFICATION.— 

16 (A) IN GENERAL.—Upon an initial applica17 tion of an individual for an affordability credit 

18 under this subtitle (or in applying section 

19 342(b)) or upon an application for a change in 

20 the affordability credit based upon a significant 

21 change in modified adjusted gross income de22 scribed in subsection (c)(1)— 

23 (i) the Commissioner shall request 

24 from the Secretary of the Treasury the dis25 closure to the Commissioner of such infor26 mation as may be permitted to verify the 
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1 information contained in such application; 

2 and 

3 (ii) the Commissioner shall use the in4 formation so disclosed to verify such infor5 mation. 

6 (B) ALTERNATIVE PROCEDURES.—The 

7 Commissioner shall establish procedures for the 

8 verification of income for purposes of this sub9 title if no income tax return is available for the 

10 most recent completed tax year. 

11 (c) SPECIAL RULES.— 

12 (1) CHANGES IN INCOME AS A PERCENT OF

13 FPL.—In the case that an individual’s income (ex14 pressed as a percentage of the Federal poverty level 

15 for a family of the size involved) for a plan year is 

16 expected (in a manner specified by the Commis17 sioner) to be significantly different from the income 

18 (as so expressed) used under subsection (a), the 

19 Commissioner shall establish rules requiring an indi20 vidual to report, consistent with the mechanism es21 tablished under paragraph (2), significant changes 

22 in such income (including a significant change in 

23 family composition) to the Commissioner and requir24 ing the substitution of such income for the income 

25 otherwise applicable. 
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1 (2) REPORTING OF SIGNIFICANT CHANGES IN

2 INCOME.—The Commissioner shall establish rules 

3 under which an individual determined to be an af4 fordable credit eligible individual would be required 

5 to inform the Commissioner when there is a signifi6 cant change in the modified adjusted gross income 

7 of the individual (expressed as a percentage of the 

8 FPL for a family of the size involved) and of the in9 formation regarding such change. Such mechanism 

10 shall provide for guidelines that specify the cir11 cumstances that qualify as a significant change, the 

12 verifiable information required to document such a 

13 change, and the process for submission of such in14 formation. If the Commissioner receives new infor15 mation from an individual regarding the modified 

16 adjusted gross income of the individual, the Commis17 sioner shall provide for a redetermination of the in18 dividual’s eligibility to be an affordable credit eligible 

19 individual. 

20 (3) TRANSITION FOR CHIP.—In the case of a 

21 child described in section 302(d)(4), the Commis22 sioner shall establish rules under which the modified 

23 adjusted gross income of the child is deemed to be 

24 no greater than the family income of the child as 
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1 most recently determined before Y1 by the State 

2 under title XXI of the Social Security Act. 

3 (4) STUDY OF GEOGRAPHIC VARIATION IN AP4 PLICATION OF FPL.— 

5 (A) IN GENERAL.—The Secretary of 

6 Health and Human Services shall conduct a 

7 study to examine the feasibility and implication 

8 of adjusting the application of the Federal pov9 erty level under this subtitle for different geo10 graphic areas so as to reflect the variations in 

11 cost-of-living among different areas within the 

12 United States. If the Secretary determines that 

13 an adjustment is feasible, the study should in14 clude a methodology to make such an adjust15 ment. Not later than the first day of Y1, the 

16 Secretary shall submit to Congress a report on 

17 such study and shall include such recommenda18 tions as the Secretary determines appropriate. 

19 (B) INCLUSION OF TERRITORIES.— 

20 (i) IN GENERAL.—The Secretary shall 

21 ensure that the study under subparagraph 

22 (A) covers the territories of the United 

23 States and that special attention is paid to 

24 the disparity that exists among poverty lev25 els and the cost of living in such territories 
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1 and to the impact of such disparity on ef2 forts to expand health coverage and ensure 

3 health care. 

4 (ii) TERRITORIES DEFINED.—In this 

5 subparagraph, the term ‘‘territories of the 

6 United States’’ includes the Common7 wealth of Puerto Rico, the United States 

8 Virgin Islands, Guam, the Northern Mar9 iana Islands, and any other territory or 

10 possession of the United States. 

11 (d) PENALTIES FOR MISREPRESENTATION.—In the 

12 case of an individual who intentionally misrepresents 

13 modified adjusted gross income or the individual fails 

14 (without regard to intent) to disclose to the Commissioner 

15 a significant change in modified adjusted gross income 

16 under subsection (c) in a manner that results in the indi17 vidual becoming an affordable credit eligible individual 

18 when the individual is not or in the amount of the afford19 ability credit exceeding the correct amount— 

20 (1) the individual is liable for repayment of the 

21 amount of the improper affordability credit; and 

22 (2) in the case of such an intentional misrepre23 sentation or other egregious circumstances specified 

24 by the Commissioner, the Commissioner may impose 

25 an additional penalty. 
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1 SEC. 346. SPECIAL RULES FOR APPLICATION TO TERRI2 TORIES. 

3 (a) ONE-TIME ELECTION FOR TREATMENT AND AP4 PLICATION OF FUNDING.— 

5 (1) IN GENERAL.—A territory may elect, in a 

6 form and manner specified by the Commissioner in 

7 consultation with the Secretary of Health and 

8 Human Services and the Secretary of the Treasury 

9 and not later than October 1, 2012, either— 

10 (A) to be treated as a State for purposes 

11 of applying this title and title II; or 

12 (B) not to be so treated but instead, to 

13 have the dollar limitation otherwise applicable 

14 to the territory under subsections (f) and (g) of 

15 section 1108 of the Social Security Act (42 

16 U.S.C. 1308) for a fiscal year increased by a 

17 dollar amount equivalent to the cap amount de18 termined under subsection (c)(2) for the terri19 tory as applied by the Secretary for the fiscal 

20 year involved. 

21 (2) CONDITIONS FOR ACCEPTANCE.—The Com22 missioner has the nonreviewable authority to accept 

23 or reject an election described in paragraph (1)(A). 

24 Any such acceptance is— 

25 (A) contingent upon entering into an 

26 agreement described in subsection (b) between 
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1 the Commissioner and the territory and sub2 section (c); and 

3 (B) subject to the approval of the Sec4 retary of Health and Human Services and the 

5 Secretary of the Treasury and subject to such 

6 other terms and conditions as the Commis7 sioner, in consultation with such Secretaries, 

8 may specify. 

9 (3) DEFAULT RULE.—A territory failing to 

10 make such an election (or having an election under 

11 paragraph (1)(A) not accepted under paragraph (2)) 

12 shall be treated as having made the election de13 scribed in paragraph (1)(B). 

14 (b) AGREEMENT FOR SUBSTITUTION OF PERCENT15 AGES FOR AFFORDABILITY CREDITS.— 

16 (1) NEGOTIATION.—In the case of a territory 

17 making an election under subsection (a)(1)(A) (in 

18 this section referred to as an ‘‘electing territory’’), 

19 the Commissioner, in consultation with the Secre20 taries of Health and Human Services and the Treas21 ury, shall enter into negotiations with the govern22 ment of such territory so that, before Y1, there is 

23 an agreement reached between the parties on the 

24 percentages that shall be applied under paragraph 
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1 (2) for that territory. The Commissioner shall not 

2 enter into such an agreement unless— 

3 (A) payments made under this subtitle 

4 with respect to residents of the territory are 

5 consistent with the cap established under sub6 section (c) for such territory and with sub7 section (d); and 

8 (B) the requirements of paragraphs (3) 

9 and (4) are met. 

10 (2) APPLICATION OF SUBSTITUTE PERCENT11 AGES AND DOLLAR AMOUNTS.—In the case of an 

12 electing territory, there shall be substituted in sec13 tion 342(a)(1)(B) and in the table in section 

14 341(d)(1) for 400 percent, 133 percent, and other 

15 percentages and dollar amounts specified in such 

16 table, such respective percentages and dollar 

17 amounts as are established under the agreement 

18 under paragraph (1) consistent with the following: 

19 (A) NO INCOME GAP BETWEEN MEDICAID

20 AND AFFORDABILITY CREDITS.—The sub21 stituted percentages shall be specified in a man22 ner so as to prevent any gap in coverage for in23 dividuals between income level at which medical 

24 assistance is available through Medicaid and 
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1 the income level at which affordability credits 

2 are available. 

3 (B) ADJUSTMENT FOR OUT-OF-POCKET

4 RESPONSIBILITY FOR PREMIUMS AND COST5 SHARING IN RELATION TO INCOME.—The sub6 stituted percentages of FPL for income tiers 

7 under such table shall be specified in a manner 

8 so that— 

9 (i) affordable credit eligible individ10 uals residing in the territory bear the same 

11 out-of-pocket responsibility for premiums 

12 and cost-sharing in relation to average in13 come for residents in that territory, as 

14 (ii) the out-of-pocket responsibility for 

15 premiums and cost-sharing for affordable 

16 credit eligible individuals residing in the 50 

17 States or the District of Columbia in rela18 tion to average income for such residents. 

19 (3) SPECIAL RULES WITH RESPECT TO APPLI20 CATION OF TAX AND PENALTY PROVISIONS.—The 

21 electing territory shall enact one or more laws under 

22 which provisions similar to the following provisions 

23 apply with respect to such territory: 

24 (A) Section 59B of the Internal Revenue 

25 Code of 1986, except that any resident of the 
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1 territory who is not an affordable credit eligible 

2 individual but who would be an affordable cred3 it eligible individual if such resident were a resi4 dent of one of the 50 States (and any quali5 fying child residing with such individual) may 

6 be treated as covered by acceptable coverage. 

7 (B) Section 4980H of the Internal Rev8 enue Code of 1986 and section 502(c)(11) of 

9 the Employee Retirement Income Security Act 

10 of 1974. 

11 (C) Section 3121(c) of the Internal Rev12 enue Code of 1986. 

13 (4) IMPLEMENTATION OF INSURANCE REFORM

14 AND CONSUMER PROTECTION REQUIREMENTS.—The 

15 electing territory shall enact and implement such 

16 laws and regulations as may be required to apply the 

17 requirements of title II with respect to health insur18 ance coverage offered in the territory. 

19 (c) CAP ON ADDITIONAL EXPENDITURES.— 

20 (1) IN GENERAL.—In entering into an agree21 ment with an electing territory under subsection (b), 

22 the Commissioner shall ensure that the aggregate 

23 expenditures under this subtitle with respect to resi24 dents of such territory during the period beginning 

25 with Y1 and ending with 2019 will not exceed the 
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1 cap amount specified in paragraph (2) for such ter2 ritory. The Commissioner shall adjust from time to 

3 time the percentages applicable under such agree4 ment as needed in order to carry out the previous 

5 sentence. 

6 (2) CAP AMOUNT.— 

7 (A) IN GENERAL.—The cap amount speci8 fied in this paragraph— 

9 (i) for Puerto Rico is $3,700,000,000 

10 increased by the amount (if any) elected 

11 under subparagraph (C); or 

12 (ii) for another territory is the portion 

13 of $300,000,000 negotiated for such terri14 tory under subparagraph (B). 

15 (B) NEGOTIATION FOR CERTAIN TERRI16 TORIES.—The Commissioner in consultation 

17 with the Secretary of Health and Human Serv18 ices shall negotiate with the governments of the 

19 territories (other than Puerto Rico) to allocate 

20 the amount specified in subparagraph (A)(ii) 

21 among such territories. 

22 (C) OPTIONAL SUPPLEMENTATION FOR

23 PUERTO RICO.— 

24 (i) IN GENERAL.—Puerto Rico may 

25 elect, in a form and manner specified by 
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1 the Secretary of Health and Human Serv2 ices in consultation with the Commissioner 

3 to increase the dollar amount specified in 

4 subparagraph (A)(i) by up to 

5 $1,000,000,000. 

6 (ii) OFFSET IN MEDICAID CAP.—If 

7 Puerto Rico makes the election described 

8 in clause (i), the Secretary shall decrease 

9 the dollar limitation otherwise applicable to 

10 Puerto Rico under subsections (f) and (g) 

11 of section 1108 of the Social Security Act 

12 (42 U.S.C. 1308) for a fiscal year by the 

13 additional aggregate payments the Sec14 retary estimates will be payable under this 

15 section for the fiscal year because of such 

16 election. 

17 (d) LIMITATION ON FUNDING.—In no case shall this 

18 section (including the agreement under subsection (b)) 

19 permit— 

20 (1) the obligation of funds for expenditures 

21 under this subtitle for periods beginning on or after 

22 January 1, 2020; or 

23 (2) any increase in the dollar limitation de24 scribed in subsection (a)(1)(B) for any portion of 

25 any fiscal year occurring on or after such date. 
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1 SEC. 347. NO FEDERAL PAYMENT FOR UNDOCUMENTED 

2 ALIENS. 

3 Nothing in this subtitle shall allow Federal payments 

4 for affordability credits on behalf of individuals who are 

5 not lawfully present in the United States. 

6 TITLE IV—SHARED 

7 RESPONSIBILITY 

8 Subtitle A—Individual 

9 Responsibility 

10 SEC. 401. INDIVIDUAL RESPONSIBILITY. 

11 For an individual’s responsibility to obtain acceptable 

12 coverage, see section 59B of the Internal Revenue Code 

13 of 1986 (as added by section 501 of this Act). 

14 Subtitle B—Employer 

15 Responsibility 

16 PART 1—HEALTH COVERAGE PARTICIPATION 

17 REQUIREMENTS 

18 SEC. 411. HEALTH COVERAGE PARTICIPATION REQUIRE19 MENTS. 

20 An employer meets the requirements of this section 

21 if such employer does all of the following: 

22 (1) OFFER OF COVERAGE.—The employer of23 fers each employee individual and family coverage 

24 under a qualified health benefits plan (or under a 

25 current employment-based health plan (within the 
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1 meaning of section 202(b))) in accordance with sec2 tion 412. 

3 (2) CONTRIBUTION TOWARDS COVERAGE.—If 

4 an employee accepts such offer of coverage, the em5 ployer makes timely contributions towards such cov6 erage in accordance with section 412. 

7 (3) CONTRIBUTION IN LIEU OF COVERAGE.— 

8 Beginning with Y2, if an employee declines such 

9 offer but otherwise obtains coverage in an Exchange10 participating health benefits plan (other than by rea11 son of being covered by family coverage as a spouse 

12 or dependent of the primary insured), the employer 

13 shall make a timely contribution to the Health In14 surance Exchange with respect to each such em15 ployee in accordance with section 413. 

16 SEC. 412. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TO17 WARD EMPLOYEE AND DEPENDENT COV18 ERAGE. 

19 (a) IN GENERAL.—An employer meets the require20 ments of this section with respect to an employee if the 

21 following requirements are met: 

22 (1) OFFERING OF COVERAGE.—The employer 

23 offers the coverage described in section 411(1). In 

24 the case of an Exchange-eligible employer, the em25 ployer may offer such coverage either through an 
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1 Exchange-participating health benefits plan or other 

2 than through such a plan. 

3 (2) EMPLOYER REQUIRED CONTRIBUTION.— 

4 The employer timely pays to the issuer of such cov5 erage an amount not less than the employer required 

6 contribution specified in subsection (b) for such cov7 erage. 

8 (3) PROVISION OF INFORMATION.—The em9 ployer provides the Health Choices Commissioner, 

10 the Secretary of Labor, the Secretary of Health and 

11 Human Services, and the Secretary of the Treasury, 

12 as applicable, with such information as the Commis13 sioner may require to ascertain compliance with the 

14 requirements of this section, including the following: 

15 (A) The name, date, and employer identi16 fication number of the employer. 

17 (B) A certification as to whether the em18 ployer offers to its full-time employees (and 

19 their dependents) the opportunity to enroll in a 

20 qualified health benefits plan or a current em21 ployment-based health plan (within the meaning 

22 of section 202(b)). 

23 (C) If the employer certifies that the em24 ployer did offer to its full-time employees (and 

25 their dependents) the opportunity to so enroll— 
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1 (i) the months during the calendar 

2 year for which such coverage was available; 

3 and 

4 (ii) the monthly premium for the low5 est cost option in each of the enrollment 

6 categories under each such plan offered to 

7 employees. 

8 (D) The name, address, and TIN of each 

9 full-time employee during the calendar year and 

10 the months (if any) during which such employee 

11 (and any dependents) were covered under any 

12 such plans. 

13 (4) AUTOENROLLMENT OF EMPLOYEES.—The 

14 employer provides for autoenrollment of the em15 ployee in accordance with subsection (c). 

16 This subsection shall supersede any law of a State which 

17 would prevent automatic payroll deduction of employee 

18 contributions to an employment-based health plan. 

19 (b) REDUCTION OF EMPLOYEE PREMIUMS THROUGH

20 MINIMUM EMPLOYER CONTRIBUTION.— 

21 (1) FULL-TIME EMPLOYEES.—The minimum 

22 employer contribution described in this subsection 

23 for coverage of a full-time employee (and, if any, the 

24 employee’s spouse and qualifying children (as de25 fined in section 152(c) of the Internal Revenue Code 
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1 of 1986)) under a qualified health benefits plan (or 

2 current employment-based health plan) is equal to— 

3 (A) in case of individual coverage, not less 

4 than 72.5 percent of the applicable premium 

5 (as defined in section 4980B(f)(4) of such 

6 Code, subject to paragraph (2)) of the lowest 

7 cost plan offered by the employer that is a 

8 qualified health benefits plan (or is such cur9 rent employment-based health plan); and 

10 (B) in the case of family coverage which 

11 includes coverage of such spouse and children, 

12 not less 65 percent of such applicable premium 

13 of such lowest cost plan. 

14 (2) APPLICABLE PREMIUM FOR EXCHANGE COV15 ERAGE.—In this subtitle, the amount of the applica16 ble premium of the lowest cost plan with respect to 

17 coverage of an employee under an Exchange-partici18 pating health benefits plan is the reference premium 

19 amount under section 343(c) for individual coverage 

20 (or, if elected, family coverage) for the premium rat21 ing area in which the individual or family resides. 

22 (3) MINIMUM EMPLOYER CONTRIBUTION FOR

23 EMPLOYEES OTHER THAN FULL-TIME EMPLOY24 EES.—In the case of coverage for an employee who 

25 is not a full-time employee, the amount of the min-
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1 imum employer contribution under this subsection 

2 shall be a proportion (as determined in accordance 

3 with rules of the Health Choices Commissioner, the 

4 Secretary of Labor, the Secretary of Health and 

5 Human Services, and the Secretary of the Treasury, 

6 as applicable) of the minimum employer contribution 

7 under this subsection with respect to a full-time em8 ployee that reflects the proportion of— 

9 (A) the average weekly hours of employ10 ment of the employee by the employer, to 

11 (B) the minimum weekly hours specified 

12 by the Commissioner for an employee to be a 

13 full-time employee. 

14 (4) SALARY REDUCTIONS NOT TREATED AS EM15 PLOYER CONTRIBUTIONS.—For purposes of this sec16 tion, any contribution on behalf of an employee with 

17 respect to which there is a corresponding reduction 

18 in the compensation of the employee shall not be 

19 treated as an amount paid by the employer. 

20 (c) AUTOMATIC ENROLLMENT FOR EMPLOYER SPON21 SORED HEALTH BENEFITS.— 

22 (1) IN GENERAL.—The requirement of this sub23 section with respect to an employer and an employee 

24 is that the employer automatically enroll such em25 ployee into the employment-based health benefits 
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1 plan for individual coverage under the plan option 

2 with the lowest applicable employee premium. 

3 (2) OPT-OUT.—In no case may an employer 

4 automatically enroll an employee in a plan under 

5 paragraph (1) if such employee makes an affirmative 

6 election to opt out of such plan or to elect coverage 

7 under an employment-based health benefits plan of8 fered by such employer. An employer shall provide 

9 an employee with a 30-day period to make such an 

10 affirmative election before the employer may auto11 matically enroll the employee in such a plan. 

12 (3) NOTICE REQUIREMENTS.— 

13 (A) IN GENERAL.—Each employer de14 scribed in paragraph (1) who automatically en15 rolls an employee into a plan as described in 

16 such paragraph shall provide the employees, 

17 within a reasonable period before the beginning 

18 of each plan year (or, in the case of new em19 ployees, within a reasonable period before the 

20 end of the enrollment period for such a new em21 ployee), written notice of the employees’ rights 

22 and obligations relating to the automatic enroll23 ment requirement under such paragraph. Such 

24 notice must be comprehensive and understood 
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1 by the average employee to whom the automatic 

2 enrollment requirement applies. 

3 (B) INCLUSION OF SPECIFIC INFORMA4 TION.—The written notice under subparagraph 

5 (A) must explain an employee’s right to opt out 

6 of being automatically enrolled in a plan and in 

7 the case that more than one level of benefits or 

8 employee premium level is offered by the em9 ployer involved, the notice must explain which 

10 level of benefits and employee premium level the 

11 employee will be automatically enrolled in the 

12 absence of an affirmative election by the em13 ployee. 

14 SEC. 413. EMPLOYER CONTRIBUTIONS IN LIEU OF COV15 ERAGE. 

16 (a) IN GENERAL.—A contribution is made in accord17 ance with this section with respect to an employee if such 

18 contribution is equal to an amount equal to 8 percent of 

19 the average wages paid by the employer during the period 

20 of enrollment (determined by taking into account all em21 ployees of the employer and in such manner as the Com22 missioner provides, including rules providing for the ap23 propriate aggregation of related employers) but not to ex24 ceed the minimum employer contribution described in sec25 tion 412(b)(1)(A). Any such contribution— 
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1 (1) shall be paid to the Health Choices Com2 missioner for deposit into the Health Insurance Ex3 change Trust Fund; and 

4 (2) shall not be applied against the premium of 

5 the employee under the Exchange-participating 

6 health benefits plan in which the employee is en7 rolled. 

8 (b) SPECIAL RULES FOR SMALL EMPLOYERS.— 

9 (1) IN GENERAL.—In the case of any employer 

10 who is a small employer for any calendar year, sub11 section (a) shall be applied by substituting the appli12 cable percentage determined in accordance with the 

13 following table for ‘‘8 percent’’: 

If the annual payroll of such employer for 

the preceding calendar year: 

The applicable 

percentage is: 

Does not exceed $500,000 ..................................... 0 percent 

Exceeds $500,000, but does not exceed $585,000 2 percent 

Exceeds $585,000, but does not exceed $670,000 4 percent 

Exceeds $670,000, but does not exceed $750,000 6 percent 

14 (2) SMALL EMPLOYER.—For purposes of this 

15 subsection, the term ‘‘small employer’’ means any 

16 employer for any calendar year if the annual payroll 

17 of such employer for the preceding calendar year 

18 does not exceed $750,000. 

19 (3) ANNUAL PAYROLL.—For purposes of this 

20 paragraph, the term ‘‘annual payroll’’ means, with 

21 respect to any employer for any calendar year, the 
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1 aggregate wages paid by the employer during such 

2 calendar year. 

3 (4) AGGREGATION RULES.—Related employers 

4 and predecessors shall be treated as a single em5 ployer for purposes of this subsection. 

6 SEC. 414. AUTHORITY RELATED TO IMPROPER STEERING. 

7 The Health Choices Commissioner (in coordination 

8 with the Secretary of Labor, the Secretary of Health and 

9 Human Services, and the Secretary of the Treasury) shall 

10 have authority to set standards for determining whether 

11 employers or insurers are undertaking any actions to af12 fect the risk pool within the Health Insurance Exchange 

13 by inducing individuals to decline coverage under a quali14 fied health benefits plan (or current employment-based 

15 health plan (within the meaning of section 202(b)) offered 

16 by the employer and instead to enroll in an Exchange-par17 ticipating health benefits plan. An employer violating such 

18 standards shall be treated as not meeting the require19 ments of this section. 

20 SEC. 415. IMPACT STUDY ON EMPLOYER RESPONSIBILITY 

21 REQUIREMENTS. 

22 (a) IN GENERAL.—The Secretary of Labor shall con23 duct a study to examine the effect of the exemptions under 

24 section 512(a) and coverage thresholds under this division 

25 (in this section referred to collectively as ‘‘employer re-
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1 sponsibility requirements’’) on employment-based health 

2 plan sponsorship, generally and within specific industries, 

3 and the effect of such requirements and thresholds on em4 ployers, employment-based health plans, and employees in 

5 each industry. 

6 (b) ANNUAL REPORT.—The Secretary of Labor an7 nually shall submit to Congress a report on findings on 

8 how employer responsibility requirements have impacted 

9 and are likely to impact employers, plans, and employees 

10 during the previous year and projected trends. 

11 (c) LEGISLATIVE RECOMMENDATIONS.—No later 

12 than January 1, 2012, and on an annual basis thereafter, 

13 the Secretary of Labor shall submit legislative rec14 ommendations to Congress to modify the employer respon15 sibility requirements if the Secretary determines that the 

16 requirements are detrimentally affecting or will detrimen17 tally affect employer plan sponsorship or otherwise cre18 ating inequities among employers, health plans, and em19 ployees. The Secretary may also submit such recommenda20 tions as the Secretary determines necessary to improve 

21 and strengthen employment-based health plan sponsor22 ship, employer responsibility, and related proposals that 

23 would enhance the delivery of health care benefits between 

24 employers and employees. 
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1 SEC. 416. STUDY ON EMPLOYER HARDSHIP EXEMPTION. 

2 (a) IN GENERAL.—The Secretary of Labor together 

3 with the Secretary of Treasury, the Secretary of Health 

4 and Human Services, and the Commissioner, shall conduct 

5 a study to examine the impact of the employer responsi6 bility requirements described in section 415(a) and make 

7 a recommendation to Congress about whether an employer 

8 hardship exemption would be appropriate. 

9 (b) ITEMS INCLUDED IN STUDY.—Within such study 

10 the Secretaries and Commissioner shall examine cases 

11 where such employer responsibility requirements may pose 

12 a particular hardship, and specifically look at employers 

13 by industry, profit margin, length of time in business, and 

14 size. In this examination, the economic conditions shall be 

15 considered, including the rate of increase in business costs, 

16 the availability of short-term credit lines, and abilities to 

17 restructure debt. In addition, the study shall examine the 

18 impact an employer hardship waiver could have on employ19 ees. 

20 (c) REPORT.—Not later than January 1, 2012, the 

21 Secretaries and Commissioner shall report to Congress on 

22 their findings and make a recommendation regarding the 

23 need or lack of need for a partial or complete employer 

24 hardship waiver. The Secretaries and Commissioner may 

25 also submit recommendations about the criteria Congress 

26 should include when developing eligibility requirements for 
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1 the employer hardship waiver and what safeguards are 

2 necessary to protect the employees of that employer. 

3 PART 2—SATISFACTION OF HEALTH COVERAGE 

4 PARTICIPATION REQUIREMENTS 

5 SEC. 421. SATISFACTION OF HEALTH COVERAGE PARTICI6 PATION REQUIREMENTS UNDER THE EM7 PLOYEE RETIREMENT INCOME SECURITY 

8 ACT OF 1974. 

9 (a) IN GENERAL.—Subtitle B of title I of the Em10 ployee Retirement Income Security Act of 1974 is amend11 ed by adding at the end the following new part: 

12 ‘‘PART 8—NATIONAL HEALTH COVERAGE 

13 PARTICIPATION REQUIREMENTS 

14 ‘‘SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NA15 TIONAL HEALTH COVERAGE PARTICIPATION 

16 REQUIREMENTS. 

17 ‘‘(a) IN GENERAL.—An employer may make an elec18 tion with the Secretary to be subject to the health coverage 

19 participation requirements. 

20 ‘‘(b) TIME AND MANNER.—An election under sub21 section (a) may be made at such time and in such form 

22 and manner as the Secretary may prescribe. 
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1 ‘‘SEC. 802. TREATMENT OF COVERAGE RESULTING FROM 

2 ELECTION. 

3 ‘‘(a) IN GENERAL.—If an employer makes an election 

4 to the Secretary under section 801— 

5 ‘‘(1) such election shall be treated as the estab6 lishment and maintenance of a group health plan (as 

7 defined in section 733(a)) for purposes of this title, 

8 subject to section 251 of the Affordable Health Care 

9 for America Act; and 

10 ‘‘(2) the health coverage participation require11 ments shall be deemed to be included as terms and 

12 conditions of such plan. 

13 ‘‘(b) PERIODIC INVESTIGATIONS TO DISCOVER NON14 COMPLIANCE.—The Secretary shall regularly audit a rep15 resentative sampling of employers and group health plans 

16 and conduct investigations and other activities under sec17 tion 504 with respect to such sampling of plans so as to 

18 discover noncompliance with the health coverage participa19 tion requirements in connection with such plans. The Sec20 retary shall communicate findings of noncompliance made 

21 by the Secretary under this subsection to the Secretary 

22 of the Treasury and the Health Choices Commissioner. 

23 The Secretary shall take such timely enforcement action 

24 as appropriate to achieve compliance. 

25 ‘‘(c) RECORDKEEPING.—To facilitate the audits de26 scribed in subsection (b), the Secretary shall promulgate 
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1 recordkeeping requirements for employers to account for 

2 both employees of the employer and individuals whom the 

3 employer has not treated as employees of the employer but 

4 with whom the employer, in the course of its trade or busi5 ness, has engaged for the performance of labor or services. 

6 The scope and content of such recordkeeping requirements 

7 shall be determined by the Secretary and shall be designed 

8 to ensure that employees who are not properly treated as 

9 such may be identified and properly treated. 

10 ‘‘SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIRE11 MENTS. 

12 ‘‘For purposes of this part, the term ‘health coverage 

13 participation requirements’ means the requirements of 

14 part 1 of subtitle B of title IV of division A of (as in effect 

15 on the date of the enactment of such Act). 

16 ‘‘SEC. 804. RULES FOR APPLYING REQUIREMENTS. 

17 ‘‘(a) AFFILIATED GROUPS.—In the case of any em18 ployer which is part of a group of employers who are treat19 ed as a single employer under subsection (b), (c), (m), or 

20 (o) of section 414 of the Internal Revenue Code of 1986, 

21 the election under section 801 shall be made by such em22 ployer as the Secretary may provide. Any such election, 

23 once made, shall apply to all members of such group. 
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1 ‘‘(b) SEPARATE ELECTIONS.—Under regulations pre2 scribed by the Secretary, separate elections may be made 

3 under section 801 with respect to— 

4 ‘‘(1) separate lines of business, and 

5 ‘‘(2) full-time employees and employees who are 

6 not full-time employees. 

7 ‘‘SEC. 805. TERMINATION OF ELECTION IN CASES OF SUB8 STANTIAL NONCOMPLIANCE. 

9 ‘‘The Secretary may terminate the election of any em10 ployer under section 801 if the Secretary (in coordination 

11 with the Health Choices Commissioner) determines that 

12 such employer is in substantial noncompliance with the 

13 health coverage participation requirements and shall refer 

14 any such determination to the Secretary of the Treasury 

15 as appropriate. 

16 ‘‘SEC. 806. REGULATIONS. 

17 ‘‘The Secretary may promulgate such regulations as 

18 may be necessary or appropriate to carry out the provi19 sions of this part, in accordance with section 424(a) of 

20 the Affordable Health Care for America Act. The Sec21 retary may promulgate any interim final rules as the Sec22 retary determines are appropriate to carry out this part.’’. 

23 (b) ENFORCEMENT OF HEALTH COVERAGE PARTICI24 PATION REQUIREMENTS.—Section 502 of such Act (29 

25 U.S.C. 1132) is amended— 
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1 (1) in subsection (a)(6), by striking ‘‘para2 graph’’ and all that follows through ‘‘subsection (c)’’ 

3 and inserting ‘‘paragraph (2), (4), (5), (6), (7), (8), 

4 (9), (10), or (11) of subsection (c)’’; and 

5 (2) in subsection (c), by redesignating the sec6 ond paragraph (10) as paragraph (12) and by in7 serting after the first paragraph (10) the following 

8 new paragraph: 

9 ‘‘(11) HEALTH COVERAGE PARTICIPATION RE10 QUIREMENTS.— 

11 ‘‘(A) CIVIL PENALTIES.—In the case of 

12 any employer who fails (during any period with 

13 respect to which an election under section 

14 801(a) is in effect) to satisfy the health cov15 erage participation requirements with respect to 

16 any employee, the Secretary may assess a civil 

17 penalty against the employer of $100 for each 

18 day in the period beginning on the date such 

19 failure first occurs and ending on the date such 

20 failure is corrected. 

21 ‘‘(B) HEALTH COVERAGE PARTICIPATION

22 REQUIREMENTS.—For purposes of this para23 graph, the term ‘health coverage participation 

24 requirements’ has the meaning provided in sec25 tion 803. 
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1 ‘‘(C) LIMITATIONS ON AMOUNT OF PEN2 ALTY.— 

3 ‘‘(i) PENALTY NOT TO APPLY WHERE

4 FAILURE NOT DISCOVERED EXERCISING

5 REASONABLE DILIGENCE.—No penalty 

6 shall be assessed under subparagraph (A) 

7 with respect to any failure during any pe8 riod for which it is established to the satis9 faction of the Secretary that the employer 

10 did not know, or exercising reasonable dili11 gence would not have known, that such 

12 failure existed. 

13 ‘‘(ii) PENALTY NOT TO APPLY TO

14 FAILURES CORRECTED WITHIN 30 DAYS.— 

15 No penalty shall be assessed under sub16 paragraph (A) with respect to any failure 

17 if— 

18 ‘‘(I) such failure was due to rea19 sonable cause and not to willful ne20 glect, and 

21 ‘‘(II) such failure is corrected 

22 during the 30-day period beginning on 

23 the 1st date that the employer knew, 

24 or exercising reasonable diligence 
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1 would have known, that such failure 

2 existed. 

3 ‘‘(iii) OVERALL LIMITATION FOR UN4 INTENTIONAL FAILURES.—In the case of 

5 failures which are due to reasonable cause 

6 and not to willful neglect, the penalty as7 sessed under subparagraph (A) for failures 

8 during any 1-year period shall not exceed 

9 the amount equal to the lesser of— 

10 ‘‘(I) 10 percent of the aggregate 

11 amount paid or incurred by the em12 ployer (or predecessor employer) dur13 ing the preceding 1-year period for 

14 group health plans, or 

15 ‘‘(II) $500,000. 

16 ‘‘(D) ADVANCE NOTIFICATION OF FAILURE

17 PRIOR TO ASSESSMENT.—Before a reasonable 

18 time prior to the assessment of any penalty 

19 under this paragraph with respect to any failure 

20 by an employer, the Secretary shall inform the 

21 employer in writing of such failure and shall 

22 provide the employer information regarding ef23 forts and procedures which may be undertaken 

24 by the employer to correct such failure. 
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1 ‘‘(E) COORDINATION WITH EXCISE TAX.— 

2 Under regulations prescribed in accordance 

3 with section 424 of the Affordable Health Care 

4 for America Act, the Secretary and the Sec5 retary of the Treasury shall coordinate the as6 sessment of penalties under this section in con7 nection with failures to satisfy health coverage 

8 participation requirements with the imposition 

9 of excise taxes on such failures under section 

10 4980H(b) of the Internal Revenue Code of 

11 1986 so as to avoid duplication of penalties 

12 with respect to such failures. 

13 ‘‘(F) DEPOSIT OF PENALTY COLLECTED.— 

14 Any amount of penalty collected under this 

15 paragraph shall be deposited as miscellaneous 

16 receipts in the Treasury of the United States.’’. 

17 (c) CLERICAL AMENDMENTS.—The table of contents 

18 in section 1 of such Act is amended by inserting after the 

19 item relating to section 734 the following new items: 

‘‘PART 8—NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

‘‘Sec. 801. Election of employer to be subject to national health coverage participation requirements. 

‘‘Sec. 802. Treatment of coverage resulting from election. 

‘‘Sec. 803. Health coverage participation requirements. 

‘‘Sec. 804. Rules for applying requirements. 

‘‘Sec. 805. Termination of election in cases of substantial noncompliance. 

‘‘Sec. 806. Regulations.’’. 
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1 (d) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to periods beginning after Decem3 ber 31, 2012. 

4 SEC. 422. SATISFACTION OF HEALTH COVERAGE PARTICI5 PATION REQUIREMENTS UNDER THE INTER6 NAL REVENUE CODE OF 1986. 

7 (a) FAILURE TO ELECT, OR SUBSTANTIALLY COM8 PLY WITH, HEALTH COVERAGE PARTICIPATION RE9 QUIREMENTS.—For employment tax on employers who fail 

10 to elect, or substantially comply with, the health coverage 

11 participation requirements described in part 1, see section 

12 3111(c) of the Internal Revenue Code of 1986 (as added 

13 by section 512 of this Act). 

14 (b) OTHER FAILURES.—For excise tax on other fail15 ures of electing employers to comply with such require16 ments, see section 4980H of the Internal Revenue Code 

17 of 1986 (as added by section 511 of this Act). 

18 SEC. 423. SATISFACTION OF HEALTH COVERAGE PARTICI19 PATION REQUIREMENTS UNDER THE PUBLIC 

20 HEALTH SERVICE ACT. 

21 (a) IN GENERAL.—Part C of title XXVII of the Pub22 lic Health Service Act is amended by adding at the end 

23 the following new section: 
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1 ‘‘SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION 

2 REQUIREMENTS. 

3 ‘‘(a) ELECTION OF EMPLOYER TO BE SUBJECT TO

4 NATIONAL HEALTH COVERAGE PARTICIPATION REQUIRE5 MENTS.— 

6 ‘‘(1) IN GENERAL.—An employer may make an 

7 election with the Secretary to be subject to the 

8 health coverage participation requirements. 

9 ‘‘(2) TIME AND MANNER.—An election under 

10 paragraph (1) may be made at such time and in 

11 such form and manner as the Secretary may pre12 scribe. 

13 ‘‘(b) TREATMENT OF COVERAGE RESULTING FROM

14 ELECTION.— 

15 ‘‘(1) IN GENERAL.—If an employer makes an 

16 election to the Secretary under subsection (a)— 

17 ‘‘(A) such election shall be treated as the 

18 establishment and maintenance of a group 

19 health plan for purposes of this title, subject to 

20 section 251 of the Affordable Health Care for 

21 America Act; and 

22 ‘‘(B) the health coverage participation re23 quirements shall be deemed to be included as 

24 terms and conditions of such plan. 

25 ‘‘(2) PERIODIC INVESTIGATIONS TO DETERMINE

26 COMPLIANCE WITH HEALTH COVERAGE PARTICIPA-
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1 TION REQUIREMENTS.—The Secretary shall regu2 larly audit a representative sampling of employers 

3 and conduct investigations and other activities with 

4 respect to such sampling of employers so as to dis5 cover noncompliance with the health coverage par6 ticipation requirements in connection with such em7 ployers (during any period with respect to which an 

8 election under subsection (a) is in effect). The Sec9 retary shall communicate findings of noncompliance 

10 made by the Secretary under this subsection to the 

11 Secretary of the Treasury and the Health Choices 

12 Commissioner. The Secretary shall take such timely 

13 enforcement action as appropriate to achieve compli14 ance. 

15 ‘‘(3) RECORDKEEPING.—To facilitate the audits 

16 described in subsection (b), the Secretary shall pro17 mulgate recordkeeping requirements for employers 

18 to account for both employees of the employer and 

19 individuals whom the employer has not treated as 

20 employees of the employer but with whom the em21 ployer, in the course of its trade or business, has en22 gaged for the performance of labor or services. The 

23 scope and content of such recordkeeping require24 ments shall be determined by the Secretary and 

25 shall be designed to ensure that employees who are 
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1 not properly treated as such may be identified and 

2 properly treated. 

3 ‘‘(c) HEALTH COVERAGE PARTICIPATION REQUIRE4 MENTS.—For purposes of this section, the term ‘health 

5 coverage participation requirements’ means the require6 ments of part 1 of subtitle B of title IV of division A of 

7 the (as in effect on the date of the enactment of this sec8 tion). 

9 ‘‘(d) SEPARATE ELECTIONS.—Under regulations pre10 scribed by the Secretary, separate elections may be made 

11 under subsection (a) with respect to full-time employees 

12 and employees who are not full-time employees. 

13 ‘‘(e) TERMINATION OF ELECTION IN CASES OF SUB14 STANTIAL NONCOMPLIANCE.—The Secretary may termi15 nate the election of any employer under subsection (a) if 

16 the Secretary (in coordination with the Health Choices 

17 Commissioner) determines that such employer is in sub18 stantial noncompliance with the health coverage participa19 tion requirements and shall refer any such determination 

20 to the Secretary of the Treasury as appropriate. 

21 ‘‘(f) ENFORCEMENT OF HEALTH COVERAGE PAR22 TICIPATION REQUIREMENTS.— 

23 ‘‘(1) CIVIL PENALTIES.—In the case of any em24 ployer who fails (during any period with respect to 

25 which the election under subsection (a) is in effect) 
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1 to satisfy the health coverage participation require2 ments with respect to any employee, the Secretary 

3 may assess a civil penalty against the employer of 

4 $100 for each day in the period beginning on the 

5 date such failure first occurs and ending on the date 

6 such failure is corrected. 

7 ‘‘(2) LIMITATIONS ON AMOUNT OF PENALTY.— 

8 ‘‘(A) PENALTY NOT TO APPLY WHERE

9 FAILURE NOT DISCOVERED EXERCISING REA10 SONABLE DILIGENCE.—No penalty shall be as11 sessed under paragraph (1) with respect to any 

12 failure during any period for which it is estab13 lished to the satisfaction of the Secretary that 

14 the employer did not know, or exercising rea15 sonable diligence would not have known, that 

16 such failure existed. 

17 ‘‘(B) PENALTY NOT TO APPLY TO FAIL18 URES CORRECTED WITHIN 30 DAYS.—No pen19 alty shall be assessed under paragraph (1) with 

20 respect to any failure if— 

21 ‘‘(i) such failure was due to reason22 able cause and not to willful neglect, and 

23 ‘‘(ii) such failure is corrected during 

24 the 30-day period beginning on the 1st 

25 date that the employer knew, or exercising 
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1 reasonable diligence would have known, 

2 that such failure existed. 

3 ‘‘(C) OVERALL LIMITATION FOR UNINTEN4 TIONAL FAILURES.—In the case of failures 

5 which are due to reasonable cause and not to 

6 willful neglect, the penalty assessed under para7 graph (1) for failures during any 1-year period 

8 shall not exceed the amount equal to the lesser 

9 of— 

10 ‘‘(i) 10 percent of the aggregate 

11 amount paid or incurred by the employer 

12 (or predecessor employer) during the pre13 ceding taxable year for group health plans, 

14 or 

15 ‘‘(ii) $500,000. 

16 ‘‘(3) ADVANCE NOTIFICATION OF FAILURE

17 PRIOR TO ASSESSMENT.—Before a reasonable time 

18 prior to the assessment of any penalty under para19 graph (1) with respect to any failure by an em20 ployer, the Secretary shall inform the employer in 

21 writing of such failure and shall provide the em22 ployer information regarding efforts and procedures 

23 which may be undertaken by the employer to correct 

24 such failure. 
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1 ‘‘(4) ACTIONS TO ENFORCE ASSESSMENTS.— 

2 The Secretary may bring a civil action in any Dis3 trict Court of the United States to collect any civil 

4 penalty under this subsection. 

5 ‘‘(5) COORDINATION WITH EXCISE TAX.— 

6 Under regulations prescribed in accordance with sec7 tion 424 of the Affordable Health Care for America 

8 Act, the Secretary and the Secretary of the Treasury 

9 shall coordinate the assessment of penalties under 

10 paragraph (1) in connection with failures to satisfy 

11 health coverage participation requirements with the 

12 imposition of excise taxes on such failures under sec13 tion 4980H(b) of the Internal Revenue Code of 

14 1986 so as to avoid duplication of penalties with re15 spect to such failures. 

16 ‘‘(6) DEPOSIT OF PENALTY COLLECTED.—Any 

17 amount of penalty collected under this subsection 

18 shall be deposited as miscellaneous receipts in the 

19 Treasury of the United States. 

20 ‘‘(g) REGULATIONS.—The Secretary may promulgate 

21 such regulations as may be necessary or appropriate to 

22 carry out the provisions of this section, in accordance with 

23 section 424(a) of the Affordable Health Care for America 

24 Act. The Secretary may promulgate any interim final rules 
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1 as the Secretary determines are appropriate to carry out 

2 this section.’’. 

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

4 subsection (a) shall apply to periods beginning after De5 cember 31, 2012. 

6 SEC. 424. ADDITIONAL RULES RELATING TO HEALTH COV7 ERAGE PARTICIPATION REQUIREMENTS. 

8 (a) ASSURING COORDINATION.—The officers con9 sisting of the Secretary of Labor, the Secretary of the 

10 Treasury, the Secretary of Health and Human Services, 

11 and the Health Choices Commissioner shall ensure, 

12 through the execution of an interagency memorandum of 

13 understanding among such officers, that— 

14 (1) regulations, rulings, and interpretations 

15 issued by such officers relating to the same matter 

16 over which two or more of such officers have respon17 sibility under subpart B of part 8 of subtitle B of 

18 title I of the Employee Retirement Income Security 

19 Act of 1974, section 4980H of the Internal Revenue 

20 Code of 1986, and section 2793 of the Public Health 

21 Service Act are administered so as to have the same 

22 effect at all times; and 

23 (2) coordination of policies relating to enforcing 

24 the same requirements through such officers in 

25 order to have a coordinated enforcement strategy 
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1 that avoids duplication of enforcement efforts and 

2 assigns priorities in enforcement. 

3 (b) MULTIEMPLOYER PLANS.—In the case of a group 

4 health plan that is a multiemployer plan (as defined in 

5 section 3(37) of the Employee Retirement Income Secu6 rity Act of 1974), the regulations prescribed in accordance 

7 with subsection (a) by the officers referred to in subsection 

8 (a) shall provide for the application of the health coverage 

9 participation requirements to the plan sponsor and con10 tributing employers of such plan. For purposes of this di11 vision, contributions made pursuant to a collective bar12 gaining agreement or other agreement to such a group 

13 health plan shall be treated as amounts paid by the em14 ployer. 
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1 TITLE V—AMENDMENTS TO IN2 TERNAL REVENUE CODE OF 

3 1986 

4 Subtitle A—Provisions Relating to 

5 Health Care Reform 

6 PART 1—SHARED RESPONSIBILITY 

7 Subpart A—Individual Responsibility 

8 SEC. 501. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE 

9 HEALTH CARE COVERAGE. 

10 (a) IN GENERAL.—Subchapter A of chapter 1 of the 

11 Internal Revenue Code of 1986 is amended by adding at 

12 the end the following new part: 

13 ‘‘PART VIII—HEALTH CARE RELATED TAXES 

‘‘SUBPART A. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE

COVERAGE. 

14 ‘‘Subpart A—Tax on Individuals Without Acceptable 

15 Health Care Coverage 

‘‘Sec. 59B. Tax on individuals without acceptable health care coverage. 

16 ‘‘SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE 

17 HEALTH CARE COVERAGE. 

18 ‘‘(a) TAX IMPOSED.—In the case of any individual 

19 who does not meet the requirements of subsection (d) at 

20 any time during the taxable year, there is hereby imposed 

21 a tax equal to 2.5 percent of the excess of— 

22 ‘‘(1) the taxpayer’s modified adjusted gross in23 come for the taxable year, over 
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1 ‘‘(2) the amount of gross income specified in 

2 section 6012(a)(1) with respect to the taxpayer. 

3 ‘‘(b) LIMITATIONS.— 

4 ‘‘(1) TAX LIMITED TO AVERAGE PREMIUM.— 

5 ‘‘(A) IN GENERAL.—The tax imposed 

6 under subsection (a) with respect to any tax7 payer for any taxable year shall not exceed the 

8 applicable national average premium for such 

9 taxable year. 

10 ‘‘(B) APPLICABLE NATIONAL AVERAGE

11 PREMIUM.— 

12 ‘‘(i) IN GENERAL.—For purposes of 

13 subparagraph (A), the ‘applicable national 

14 average premium’ means, with respect to 

15 any taxable year, the average premium (as 

16 determined by the Secretary, in coordina17 tion with the Health Choices Commis18 sioner) for self-only coverage under a basic 

19 plan which is offered in a Health Insur20 ance Exchange for the calendar year in 

21 which such taxable year begins. 

22 ‘‘(ii) FAILURE TO PROVIDE COVERAGE

23 FOR MORE THAN ONE INDIVIDUAL.—In the 

24 case of any taxpayer who fails to meet the 

25 requirements of subsection (d) with respect 
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1 to more than one individual during the tax2 able year, clause (i) shall be applied by 

3 substituting ‘family coverage’ for ‘self-only 

4 coverage’. 

5 ‘‘(2) PRORATION FOR PART YEAR FAILURES.— 

6 The tax imposed under subsection (a) with respect 

7 to any taxpayer for any taxable year shall not exceed 

8 the amount which bears the same ratio to the 

9 amount of tax so imposed (determined without re10 gard to this paragraph and after application of para11 graph (1)) as— 

12 ‘‘(A) the aggregate periods during such 

13 taxable year for which such individual failed to 

14 meet the requirements of subsection (d), bears 

15 to 

16 ‘‘(B) the entire taxable year. 

17 ‘‘(c) EXCEPTIONS.— 

18 ‘‘(1) DEPENDENTS.—Subsection (a) shall not 

19 apply to any individual for any taxable year if a de20 duction is allowable under section 151 with respect 

21 to such individual to another taxpayer for any tax22 able year beginning in the same calendar year as 

23 such taxable year. 
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1 ‘‘(2) NONRESIDENT ALIENS.—Subsection (a) 

2 shall not apply to any individual who is a non3 resident alien. 

4 ‘‘(3) INDIVIDUALS RESIDING OUTSIDE UNITED

5 STATES.—Any qualified individual (as defined in 

6 section 911(d)) (and any qualifying child residing 

7 with such individual) shall be treated for purposes of 

8 this section as covered by acceptable coverage during 

9 the period described in subparagraph (A) or (B) of 

10 section 911(d)(1), whichever is applicable. 

11 ‘‘(4) INDIVIDUALS RESIDING IN POSSESSIONS

12 OF THE UNITED STATES.—Any individual who is a 

13 bona fide resident of any possession of the United 

14 States (as determined under section 937(a)) for any 

15 taxable year (and any qualifying child residing with 

16 such individual) shall be treated for purposes of this 

17 section as covered by acceptable coverage during 

18 such taxable year. 

19 ‘‘(5) RELIGIOUS CONSCIENCE EXEMPTION.— 

20 ‘‘(A) IN GENERAL.—Subsection (a) shall 

21 not apply to any individual (and any qualifying 

22 child residing with such individual) for any pe23 riod if such individual has in effect an exemp24 tion which certifies that such individual is a 

25 member of a recognized religious sect or divi-
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1 sion thereof described in section 1402(g)(1) and 

2 an adherent of established tenets or teachings 

3 of such sect or division as described in such sec4 tion. 

5 ‘‘(B) EXEMPTION.—An application for the 

6 exemption described in subparagraph (A) shall 

7 be filed with the Secretary at such time and in 

8 such form and manner as the Secretary may 

9 prescribe. The Secretary may treat an applica10 tion for exemption under section 1402(g)(1) as 

11 an application for exemption under this section, 

12 or may otherwise coordinate applications under 

13 such sections, as the Secretary determines ap14 propriate. Any such exemption granted by the 

15 Secretary shall be effective for such period as 

16 the Secretary determines appropriate. 

17 ‘‘(d) ACCEPTABLE COVERAGE REQUIREMENT.— 

18 ‘‘(1) IN GENERAL.—The requirements of this 

19 subsection are met with respect to any individual for 

20 any period if such individual (and each qualifying 

21 child of such individual) is covered by acceptable 

22 coverage at all times during such period. 

23 ‘‘(2) ACCEPTABLE COVERAGE.—For purposes 

24 of this section, the term ‘acceptable coverage’ means 

25 any of the following: 
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1 ‘‘(A) QUALIFIED HEALTH BENEFITS PLAN

2 COVERAGE.—Coverage under a qualified health 

3 benefits plan (as defined in section 100(c) of 

4 the Affordable Health Care for America Act). 

5 ‘‘(B) GRANDFATHERED HEALTH INSUR6 ANCE COVERAGE; COVERAGE UNDER GRAND7 FATHERED EMPLOYMENT-BASED HEALTH

8 PLAN.—Coverage under a grandfathered health 

9 insurance coverage (as defined in subsection (a) 

10 of section 202 of the Affordable Health Care 

11 for America Act) or under a current employ12 ment-based health plan (within the meaning of 

13 subsection (b) of such section). 

14 ‘‘(C) MEDICARE.—Coverage under part A 

15 of title XVIII of the Social Security Act. 

16 ‘‘(D) MEDICAID.—Coverage for medical as17 sistance under title XIX of the Social Security 

18 Act. 

19 ‘‘(E) MEMBERS OF THE ARMED FORCES

20 AND DEPENDENTS (INCLUDING TRICARE).— 

21 Coverage under chapter 55 of title 10, United 

22 States Code, including similar coverage fur23 nished under section 1781 of title 38 of such 

24 Code. 
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1 ‘‘(F) VA.—Coverage under the veteran’s 

2 health care program under chapter 17 of title 

3 38, United States Code. 

4 ‘‘(G) MEMBERS OF INDIAN TRIBES.— 

5 Health care services made available through the 

6 Indian Health Service, a tribal organization (as 

7 defined in section 4 of the Indian Health Care 

8 Improvement Act), or an urban Indian organi9 zation (as defined in such section) to members 

10 of an Indian tribe (as defined in such section). 

11 ‘‘(H) OTHER COVERAGE.—Such other 

12 health benefits coverage as the Secretary, in co13 ordination with the Health Choices Commis14 sioner, recognizes for purposes of this sub15 section. 

16 ‘‘(e) OTHER DEFINITIONS AND SPECIAL RULES.— 

17 ‘‘(1) QUALIFYING CHILD.—For purposes of this 

18 section, the term ‘qualifying child’ has the meaning 

19 given such term by section 152(c). With respect to 

20 any period during which health coverage for a child 

21 must be provided by an individual pursuant to a 

22 child support order, such child shall be treated as a 

23 qualifying child of such individual (and not as a 

24 qualifying child of any other individual). 
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1 ‘‘(2) BASIC PLAN.—For purposes of this sec2 tion, the term ‘basic plan’ has the meaning given 

3 such term under section 100(c) of the Affordable 

4 Health Care for America Act. 

5 ‘‘(3) HEALTH INSURANCE EXCHANGE.—For 

6 purposes of this section, the term ‘Health Insurance 

7 Exchange’ has the meaning given such term under 

8 section 100(c) of the Affordable Health Care for 

9 America Act, including any State-based health insur10 ance exchange approved for operation under section 

11 308 of such Act. 

12 ‘‘(4) FAMILY COVERAGE.—For purposes of this 

13 section, the term ‘family coverage’ means any cov14 erage other than self-only coverage. 

15 ‘‘(5) MODIFIED ADJUSTED GROSS INCOME.— 

16 For purposes of this section, the term ‘modified ad17 justed gross income’ means adjusted gross income 

18 increased by— 

19 ‘‘(A) any amount excluded from gross in20 come under section 911, and 

21 ‘‘(B) any amount of interest received or 

22 accrued by the taxpayer during the taxable year 

23 which is exempt from tax. 

24 ‘‘(6) NOT TREATED AS TAX IMPOSED BY THIS

25 CHAPTER FOR CERTAIN PURPOSES.—The tax im-
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1 posed under this section shall not be treated as tax 

2 imposed by this chapter for purposes of determining 

3 the amount of any credit under this chapter or for 

4 purposes of section 55. 

5 ‘‘(f) REGULATIONS.—The Secretary shall prescribe 

6 such regulations or other guidance as may be necessary 

7 or appropriate to carry out the purposes of this section, 

8 including regulations or other guidance (developed in co9 ordination with the Health Choices Commissioner) which 

10 provide— 

11 ‘‘(1) exemption from the tax imposed under 

12 subsection (a) in cases of de minimis lapses of ac13 ceptable coverage, and 

14 ‘‘(2) a waiver of the application of subsection 

15 (a) in cases of hardship, including a process for ap16 plying for such a waiver.’’. 

17 (b) INFORMATION REPORTING.— 

18 (1) IN GENERAL.—Subpart B of part III of 

19 subchapter A of chapter 61 of such Code is amended 

20 by inserting after section 6050W the following new 

21 section: 

22 ‘‘SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE 

23 COVERAGE. 

24 ‘‘(a) REQUIREMENT OF REPORTING.—Every person 

25 who provides acceptable coverage (as defined in section 
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1 59B(d)) to any individual during any calendar year shall, 

2 at such time as the Secretary may prescribe, make the 

3 return described in subsection (b) with respect to such in4 dividual. 

5 ‘‘(b) FORM AND MANNER OF RETURNS.—A return 

6 is described in this subsection if such return— 

7 ‘‘(1) is in such form as the Secretary may pre8 scribe, and 

9 ‘‘(2) contains— 

10 ‘‘(A) the name, address, and TIN of the 

11 primary insured and the name of each other in12 dividual obtaining coverage under the policy, 

13 ‘‘(B) the period for which each such indi14 vidual was provided with the coverage referred 

15 to in subsection (a), and 

16 ‘‘(C) such other information as the Sec17 retary may require. 

18 ‘‘(c) STATEMENTS TO BE FURNISHED TO INDIVID19 UALS WITH RESPECT TO WHOM INFORMATION IS RE20 QUIRED.—Every person required to make a return under 

21 subsection (a) shall furnish to each primary insured whose 

22 name is required to be set forth in such return a written 

23 statement showing— 
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1 ‘‘(1) the name and address of the person re2 quired to make such return and the phone number 

3 of the information contact for such person, and 

4 ‘‘(2) the information required to be shown on 

5 the return with respect to such individual. 

6 The written statement required under the preceding sen7 tence shall be furnished on or before January 31 of the 

8 year following the calendar year for which the return 

9 under subsection (a) is required to be made. 

10 ‘‘(d) COVERAGE PROVIDED BY GOVERNMENTAL

11 UNITS.—In the case of coverage provided by any govern12 mental unit or any agency or instrumentality thereof, the 

13 officer or employee who enters into the agreement to pro14 vide such coverage (or the person appropriately designated 

15 for purposes of this section) shall make the returns and 

16 statements required by this section.’’. 

17 (2) PENALTY FOR FAILURE TO FILE.— 

18 (A) RETURN.—Subparagraph (B) of sec19 tion 6724(d)(1) of such Code is amended by 

20 striking ‘‘or’’ at the end of clause (xxii), by 

21 striking ‘‘and’’ at the end of clause (xxiii) and 

22 inserting ‘‘or’’, and by adding at the end the 

23 following new clause: 
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1 ‘‘(xxiv) section 6050X (relating to re2 turns relating to health insurance cov3 erage), and’’. 

4 (B) STATEMENT.—Paragraph (2) of sec5 tion 6724(d) of such Code is amended by strik6 ing ‘‘or’’ at the end of subparagraph (EE), by 

7 striking the period at the end of subparagraph 

8 (FF) and inserting ‘‘, or’’, and by inserting 

9 after subparagraph (FF) the following new sub10 paragraph: 

11 ‘‘(GG) section 6050X (relating to returns 

12 relating to health insurance coverage).’’. 

13 (c) RETURN REQUIREMENT.—Subsection (a) of sec14 tion 6012 of such Code is amended by inserting after 

15 paragraph (9) the following new paragraph: 

16 ‘‘(10) Every individual to whom section 59B(a) 

17 applies and who fails to meet the requirements of 

18 section 59B(d) with respect to such individual or 

19 any qualifying child (as defined in section 152(c)) of 

20 such individual.’’. 

21 (d) CLERICAL AMENDMENTS.— 

22 (1) The table of parts for subchapter A of chap23 ter 1 of the Internal Revenue Code of 1986 is 

24 amended by adding at the end the following new 

25 item: 

‘‘PART VIII. HEALTH CARE RELATED TAXES.’’. 
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1 (2) The table of sections for subpart B of part 

2 III of subchapter A of chapter 61 is amended by 

3 adding at the end the following new item: 

‘‘Sec. 6050X. Returns relating to health insurance coverage.’’. 

4 (e) SECTION 15 NOT TO APPLY.—The amendment 

5 made by subsection (a) shall not be treated as a change 

6 in a rate of tax for purposes of section 15 of the Internal 

7 Revenue Code of 1986. 

8 (f) EFFECTIVE DATE.— 

9 (1) IN GENERAL.—The amendments made by 

10 this section shall apply to taxable years beginning 

11 after December 31, 2012. 

12 (2) RETURNS.—The amendments made by sub13 section (b) shall apply to calendar years beginning 

14 after December 31, 2012. 

15 Subpart B—Employer Responsibility 

16 SEC. 511. ELECTION TO SATISFY HEALTH COVERAGE PAR17 TICIPATION REQUIREMENTS. 

18 (a) IN GENERAL.—Chapter 43 of the Internal Rev19 enue Code of 1986 is amended by adding at the end the 

20 following new section: 

21 ‘‘SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COV22 ERAGE PARTICIPATION REQUIREMENTS. 

23 ‘‘(a) ELECTION OF EMPLOYER RESPONSIBILITY TO

24 PROVIDE HEALTH COVERAGE.— 
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1 ‘‘(1) IN GENERAL.—Subsection (b) shall apply 

2 to any employer with respect to whom an election 

3 under paragraph (2) is in effect. 

4 ‘‘(2) TIME AND MANNER.—An employer may 

5 make an election under this paragraph at such time 

6 and in such form and manner as the Secretary may 

7 prescribe. 

8 ‘‘(3) AFFILIATED GROUPS.—In the case of any 

9 employer which is part of a group of employers who 

10 are treated as a single employer under subsection 

11 (b), (c), (m), or (o) of section 414, the election 

12 under paragraph (2) shall be made by such person 

13 as the Secretary may provide. Any such election, 

14 once made, shall apply to all members of such 

15 group. 

16 ‘‘(4) SEPARATE ELECTIONS.—Under regula17 tions prescribed by the Secretary, separate elections 

18 may be made under paragraph (2) with respect to— 

19 ‘‘(A) separate lines of business, and 

20 ‘‘(B) full-time employees and employees 

21 who are not full-time employees. 

22 ‘‘(5) TERMINATION OF ELECTION IN CASES OF

23 SUBSTANTIAL NONCOMPLIANCE.—The Secretary 

24 may terminate the election of any employer under 

25 paragraph (2) if the Secretary (in coordination with 
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1 the Health Choices Commissioner) determines that 

2 such employer is in substantial noncompliance with 

3 the health coverage participation requirements. 

4 ‘‘(b) EXCISE TAX WITH RESPECT TO FAILURE TO

5 MEET HEALTH COVERAGE PARTICIPATION REQUIRE6 MENTS.— 

7 ‘‘(1) IN GENERAL.—In the case of any employer 

8 who fails (during any period with respect to which 

9 the election under subsection (a) is in effect) to sat10 isfy the health coverage participation requirements 

11 with respect to any employee to whom such election 

12 applies, there is hereby imposed on each such failure 

13 with respect to each such employee a tax of $100 for 

14 each day in the period beginning on the date such 

15 failure first occurs and ending on the date such fail16 ure is corrected. 

17 ‘‘(2) LIMITATIONS ON AMOUNT OF TAX.— 

18 ‘‘(A) TAX NOT TO APPLY WHERE FAILURE

19 NOT DISCOVERED EXERCISING REASONABLE

20 DILIGENCE.—No tax shall be imposed by para21 graph (1) on any failure during any period for 

22 which it is established to the satisfaction of the 

23 Secretary that the employer neither knew, nor 

24 exercising reasonable diligence would have 

25 known, that such failure existed. 
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1 ‘‘(B) TAX NOT TO APPLY TO FAILURES

2 CORRECTED WITHIN 30 DAYS.—No tax shall be 

3 imposed by paragraph (1) on any failure if— 

4 ‘‘(i) such failure was due to reason5 able cause and not to willful neglect, and 

6 ‘‘(ii) such failure is corrected during 

7 the 30-day period beginning on the 1st 

8 date that the employer knew, or exercising 

9 reasonable diligence would have known, 

10 that such failure existed. 

11 ‘‘(C) OVERALL LIMITATION FOR UNINTEN12 TIONAL FAILURES.—In the case of failures 

13 which are due to reasonable cause and not to 

14 willful neglect, the tax imposed by subsection 

15 (a) for failures during the taxable year of the 

16 employer shall not exceed the amount equal to 

17 the lesser of— 

18 ‘‘(i) 10 percent of the aggregate 

19 amount paid or incurred by the employer 

20 (or predecessor employer) during the pre21 ceding taxable year for employment-based 

22 health plans, or 

23 ‘‘(ii) $500,000. 

24 ‘‘(D) COORDINATION WITH OTHER EN25 FORCEMENT PROVISIONS.—The tax imposed 
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1 under paragraph (1) with respect to any failure 

2 shall be reduced (but not below zero) by the 

3 amount of any civil penalty collected under sec4 tion 502(c)(11) of the Employee Retirement In5 come Security Act of 1974 or section 2793(g) 

6 of the Public Health Service Act with respect to 

7 such failure. 

8 ‘‘(c) HEALTH COVERAGE PARTICIPATION REQUIRE9 MENTS.—For purposes of this section, the term ‘health 

10 coverage participation requirements’ means the require11 ments of part I of subtitle B of title IV of the (as in effect 

12 on the date of the enactment of this section).’’. 

13 (b) CLERICAL AMENDMENT.—The table of sections 

14 for chapter 43 of such Code is amended by adding at the 

15 end the following new item: 

‘‘Sec. 4980H. Election with respect to health coverage participation requirements.’’. 

16 (c) EFFECTIVE DATE.—The amendments made by 

17 this section shall apply to periods beginning after Decem18 ber 31, 2012. 

19 SEC. 512. HEALTH CARE CONTRIBUTIONS OF NON20 ELECTING EMPLOYERS. 

21 (a) IN GENERAL.—Section 3111 of the Internal Rev22 enue Code of 1986 is amended by redesignating subsection 

23 (c) as subsection (d) and by inserting after subsection (b) 

24 the following new subsection: 
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1 ‘‘(c) EMPLOYERS ELECTING NOT TO PROVIDE

2 HEALTH BENEFITS.— 

3 ‘‘(1) IN GENERAL.—In addition to other taxes, 

4 there is hereby imposed on every nonelecting em5 ployer an excise tax, with respect to having individ6 uals in his employ, equal to 8 percent of the wages 

7 (as defined in section 3121(a)) paid by him with re8 spect to employment (as defined in section 3121(b)). 

9 ‘‘(2) SPECIAL RULES FOR SMALL EMPLOY10 ERS.— 

11 ‘‘(A) IN GENERAL.—In the case of any em12 ployer who is small employer for any calendar 

13 year, paragraph (1) shall be applied by sub14 stituting the applicable percentage determined 

15 in accordance with the following table for ‘8 

16 percent’: 

‘‘If the annual payroll of such employer for 

the preceding calendar year: 

The applicable 

percentage is: 

Does not exceed $500,000 ..................................... 0 percent 

Exceeds $500,000, but does not exceed $585,000 2 percent 

Exceeds $585,000, but does not exceed $670,000 4 percent 

Exceeds $670,000, but does not exceed $750,000 6 percent 

17 ‘‘(B) SMALL EMPLOYER.—For purposes of 

18 this paragraph, the term ‘small employer’ 

19 means any employer for any calendar year if 

20 the annual payroll of such employer for the pre21 ceding calendar year does not exceed $750,000. 
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1 ‘‘(C) ANNUAL PAYROLL.—For purposes of 

2 this paragraph, the term ‘annual payroll’ 

3 means, with respect to any employer for any 

4 calendar year, the aggregate wages (as defined 

5 in section 3121(a)) paid by him with respect to 

6 employment (as defined in section 3121(b)) 

7 during such calendar year. 

8 ‘‘(3) NONELECTING EMPLOYER.—For purposes 

9 of paragraph (1), the term ‘nonelecting employer’ 

10 means any employer for any period with respect to 

11 which such employer does not have an election under 

12 section 4980H(a) in effect. 

13 ‘‘(4) SPECIAL RULE FOR SEPARATE ELEC14 TIONS.—In the case of an employer who makes a 

15 separate election described in section 4980H(a)(4) 

16 for any period, paragraph (1) shall be applied for 

17 such period by taking into account only the wages 

18 paid to employees who are not subject to such elec19 tion. 

20 ‘‘(5) AGGREGATION; PREDECESSORS.—For pur21 poses of this subsection— 

22 ‘‘(A) all persons treated as a single em23 ployer under subsection (b), (c), (m), or (o) of 

24 section 414 shall be treated as 1 employer, and 
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1 ‘‘(B) any reference to any person shall be 

2 treated as including a reference to any prede3 cessor of such person.’’. 

4 (b) DEFINITIONS.—Section 3121 of such Code is 

5 amended by adding at the end the following new sub6 section: 

7 ‘‘(aa) SPECIAL RULES FOR TAX ON EMPLOYERS

8 ELECTING NOT TO PROVIDE HEALTH BENEFITS.—For 

9 purposes of section 3111(c)— 

10 ‘‘(1) Paragraphs (1), (5), and (19) of sub11 section (b) shall not apply. 

12 ‘‘(2) Paragraph (7) of subsection (b) shall apply 

13 by treating all services as not covered by the retire14 ment systems referred to in subparagraphs (C) and 

15 (F) thereof. 

16 ‘‘(3) Subsection (e) shall not apply and the 

17 term ‘State’ shall include the District of Columbia.’’. 

18 (c) CONFORMING AMENDMENT.—Subsection (d) of 

19 section 3111 of such Code, as redesignated by this section, 

20 is amended by striking ‘‘this section’’ and inserting ‘‘sub21 sections (a) and (b)’’. 

22 (d) APPLICATION TO RAILROADS.— 

23 (1) IN GENERAL.—Section 3221 of such Code 

24 is amended by redesignating subsection (c) as sub-
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1 section (d) and by inserting after subsection (b) the 

2 following new subsection: 

3 ‘‘(c) EMPLOYERS ELECTING NOT TO PROVIDE

4 HEALTH BENEFITS.— 

5 ‘‘(1) IN GENERAL.—In addition to other taxes, 

6 there is hereby imposed on every nonelecting em7 ployer an excise tax, with respect to having individ8 uals in his employ, equal to 8 percent of the com9 pensation paid during any calendar year by such em10 ployer for services rendered to such employer. 

11 ‘‘(2) EXCEPTION FOR SMALL EMPLOYERS.— 

12 Rules similar to the rules of section 3111(c)(2) shall 

13 apply for purposes of this subsection. 

14 ‘‘(3) NONELECTING EMPLOYER.—For purposes 

15 of paragraph (1), the term ‘nonelecting employer’ 

16 means any employer for any period with respect to 

17 which such employer does not have an election under 

18 section 4980H(a) in effect. 

19 ‘‘(4) SPECIAL RULE FOR SEPARATE ELEC20 TIONS.—In the case of an employer who makes a 

21 separate election described in section 4980H(a)(4) 

22 for any period, subsection (a) shall be applied for 

23 such period by taking into account only the com24 pensation paid to employees who are not subject to 

25 such election.’’. 
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1 (2) DEFINITIONS.—Subsection (e) of section 

2 3231 of such Code is amended by adding at the end 

3 the following new paragraph: 

4 ‘‘(13) SPECIAL RULES FOR TAX ON EMPLOYERS

5 ELECTING NOT TO PROVIDE HEALTH BENEFITS.— 

6 For purposes of section 3221(c)— 

7 ‘‘(A) Paragraph (1) shall be applied with8 out regard to the third sentence thereof. 

9 ‘‘(B) Paragraph (2) shall not apply.’’. 

10 (3) CONFORMING AMENDMENT.—Subsection (d) 

11 of section 3221 of such Code, as redesignated by 

12 this section, is amended by striking ‘‘subsections (a) 

13 and (b), see section 3231(e)(2)’’ and inserting ‘‘this 

14 section, see paragraphs (2) and (13)(B) of section 

15 3231(e)’’. 

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

17 this section shall apply to periods beginning after Decem18 ber 31, 2012. 

19 PART 2—CREDIT FOR SMALL BUSINESS 

20 EMPLOYEE HEALTH COVERAGE EXPENSES 

21 SEC. 521. CREDIT FOR SMALL BUSINESS EMPLOYEE 

22 HEALTH COVERAGE EXPENSES. 

23 (a) IN GENERAL.—Subpart D of part IV of sub24 chapter A of chapter 1 of the Internal Revenue Code of 
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1 1986 (relating to business-related credits) is amended by 

2 adding at the end the following new section: 

3 ‘‘SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COV4 ERAGE CREDIT. 

5 ‘‘(a) IN GENERAL.—For purposes of section 38, in 

6 the case of a qualified small employer, the small business 

7 employee health coverage credit determined under this sec8 tion for the taxable year is an amount equal to the applica9 ble percentage of the qualified employee health coverage 

10 expenses of such employer for such taxable year. 

11 ‘‘(b) APPLICABLE PERCENTAGE.— 

12 ‘‘(1) IN GENERAL.—For purposes of this sec13 tion, the applicable percentage is 50 percent. 

14 ‘‘(2) PHASEOUT BASED ON AVERAGE COM15 PENSATION OF EMPLOYEES.—In the case of an em16 ployer whose average annual employee compensation 

17 for the taxable year exceeds $20,000, the percentage 

18 specified in paragraph (1) shall be reduced by a 

19 number of percentage points which bears the same 

20 ratio to 50 as such excess bears to $20,000. 

21 ‘‘(c) LIMITATIONS.— 

22 ‘‘(1) PHASEOUT BASED ON EMPLOYER SIZE.— 

23 In the case of an employer who employs more than 

24 10 qualified employees during the taxable year, the 

25 credit determined under subsection (a) shall be re-
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1 duced by an amount which bears the same ratio to 

2 the amount of such credit (determined without re3 gard to this paragraph and after the application of 

4 the other provisions of this section) as— 

5 ‘‘(A) the excess of— 

6 ‘‘(i) the number of qualified employees 

7 employed by the employer during the tax8 able year, over 

9 ‘‘(ii) 10, bears to 

10 ‘‘(B) 15. 

11 ‘‘(2) CREDIT NOT ALLOWED WITH RESPECT TO

12 CERTAIN HIGHLY COMPENSATED EMPLOYEES.—No 

13 credit shall be determined under subsection (a) with 

14 respect to qualified employee health coverage ex15 penses paid or incurred with respect to any employee 

16 for any taxable year if the aggregate compensation 

17 paid by the employer to such employee during such 

18 taxable year exceeds $80,000. 

19 ‘‘(3) CREDIT ALLOWED FOR ONLY 2 TAXABLE

20 YEARS.—No credit shall be determined under sub21 section (a) with respect to any employer for any tax22 able year unless the employer elects to have this sec23 tion apply for such taxable year. An employer may 

24 elect the application of this section with respect to 

25 not more than 2 taxable years. 
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1 ‘‘(d) QUALIFIED EMPLOYEE HEALTH COVERAGE EX2 PENSES.—For purposes of this section— 

3 ‘‘(1) IN GENERAL.—The term ‘qualified em4 ployee health coverage expenses’ means, with respect 

5 to any employer for any taxable year, the aggregate 

6 amount paid or incurred by such employer during 

7 such taxable year for coverage of any qualified em8 ployee of the employer (including any family cov9 erage which covers such employee) under qualified 

10 health coverage. 

11 ‘‘(2) QUALIFIED HEALTH COVERAGE.—The 

12 term ‘qualified health coverage’ means acceptable 

13 coverage (as defined in section 59B(d)) which— 

14 ‘‘(A) is provided pursuant to an election 

15 under section 4980H(a), and 

16 ‘‘(B) satisfies the requirements referred to 

17 in section 4980H(c). 

18 ‘‘(e) OTHER DEFINITIONS.—For purposes of this 

19 section— 

20 ‘‘(1) QUALIFIED SMALL EMPLOYER.—For pur21 poses of this section, the term ‘qualified small em22 ployer’ means any employer for any taxable year 

23 if— 
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1 ‘‘(A) the number of qualified employees 

2 employed by such employer during the taxable 

3 year does not exceed 25, and 

4 ‘‘(B) the average annual employee com5 pensation of such employer for such taxable 

6 year does not exceed the sum of the dollar 

7 amounts in effect under subsection (b)(2). 

8 ‘‘(2) QUALIFIED EMPLOYEE.—The term ‘quali9 fied employee’ means any employee of an employer 

10 for any taxable year of the employer if such em11 ployee received at least $5,000 of compensation from 

12 such employer for services performed in the trade or 

13 business of such employer during such taxable year. 

14 ‘‘(3) AVERAGE ANNUAL EMPLOYEE COMPENSA15 TION.—The term ‘average annual employee com16 pensation’ means, with respect to any employer for 

17 any taxable year, the average amount of compensa18 tion paid by such employer to qualified employees of 

19 such employer during such taxable year. 

20 ‘‘(4) COMPENSATION.—The term ‘compensa21 tion’ has the meaning given such term in section 

22 408(p)(6)(A). 

23 ‘‘(5) FAMILY COVERAGE.—The term ‘family 

24 coverage’ means any coverage other than self-only 

25 coverage. 
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1 ‘‘(f) SPECIAL RULES.—For purposes of this sec2 tion— 

3 ‘‘(1) SPECIAL RULE FOR PARTNERSHIPS AND

4 SELF-EMPLOYED.—In the case of a partnership (or 

5 a trade or business carried on by an individual) 

6 which has one or more qualified employees (deter7 mined without regard to this paragraph) with re8 spect to whom the election under section 4980H(a) 

9 applies, each partner (or, in the case of a trade or 

10 business carried on by an individual, such indi11 vidual) shall be treated as an employee. 

12 ‘‘(2) AGGREGATION RULE.—All persons treated 

13 as a single employer under subsection (b), (c), (m), 

14 or (o) of section 414 shall be treated as 1 employer. 

15 ‘‘(3) PREDECESSORS.—Any reference in this 

16 section to an employer shall include a reference to 

17 any predecessor of such employer. 

18 ‘‘(4) DENIAL OF DOUBLE BENEFIT.—Any de19 duction otherwise allowable with respect to amounts 

20 paid or incurred for health insurance coverage to 

21 which subsection (a) applies shall be reduced by the 

22 amount of the credit determined under this section. 

23 ‘‘(5) INFLATION ADJUSTMENT.—In the case of 

24 any taxable year beginning after 2013, each of the 
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1 dollar amounts in subsections (b)(2), (c)(2), and 

2 (e)(2) shall be increased by an amount equal to— 

3 ‘‘(A) such dollar amount, multiplied by 

4 ‘‘(B) the cost of living adjustment deter5 mined under section 1(f)(3) for the calendar 

6 year in which the taxable year begins deter7 mined by substituting ‘calendar year 2012’ for 

8 ‘calendar year 1992’ in subparagraph (B) 

9 thereof. 

10 If any increase determined under this paragraph is 

11 not a multiple of $50, such increase shall be rounded 

12 to the next lowest multiple of $50.’’. 

13 (b) CREDIT TO BE PART OF GENERAL BUSINESS

14 CREDIT.—Subsection (b) of section 38 of such Code (re15 lating to general business credit) is amended by striking 

16 ‘‘plus’’ at the end of paragraph (34), by striking the period 

17 at the end of paragraph (35) and inserting ‘‘, plus’’, and 

18 by adding at the end the following new paragraph: 

19 ‘‘(36) in the case of a qualified small employer 

20 (as defined in section 45R(e)), the small business 

21 employee health coverage credit determined under 

22 section 45R(a).’’. 

23 (c) CLERICAL AMENDMENT.—The table of sections 

24 for subpart D of part IV of subchapter A of chapter 1 
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1 of such Code is amended by inserting after the item relat2 ing to section 45Q the following new item: 

‘‘Sec. 45R. Small business employee health coverage credit.’’. 

3 (d) EFFECTIVE DATE.—The amendments made by 

4 this section shall apply to taxable years beginning after 

5 December 31, 2012. 

6 PART 3—LIMITATIONS ON HEALTH CARE 

7 RELATED EXPENDITURES 

8 SEC. 531. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY 

9 IF FOR PRESCRIBED DRUG OR INSULIN. 

10 (a) HSAS.—Subparagraph (A) of section 223(d)(2) 

11 of the Internal Revenue Code of 1986 is amended by add12 ing at the end the following: ‘‘Such term shall include an 

13 amount paid for medicine or a drug only if such medicine 

14 or drug is a prescribed drug or is insulin.’’. 

15 (b) ARCHER MSAS.—Subparagraph (A) of section 

16 220(d)(2) of such Code is amended by adding at the end 

17 the following: ‘‘Such term shall include an amount paid 

18 for medicine or a drug only if such medicine or drug is 

19 a prescribed drug or is insulin.’’. 

20 (c) HEALTH FLEXIBLE SPENDING ARRANGEMENTS

21 AND HEALTH REIMBURSEMENT ARRANGEMENTS.—Sec22 tion 106 of such Code is amended by adding at the end 

23 the following new subsection: 

24 ‘‘(f) REIMBURSEMENTS FOR MEDICINE RESTRICTED

25 TO PRESCRIBED DRUGS AND INSULIN.—For purposes of 
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1 this section and section 105, reimbursement for expenses 

2 incurred for a medicine or a drug shall be treated as a 

3 reimbursement for medical expenses only if such medicine 

4 or drug is a prescribed drug or is insulin.’’. 

5 (d) EFFECTIVE DATES.—The amendment made by 

6 this section shall apply to expenses incurred after Decem7 ber 31, 2010. 

8 SEC. 532. LIMITATION ON HEALTH FLEXIBLE SPENDING AR9 RANGEMENTS UNDER CAFETERIA PLANS. 

10 (a) IN GENERAL.—Section 125 of the Internal Rev11 enue Code of 1986 is amended— 

12 (1) by redesignating subsections (i) and (j) as 

13 subsections (j) and (k), respectively; and 

14 (2) by inserting after subsection (h) the fol15 lowing new subsection: 

16 ‘‘(i) LIMITATION ON HEALTH FLEXIBLE SPENDING

17 ARRANGEMENTS.— 

18 ‘‘(1) IN GENERAL.—For purposes of this sec19 tion, if a benefit is provided under a cafeteria plan 

20 through employer contributions to a health flexible 

21 spending arrangement, such benefit shall not be 

22 treated as a qualified benefit unless the cafeteria 

23 plan provides that an employee may not elect for 

24 any taxable year to have salary reduction contribu25 tions in excess of $2,500 made to such arrangement. 
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1 ‘‘(2) INFLATION ADJUSTMENT.—In the case of 

2 any taxable year beginning after 2013, the dollar 

3 amount in paragraph (1) shall be increased by an 

4 amount equal to— 

5 ‘‘(A) such dollar amount, multiplied by 

6 ‘‘(B) the cost of living adjustment deter7 mined under section 1(f)(3) for the calendar 

8 year in which the taxable year begins deter9 mined by substituting ‘calendar year 2012’ for 

10 ‘calendar year 1992’ in subparagraph (B) 

11 thereof. 

12 If any increase determined under this paragraph is 

13 not a multiple of $50, such increase shall be rounded 

14 to the next lowest multiple of $50.’’. 

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

16 this section shall apply to taxable years beginning after 

17 December 31, 2012. 

18 SEC. 533. INCREASE IN PENALTY FOR NONQUALIFIED DIS19 TRIBUTIONS FROM HEALTH SAVINGS AC20 COUNTS. 

21 (a) IN GENERAL.—Subparagraph (A) of section 

22 223(f)(4) of the Internal Revenue Code of 1986 is amend23 ed by striking ‘‘10 percent’’ and inserting ‘‘20 percent’’. 
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1 (b) EFFECTIVE DATE.—The amendment made by 

2 this section shall apply to taxable years beginning after 

3 December 31, 2010. 

4 SEC. 534. DENIAL OF DEDUCTION FOR FEDERAL SUBSIDIES 

5 FOR PRESCRIPTION DRUG PLANS WHICH 

6 HAVE BEEN EXCLUDED FROM GROSS IN7 COME. 

8 (a) IN GENERAL.—Section 139A of the Internal Rev9 enue Code of 1986 is amended by striking the second sen10 tence. 

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

12 this section shall apply to taxable years beginning after 

13 December 31, 2012. 

14 PART 4—OTHER PROVISIONS TO CARRY OUT 

15 HEALTH INSURANCE REFORM 

16 SEC. 541. DISCLOSURES TO CARRY OUT HEALTH INSUR17 ANCE EXCHANGE SUBSIDIES. 

18 (a) IN GENERAL.—Subsection (l) of section 6103 of 

19 the Internal Revenue Code of 1986 is amended by adding 

20 at the end the following new paragraph: 

21 ‘‘(21) DISCLOSURE OF RETURN INFORMATION

22 TO CARRY OUT HEALTH INSURANCE EXCHANGE SUB23 SIDIES.— 

24 ‘‘(A) IN GENERAL.—The Secretary, upon 

25 written request from the Health Choices Com-
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1 missioner or the head of a State-based health 

2 insurance exchange approved for operation 

3 under section 308 of the Affordable Health 

4 Care for America Act, shall disclose to officers 

5 and employees of the Health Choices Adminis6 tration or such State-based health insurance ex7 change, as the case may be, return information 

8 of any taxpayer whose income is relevant in de9 termining any affordability credit described in 

10 subtitle C of title III of the Affordable Health 

11 Care for America Act. Such return information 

12 shall be limited to— 

13 ‘‘(i) taxpayer identity information 

14 with respect to such taxpayer, 

15 ‘‘(ii) the filing status of such tax16 payer, 

17 ‘‘(iii) the modified adjusted gross in18 come of such taxpayer (as defined in sec19 tion 59B(e)(5)), 

20 ‘‘(iv) the number of dependents of the 

21 taxpayer, 

22 ‘‘(v) such other information as is pre23 scribed by the Secretary by regulation as 

24 might indicate whether the taxpayer is eli-
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1 gible for such affordability credits (and the 

2 amount thereof), and 

3 ‘‘(vi) the taxable year with respect to 

4 which the preceding information relates or, 

5 if applicable, the fact that such informa6 tion is not available. 

7 ‘‘(B) RESTRICTION ON USE OF DISCLOSED

8 INFORMATION.—Return information disclosed 

9 under subparagraph (A) may be used by offi10 cers and employees of the Health Choices Ad11 ministration or such State-based health insur12 ance exchange, as the case may be, only for the 

13 purposes of, and to the extent necessary in, es14 tablishing and verifying the appropriate amount 

15 of any affordability credit described in subtitle 

16 C of title III of the Affordable Health Care for 

17 America Act and providing for the repayment of 

18 any such credit which was in excess of such ap19 propriate amount.’’. 

20 (b) PROCEDURES AND RECORDKEEPING RELATED

21 TO DISCLOSURES.—Paragraph (4) of section 6103(p) of 

22 such Code is amended— 

23 (1) by inserting ‘‘, or any entity described in 

24 subsection (l)(21),’’ after ‘‘or (20)’’ in the matter 

25 preceding subparagraph (A); 
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1 (2) by inserting ‘‘or any entity described in sub2 section (l)(21),’’ after ‘‘or (o)(1)(A),’’ in subpara3 graph (F)(ii); and 

4 (3) by inserting ‘‘or any entity described in sub5 section (l)(21),’’ after ‘‘or (20),’’ both places it ap6 pears in the matter after subparagraph (F). 

7 (c) UNAUTHORIZED DISCLOSURE OR INSPECTION.— 

8 Paragraph (2) of section 7213(a) of such Code is amended 

9 by striking ‘‘or (20)’’ and inserting ‘‘(20), or (21)’’. 

10 SEC. 542. OFFERING OF EXCHANGE-PARTICIPATING 

11 HEALTH BENEFITS PLANS THROUGH CAFE12 TERIA PLANS. 

13 (a) IN GENERAL.—Subsection (f) of section 125 of 

14 the Internal Revenue Code of 1986 is amended by adding 

15 at the end the following new paragraph: 

16 ‘‘(3) CERTAIN EXCHANGE-PARTICIPATING

17 HEALTH BENEFITS PLANS NOT QUALIFIED.— 

18 ‘‘(A) IN GENERAL.—The term ‘qualified 

19 benefit’ shall not include any exchange-partici20 pating health benefits plan (as defined in sec21 tion 101(c) of the Affordable Health Care for 

22 America Act). 

23 ‘‘(B) EXCEPTION FOR EXCHANGE-ELIGI24 BLE EMPLOYERS.—Subparagraph (A) shall not 

25 apply with respect to any employee if such em-
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1 ployee’s employer is an exchange-eligible em2 ployer (as defined in section 302 of the Afford3 able Health Care for America Act).’’. 

4 (b) CONFORMING AMENDMENTS.—Subsection (f) of 

5 section 125 of such Code is amended— 

6 (1) by striking ‘‘For purposes of this section, 

7 the term’’ and inserting ‘‘For purposes of this sec8 tion— 

9 ‘‘(1) IN GENERAL.—The term’’; and 

10 (2) by striking ‘‘Such term shall not include’’ 

11 and inserting the following: 

12 ‘‘(2) LONG-TERM CARE INSURANCE NOT QUALI13 FIED.—The term ‘qualified benefit’ shall not in14 clude’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to taxable years beginning after 

17 December 31, 2012. 

18 SEC. 543. EXCLUSION FROM GROSS INCOME OF PAYMENTS 

19 MADE UNDER REINSURANCE PROGRAM FOR 

20 RETIREES. 

21 (a) IN GENERAL.—Section 139A of the Internal Rev22 enue Code of 1986 is amended— 

23 (1) by striking ‘‘Gross income’’ and inserting 

24 the following: 
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1 ‘‘(a) FEDERAL SUBSIDIES FOR PRESCRIPTION DRUG

2 PLANS.—Gross income’’; and 

3 (2) by adding at the end the following new sub4 section: 

5 ‘‘(b) FEDERAL REINSURANCE PROGRAM FOR RETIR6 EES.—A rule similar to the rule of subsection (a) shall 

7 apply with respect to payments made under section 111 

8 of the Affordable Health Care for America Act.’’. 

9 (b) CONFORMING AMENDMENT.—The heading of sec10 tion 139A of such Code (and the item relating to such 

11 section in the table of sections for part III of subchapter 

12 B of chapter 1 of such Code) is amended by inserting 

13 ‘‘AND RETIREE HEALTH PLANS’’ after ‘‘PRESCRIP14 TION DRUG PLANS’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to taxable years ending after the 

17 date of the enactment of this Act. 

18 SEC. 544. CLASS PROGRAM TREATED IN SAME MANNER AS 

19 LONG-TERM CARE INSURANCE. 

20 (a) IN GENERAL.—Subsection (f) of section 7702B 

21 of the Internal Revenue Code of 1986 is amended— 

22 (1) by striking ‘‘State long-term care plan’’ in 

23 paragraph (1)(A) and inserting ‘‘government long24 term care plan’’; 
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1 (2) by redesignating paragraph (2) as para2 graph (3); and 

3 (3) by inserting after paragraph (2) the fol4 lowing new paragraph: 

5 ‘‘(2) GOVERNMENT LONG-TERM CARE PLAN.— 

6 For purposes of this subsection, the term ‘govern7 ment long-term care plan’ means— 

8 ‘‘(A) the CLASS program established 

9 under title XXXII of the Public Health Service 

10 Act, and 

11 ‘‘(B) any State long-term care plan.’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) Paragraph (3) of section 7702B(f) of such 

14 Code, as redesignated by subsection (a), is amended 

15 by striking ‘‘paragraph (1)’’ and inserting ‘‘this sub16 section’’. 

17 (2) Subsection (f) of section 7702(B) of such 

18 Code is amended by striking ‘‘STATE-MAINTAINED’’ 

19 in the heading thereof and inserting ‘‘GOVERN20 MENT’’. 

21 (c) EFFECTIVE DATE.—The amendments made by 

22 this section shall apply to taxable years ending after De23 cember 31, 2010. 
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1 SEC. 545. EXCLUSION FROM GROSS INCOME FOR MEDICAL 

2 CARE PROVIDED FOR INDIANS. 

3 (a) IN GENERAL.—Part III of subchapter B of chap4 ter 1 of the Internal Revenue Code of 1986 (relating to 

5 items specifically excluded from gross income) is amended 

6 by inserting after section 139C the following new section: 

7 ‘‘SEC. 139D. MEDICAL CARE PROVIDED FOR INDIANS. 

8 ‘‘(a) IN GENERAL.—Gross income does not include— 

9 ‘‘(1) health services or benefits provided or pur10 chased by the Indian Health Service, either directly 

11 or indirectly, through a grant to or a contract or 

12 compact with an Indian tribe or tribal organization 

13 or through programs of third parties funded by the 

14 Indian Health Service, 

15 ‘‘(2) medical care provided by an Indian tribe 

16 or tribal organization to a member of an Indian 

17 tribe (including for this purpose, to the member’s 

18 spouse or dependents) through any one of the fol19 lowing: provided or purchased medical care services; 

20 accident or health insurance (or an arrangement 

21 having the effect of accident or health insurance); or 

22 amounts paid, directly or indirectly, to reimburse the 

23 member for expenses incurred for medical care, 

24 ‘‘(3) the value of accident or health plan cov25 erage provided by an Indian tribe or tribal organiza26 tion for medical care to a member of an Indian tribe 
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1 (including for this purpose, coverage that extends to 

2 such member’s spouse or dependents) under an acci3 dent or health plan (or through an arrangement hav4 ing the effect of accident or health insurance), and 

5 ‘‘(4) any other medical care provided by an In6 dian tribe that supplements, replaces, or substitutes 

7 for the programs and services provided by the Fed8 eral Government to Indian tribes or Indians. 

9 ‘‘(b) DEFINITIONS.—For purposes of this section— 

10 ‘‘(1) IN GENERAL.—The terms ‘accident or 

11 health insurance’ and ‘accident or health plan’ have 

12 the same meaning as when used in sections 104 and 

13 106. 

14 ‘‘(2) MEDICAL CARE.—The term ‘medical care’ 

15 has the meaning given such term in section 213. 

16 ‘‘(3) DEPENDENT.—The term ‘dependent’ has 

17 the meaning given such term in section 152, deter18 mined without regard to subsections (b)(1), (b)(2), 

19 and (d)(1)(B). 

20 ‘‘(4) INDIAN TRIBE.—The term ‘Indian tribe’ 

21 means any Indian tribe, band, nation, pueblo, or 

22 other organized group or community, including any 

23 Alaska Native village, or regional or village corpora24 tion, as defined in, or established pursuant to, the 

25 Alaska Native Claims Settlement Act (43 U.S.C. 
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1 1601 et seq.), which is recognized as eligible for the 

2 special programs and services provided by the 

3 United States to Indians because of their status as 

4 Indians. 

5 ‘‘(5) TRIBAL ORGANIZATION.—The term ‘tribal 

6 organization’ has the meaning given such term in 

7 section 4(l) of the Indian Self-Determination and 

8 Education Assistance Act (25 U.S.C. 450b(l)).’’. 

9 (b) CLERICAL AMENDMENT.—The table of sections 

10 for such part III is amended by inserting after the item 

11 relating to section 139C the following new item: 

‘‘Sec. 139D. Medical care provided for Indians.’’. 

12 (c) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to health benefits and coverage 

14 provided after the date of enactment of this Act. 

15 (d) NO INFERENCE.—Nothing in the amendments 

16 made by this section shall be construed to create an infer17 ence with respect to the exclusion from gross income of— 

18 (1) benefits provided by Indian tribes that are 

19 not within the scope of this section; and 

20 (2) health benefits or coverage provided by In21 dian tribes prior to the effective date of this section. 
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1 Subtitle B—Other Revenue 

2 Provisions 

3 PART 1—GENERAL PROVISIONS 

4 SEC. 551. SURCHARGE ON HIGH INCOME INDIVIDUALS. 

5 (a) IN GENERAL.—Part VIII of subchapter A of 

6 chapter 1 of the Internal Revenue Code of 1986, as added 

7 by this title, is amended by adding at the end the following 

8 new subpart: 

9 ‘‘Subpart B—Surcharge on High Income Individuals 

‘‘Sec. 59C. Surcharge on high income individuals. 

10 ‘‘SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS. 

11 ‘‘(a) GENERAL RULE.—In the case of a taxpayer 

12 other than a corporation, there is hereby imposed (in addi13 tion to any other tax imposed by this subtitle) a tax equal 

14 to 5.4 percent of so much of the modified adjusted gross 

15 income of the taxpayer as exceeds $1,000,000. 

16 ‘‘(b) TAXPAYERS NOT MAKING A JOINT RETURN.— 

17 In the case of any taxpayer other than a taxpayer making 

18 a joint return under section 6013 or a surviving spouse 

19 (as defined in section 2(a)), subsection (a) shall be applied 

20 by substituting ‘$500,000’ for ‘$1,000,000’. 

21 ‘‘(c) MODIFIED ADJUSTED GROSS INCOME.—For 

22 purposes of this section, the term ‘modified adjusted gross 

23 income’ means adjusted gross income reduced by any de24 duction (not taken into account in determining adjusted 
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1 gross income) allowed for investment interest (as defined 

2 in section 163(d)). In the case of an estate or trust, ad3 justed gross income shall be determined as provided in sec4 tion 67(e). 

5 ‘‘(d) SPECIAL RULES.— 

6 ‘‘(1) NONRESIDENT ALIEN.—In the case of a 

7 nonresident alien individual, only amounts taken 

8 into account in connection with the tax imposed 

9 under section 871(b) shall be taken into account 

10 under this section. 

11 ‘‘(2) CITIZENS AND RESIDENTS LIVING

12 ABROAD.—The dollar amount in effect under sub13 section (a) (after the application of subsection (b)) 

14 shall be decreased by the excess of— 

15 ‘‘(A) the amounts excluded from the tax16 payer’s gross income under section 911, over 

17 ‘‘(B) the amounts of any deductions or ex18 clusions disallowed under section 911(d)(6) 

19 with respect to the amounts described in sub20 paragraph (A). 

21 ‘‘(3) CHARITABLE TRUSTS.—Subsection (a) 

22 shall not apply to a trust all the unexpired interests 

23 in which are devoted to one or more of the purposes 

24 described in section 170(c)(2)(B). 
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1 ‘‘(4) NOT TREATED AS TAX IMPOSED BY THIS

2 CHAPTER FOR CERTAIN PURPOSES.—The tax im3 posed under this section shall not be treated as tax 

4 imposed by this chapter for purposes of determining 

5 the amount of any credit under this chapter or for 

6 purposes of section 55.’’. 

7 (b) CLERICAL AMENDMENT.—The table of subparts 

8 for part VIII of subchapter A of chapter 1 of such Code, 

9 as added by this title, is amended by inserting after the 

10 item relating to subpart A the following new item: 

‘‘SUBPART B. SURCHARGE ON HIGH INCOME INDIVIDUALS.’’. 

11 (c) SECTION 15 NOT TO APPLY.—The amendment 

12 made by subsection (a) shall not be treated as a change 

13 in a rate of tax for purposes of section 15 of the Internal 

14 Revenue Code of 1986. 

15 (d) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to taxable years beginning after 

17 December 31, 2010. 

18 SEC. 552. EXCISE TAX ON MEDICAL DEVICES. 

19 (a) IN GENERAL.—Chapter 31 of the Internal Rev20 enue Code of 1986 is amended by adding at the end the 

21 following new subchapter: 

22 ‘‘Subchapter D—Medical Devices 

‘‘Sec. 4061. Medical devices. 
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1 ‘‘SEC. 4061. MEDICAL DEVICES. 

2 ‘‘(a) IN GENERAL.—There is hereby imposed on the 

3 first taxable sale of any medical device a tax equal to 2.5 

4 percent of the price for which so sold. 

5 ‘‘(b) FIRST TAXABLE SALE.—For purposes of this 

6 section— 

7 ‘‘(1) IN GENERAL.—The term ‘first taxable 

8 sale’ means the first sale, for a purpose other than 

9 for resale, after production, manufacture, or impor10 tation. 

11 ‘‘(2) EXCEPTION FOR SALES AT RETAIL ESTAB12 LISHMENTS.—Such term shall not include the sale 

13 of any medical device if— 

14 ‘‘(A) such sale is made at a retail estab15 lishment on terms which are available to the 

16 general public, and 

17 ‘‘(B) such medical device is of a type (and 

18 purchased in a quantity) which is purchased by 

19 the general public. 

20 ‘‘(3) EXCEPTION FOR EXPORTS, ETC.—Rules 

21 similar to the rules of sections 4221 (other than 

22 paragraphs (3), (4), (5), and (6) of subsection (a) 

23 thereof) and 4222 shall apply for purposes of this 

24 section. To the extent provided by the Secretary, 

25 section 4222 may be extended to, and made applica-
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1 ble with respect to, the exemption provided by para2 graph (2). 

3 ‘‘(4) SALES TO PATIENTS NOT TREATED AS RE4 SALES.—If a medical device is sold for use in con5 nection with providing any health care service to an 

6 individual, such sale shall not be treated as being for 

7 the purpose of resale (even if such device is sold to 

8 such individual). 

9 ‘‘(c) OTHER DEFINITIONS AND SPECIAL RULES.— 

10 For purposes of this section— 

11 ‘‘(1) MEDICAL DEVICE.—The term ‘medical de12 vice’ means any device (as defined in section 201(h) 

13 of the Federal Food, Drug, and Cosmetic Act) in14 tended for humans. 

15 ‘‘(2) LEASE TREATED AS SALE.—Rules similar 

16 to the rules of section 4217 shall apply. 

17 ‘‘(3) USE TREATED AS SALE.— 

18 ‘‘(A) IN GENERAL.—If any person uses a 

19 medical device before the first taxable sale of 

20 such device, then such person shall be liable for 

21 tax under such subsection in the same manner 

22 as if such use were the first taxable sale of such 

23 device. 

24 ‘‘(B) EXCEPTIONS.—The preceding sen25 tence shall not apply to— 
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1 ‘‘(i) use of a medical device as mate2 rial in the manufacture or production of, 

3 or as a component part of, another medical 

4 device to be manufactured or produced by 

5 such person, or 

6 ‘‘(ii) use of a medical device after a 

7 sale described in subsection (b)(2). 

8 ‘‘(4) DETERMINATION OF PRICE.— 

9 ‘‘(A) IN GENERAL.—Rules similar to the 

10 rules of subsections (a), (c), and (d) of section 

11 4216 shall apply for purposes of this section. 

12 ‘‘(B) CONSTRUCTIVE SALE PRICE.—If— 

13 ‘‘(i) a medical device is sold (otherwise 

14 than through an arm’s length transaction) 

15 at less than the fair market price, or 

16 ‘‘(ii) a person is liable for tax for a 

17 use described in paragraph (3), 

18 the tax under this section shall be computed on 

19 the price for which such or similar devices are 

20 sold in the ordinary course of trade as deter21 mined by the Secretary. 

22 ‘‘(5) RESALES PURSUANT TO CERTAIN CON23 TRACT ARRANGEMENTS.— 

24 ‘‘(A) IN GENERAL.—In the case of a speci25 fied contract sale of a medical device, the seller 
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1 referred to in subparagraph (B)(i) shall be enti2 tled to recover from the producer, manufac3 turer, or importer referred to in subparagraph 

4 (B)(ii) the amount of the tax paid by such sell5 er under this section with respect to such sale. 

6 ‘‘(B) SPECIFIED CONTRACT SALE.—For 

7 purposes of this paragraph, the term ‘specified 

8 contract sale’ means, with respect to any med9 ical device, the first taxable sale of such device 

10 if— 

11 ‘‘(i) the seller is not the producer, 

12 manufacturer, or importer of such device, 

13 and 

14 ‘‘(ii) the price at which such device is 

15 so sold is determined in accordance with a 

16 contract between the producer, manufac17 turer, or importer of such device and the 

18 person to whom such device is so sold. 

19 ‘‘(C) SPECIAL RULES RELATED TO CRED20 ITS AND REFUNDS.—In the case of any credit 

21 or refund under section 6416 of the tax im22 posed under this section on a specified contract 

23 sale of a medical device— 

24 ‘‘(i) such credit or refund shall be al25 lowed or made only if the seller has filed 
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1 with the Secretary the written consent of 

2 the producer, manufacturer, or importer 

3 referred to in subparagraph (B)(ii) to the 

4 allowance of such credit or the making of 

5 such refund, and 

6 ‘‘(ii) the amount of tax taken into ac7 count under subparagraph (A) shall be re8 duced by the amount of such credit or re9 fund.’’. 

10 (b) CONFORMING AMENDMENTS.— 

11 (1) Paragraph (2) of section 6416(b) of such 

12 Code is amended— 

13 (A) by inserting ‘‘or 4061’’ after ‘‘under 

14 section 4051’’; and 

15 (B) by adding at the end the following: ‘‘In 

16 the case of the tax imposed by section 4061, 

17 subparagraphs (B), (C), (D), and (E) shall not 

18 apply.’’. 

19 (2) The table of subchapters for chapter 31 of 

20 such Code is amended by adding at the end the fol21 lowing new item: 

‘‘SUBCHAPTER D. MEDICAL DEVICES.’’. 

22 (c) EFFECTIVE DATE.—The amendments made by 

23 this section shall apply to sales (and leases and uses treat24 ed as sales) after December 31, 2012. 
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1 SEC. 553. EXPANSION OF INFORMATION REPORTING RE2 QUIREMENTS. 

3 (a) IN GENERAL.—Section 6041 of the Internal Rev4 enue Code of 1986 is amended by adding at the end the 

5 following new subsections: 

6 ‘‘(h) APPLICATION TO CORPORATIONS.—Notwith7 standing any regulation prescribed by the Secretary before 

8 the date of the enactment of this subsection, for purposes 

9 of this section the term ‘person’ includes any corporation 

10 that is not an organization exempt from tax under section 

11 501(a). 

12 ‘‘(i) REGULATIONS.—The Secretary may prescribe 

13 such regulations and other guidance as may be appro14 priate or necessary to carry out the purposes of this sec15 tion, including rules to prevent duplicative reporting of 

16 transactions.’’. 

17 (b) PAYMENTS FOR PROPERTY AND OTHER GROSS

18 PROCEEDS.—Subsection (a) of section 6041 of the Inter19 nal Revenue Code of 1986 is amended— 

20 (1) by inserting ‘‘amounts in consideration for 

21 property,’’ after ‘‘wages,’’; 

22 (2) by inserting ‘‘gross proceeds,’’ after ‘‘emolu23 ments, or other’’; and 

24 (3) by inserting ‘‘gross proceeds,’’ after ‘‘setting 

25 forth the amount of such’’. 
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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to payments made after December 

3 31, 2011. 

4 SEC. 554. REPEAL OF WORLDWIDE ALLOCATION OF INTER5 EST. 

6 (a) IN GENERAL.—Section 864 of the Internal Rev7 enue Code of 1986 is amended by striking subsection (f) 

8 and by redesignating subsection (g) as subsection (f). 

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

10 this section shall apply to taxable years beginning after 

11 December 31, 2010. 

12 SEC. 555. EXCLUSION OF UNPROCESSED FUELS FROM THE 

13 CELLULOSIC BIOFUEL PRODUCER CREDIT. 

14 (a) IN GENERAL.—Subparagraph (E) of section 

15 40(b)(6) of the Internal Revenue Code of 1986 is amended 

16 by adding at the end the following new clause: 

17 ‘‘(iii) EXCLUSION OF UNPROCESSED

18 FUELS.—The term ‘cellulosic biofuel’ shall 

19 not include any fuel if— 

20 ‘‘(I) more than 4 percent of such 

21 fuel (determined by weight) is any 

22 combination of water and sediment, or 

23 ‘‘(II) the ash content of such fuel 

24 is more than 1 percent (determined by 

25 weight).’’. 
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1 (b) EFFECTIVE DATE.—The amendment made by 

2 this section shall apply to fuels sold or used after the date 

3 of the enactment of this Act. 

4 PART 2—PREVENTION OF TAX AVOIDANCE 

5 SEC. 561. LIMITATION ON TREATY BENEFITS FOR CERTAIN 

6 DEDUCTIBLE PAYMENTS. 

7 (a) IN GENERAL.—Section 894 of the Internal Rev8 enue Code of 1986 (relating to income affected by treaty) 

9 is amended by adding at the end the following new sub10 section: 

11 ‘‘(d) LIMITATION ON TREATY BENEFITS FOR CER12 TAIN DEDUCTIBLE PAYMENTS.— 

13 ‘‘(1) IN GENERAL.—In the case of any deduct14 ible related-party payment, any withholding tax im15 posed under chapter 3 (and any tax imposed under 

16 subpart A or B of this part) with respect to such 

17 payment may not be reduced under any treaty of the 

18 United States unless any such withholding tax would 

19 be reduced under a treaty of the United States if 

20 such payment were made directly to the foreign par21 ent corporation. 

22 ‘‘(2) DEDUCTIBLE RELATED-PARTY PAY23 MENT.—For purposes of this subsection, the term 

24 ‘deductible related-party payment’ means any pay25 ment made, directly or indirectly, by any person to 
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1 any other person if the payment is allowable as a de2 duction under this chapter and both persons are 

3 members of the same foreign controlled group of en4 tities. 

5 ‘‘(3) FOREIGN CONTROLLED GROUP OF ENTI6 TIES.—For purposes of this subsection— 

7 ‘‘(A) IN GENERAL.—The term ‘foreign 

8 controlled group of entities’ means a controlled 

9 group of entities the common parent of which 

10 is a foreign corporation. 

11 ‘‘(B) CONTROLLED GROUP OF ENTITIES.— 

12 The term ‘controlled group of entities’ means a 

13 controlled group of corporations as defined in 

14 section 1563(a)(1), except that— 

15 ‘‘(i) ‘more than 50 percent’ shall be 

16 substituted for ‘at least 80 percent’ each 

17 place it appears therein, and 

18 ‘‘(ii) the determination shall be made 

19 without regard to subsections (a)(4) and 

20 (b)(2) of section 1563. 

21 A partnership or any other entity (other than a 

22 corporation) shall be treated as a member of a 

23 controlled group of entities if such entity is con24 trolled (within the meaning of section 

25 954(d)(3)) by members of such group (includ-
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1 ing any entity treated as a member of such 

2 group by reason of this sentence). 

3 ‘‘(4) FOREIGN PARENT CORPORATION.—For 

4 purposes of this subsection, the term ‘foreign parent 

5 corporation’ means, with respect to any deductible 

6 related-party payment, the common parent of the 

7 foreign controlled group of entities referred to in 

8 paragraph (3)(A). 

9 ‘‘(5) REGULATIONS.—The Secretary may pre10 scribe such regulations or other guidance as are nec11 essary or appropriate to carry out the purposes of 

12 this subsection, including regulations or other guid13 ance which provide for— 

14 ‘‘(A) the treatment of two or more persons 

15 as members of a foreign controlled group of en16 tities if such persons would be the common par17 ent of such group if treated as one corporation, 

18 and 

19 ‘‘(B) the treatment of any member of a 

20 foreign controlled group of entities as the com21 mon parent of such group if such treatment is 

22 appropriate taking into account the economic 

23 relationships among such entities.’’. 
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1 (b) EFFECTIVE DATE.—The amendment made by 

2 this section shall apply to payments made after the date 

3 of the enactment of this Act. 

4 SEC. 562. CODIFICATION OF ECONOMIC SUBSTANCE DOC5 TRINE; PENALTIES. 

6 (a) IN GENERAL.—Section 7701 of the Internal Rev7 enue Code of 1986 is amended by redesignating subsection 

8 (o) as subsection (p) and by inserting after subsection (n) 

9 the following new subsection: 

10 ‘‘(o) CLARIFICATION OF ECONOMIC SUBSTANCE

11 DOCTRINE.— 

12 ‘‘(1) APPLICATION OF DOCTRINE.—In the case 

13 of any transaction to which the economic substance 

14 doctrine is relevant, such transaction shall be treated 

15 as having economic substance only if— 

16 ‘‘(A) the transaction changes in a mean17 ingful way (apart from Federal income tax ef18 fects) the taxpayer’s economic position, and 

19 ‘‘(B) the taxpayer has a substantial pur20 pose (apart from Federal income tax effects) 

21 for entering into such transaction. 

22 ‘‘(2) SPECIAL RULE WHERE TAXPAYER RELIES

23 ON PROFIT POTENTIAL.— 

24 ‘‘(A) IN GENERAL.—The potential for 

25 profit of a transaction shall be taken into ac-
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1 count in determining whether the requirements 

2 of subparagraphs (A) and (B) of paragraph (1) 

3 are met with respect to the transaction only if 

4 the present value of the reasonably expected 

5 pre-tax profit from the transaction is substan6 tial in relation to the present value of the ex7 pected net tax benefits that would be allowed if 

8 the transaction were respected. 

9 ‘‘(B) TREATMENT OF FEES AND FOREIGN

10 TAXES.—Fees and other transaction expenses 

11 and foreign taxes shall be taken into account as 

12 expenses in determining pre-tax profit under 

13 subparagraph (A). 

14 ‘‘(3) STATE AND LOCAL TAX BENEFITS.—For 

15 purposes of paragraph (1), any State or local income 

16 tax effect which is related to a Federal income tax 

17 effect shall be treated in the same manner as a Fed18 eral income tax effect. 

19 ‘‘(4) FINANCIAL ACCOUNTING BENEFITS.—For 

20 purposes of paragraph (1)(B), achieving a financial 

21 accounting benefit shall not be taken into account as 

22 a purpose for entering into a transaction if the ori23 gin of such financial accounting benefit is a reduc24 tion of Federal income tax. 
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1 ‘‘(5) DEFINITIONS AND SPECIAL RULES.—For 

2 purposes of this subsection— 

3 ‘‘(A) ECONOMIC SUBSTANCE DOCTRINE.— 

4 The term ‘economic substance doctrine’ means 

5 the common law doctrine under which tax bene6 fits under subtitle A with respect to a trans7 action are not allowable if the transaction does 

8 not have economic substance or lacks a business 

9 purpose. 

10 ‘‘(B) EXCEPTION FOR PERSONAL TRANS11 ACTIONS OF INDIVIDUALS.—In the case of an 

12 individual, paragraph (1) shall apply only to 

13 transactions entered into in connection with a 

14 trade or business or an activity engaged in for 

15 the production of income. 

16 ‘‘(C) OTHER COMMON LAW DOCTRINES

17 NOT AFFECTED.—Except as specifically pro18 vided in this subsection, the provisions of this 

19 subsection shall not be construed as altering or 

20 supplanting any other rule of law, and the re21 quirements of this subsection shall be construed 

22 as being in addition to any such other rule of 

23 law. 

24 ‘‘(D) DETERMINATION OF APPLICATION OF

25 DOCTRINE NOT AFFECTED.—The determination 
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1 of whether the economic substance doctrine is 

2 relevant to a transaction (or series of trans3 actions) shall be made in the same manner as 

4 if this subsection had never been enacted. 

5 ‘‘(6) REGULATIONS.—The Secretary shall pre6 scribe such regulations as may be necessary or ap7 propriate to carry out the purposes of this sub8 section.’’. 

9 (b) PENALTY FOR UNDERPAYMENTS ATTRIBUTABLE

10 TO TRANSACTIONS LACKING ECONOMIC SUBSTANCE.— 

11 (1) IN GENERAL.—Subsection (b) of section 

12 6662 of such Code is amended by inserting after 

13 paragraph (5) the following new paragraph: 

14 ‘‘(6) Any disallowance of claimed tax benefits 

15 by reason of a transaction lacking economic sub16 stance (within the meaning of section 7701(o)) or 

17 failing to meet the requirements of any similar rule 

18 of law.’’. 

19 (2) INCREASED PENALTY FOR NONDISCLOSED

20 TRANSACTIONS.—Section 6662 of such Code is 

21 amended by adding at the end the following new 

22 subsection: 

23 ‘‘(i) INCREASE IN PENALTY IN CASE OF NONDIS24 CLOSED NONECONOMIC SUBSTANCE TRANSACTIONS.— 
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1 ‘‘(1) IN GENERAL.—In the case of any portion 

2 of an underpayment which is attributable to one or 

3 more nondisclosed noneconomic substance trans4 actions, subsection (a) shall be applied with respect 

5 to such portion by substituting ‘40 percent’ for ‘20 

6 percent’. 

7 ‘‘(2) NONDISCLOSED NONECONOMIC SUB8 STANCE TRANSACTIONS.—For purposes of this sub9 section, the term ‘nondisclosed noneconomic sub10 stance transaction’ means any portion of a trans11 action described in subsection (b)(6) with respect to 

12 which the relevant facts affecting the tax treatment 

13 are not adequately disclosed in the return nor in a 

14 statement attached to the return. 

15 ‘‘(3) SPECIAL RULE FOR AMENDED RE16 TURNS.—Except as provided in regulations, in no 

17 event shall any amendment or supplement to a re18 turn of tax be taken into account for purposes of 

19 this subsection if the amendment or supplement is 

20 filed after the earlier of the date the taxpayer is first 

21 contacted by the Secretary regarding the examina22 tion of the return or such other date as is specified 

23 by the Secretary.’’. 
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1 (3) CONFORMING AMENDMENT.—Subparagraph 

2 (B) of section 6662A(e)(2) of such Code is amend3 ed— 

4 (A) by striking ‘‘section 6662(h)’’ and in5 serting ‘‘subsections (h) or (i) of section 6662’’; 

6 and 

7 (B) by striking ‘‘GROSS VALUATION

8 MISSTATEMENT PENALTY’’ in the heading and 

9 inserting ‘‘CERTAIN INCREASED UNDER10 PAYMENT PENALTIES’’. 

11 (c) REASONABLE CAUSE EXCEPTION NOT APPLICA12 BLE TO NONECONOMIC SUBSTANCE TRANSACTIONS AND

13 TAX SHELTERS.— 

14 (1) REASONABLE CAUSE EXCEPTION FOR UN15 DERPAYMENTS.—Subsection (c) of section 6664 of 

16 such Code is amended— 

17 (A) by redesignating paragraphs (2) and 

18 (3) as paragraphs (3) and (4), respectively; 

19 (B) by striking ‘‘paragraph (2)’’ in para20 graph (4)(A), as so redesignated, and inserting 

21 ‘‘paragraph (3)’’; and 

22 (C) by inserting after paragraph (1) the 

23 following new paragraph: 

24 ‘‘(2) EXCEPTION.—Paragraph (1) shall not 

25 apply to any portion of an underpayment which is 
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1 attributable to one or more tax shelters (as defined 

2 in section 6662(d)(2)(C)) or transactions described 

3 in section 6662(b)(6).’’. 

4 (2) REASONABLE CAUSE EXCEPTION FOR RE5 PORTABLE TRANSACTION UNDERSTATEMENTS.— 

6 Subsection (d) of section 6664 of such Code is 

7 amended— 

8 (A) by redesignating paragraphs (2) and 

9 (3) as paragraphs (3) and (4), respectively; 

10 (B) by striking ‘‘paragraph (2)(C)’’ in 

11 paragraph (4), as so redesignated, and inserting 

12 ‘‘paragraph (3)(C)’’; and 

13 (C) by inserting after paragraph (1) the 

14 following new paragraph: 

15 ‘‘(2) EXCEPTION.—Paragraph (1) shall not 

16 apply to any portion of a reportable transaction un17 derstatement which is attributable to one or more 

18 tax shelters (as defined in section 6662(d)(2)(C)) or 

19 transactions described in section 6662(b)(6).’’. 

20 (d) APPLICATION OF PENALTY FOR ERRONEOUS

21 CLAIM FOR REFUND OR CREDIT TO NONECONOMIC SUB22 STANCE TRANSACTIONS.—Section 6676 of such Code is 

23 amended by redesignating subsection (c) as subsection (d) 

24 and inserting after subsection (b) the following new sub25 section: 
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1 ‘‘(c) NONECONOMIC SUBSTANCE TRANSACTIONS

2 TREATED AS LACKING REASONABLE BASIS.—For pur3 poses of this section, any excessive amount which is attrib4 utable to any transaction described in section 6662(b)(6) 

5 shall not be treated as having a reasonable basis.’’. 

6 (e) EFFECTIVE DATE.— 

7 (1) IN GENERAL.—Except as otherwise pro8 vided in this subsection, the amendments made by 

9 this section shall apply to transactions entered into 

10 after the date of the enactment of this Act. 

11 (2) UNDERPAYMENTS.—The amendments made 

12 by subsections (b) and (c)(1) shall apply to under13 payments attributable to transactions entered into 

14 after the date of the enactment of this Act. 

15 (3) UNDERSTATEMENTS.—The amendments 

16 made by subsection (c)(2) shall apply to understate17 ments attributable to transactions entered into after 

18 the date of the enactment of this Act. 

19 (4) REFUNDS AND CREDITS.—The amendment 

20 made by subsection (d) shall apply to refunds and 

21 credits attributable to transactions entered into after 

22 the date of the enactment of this Act. 
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1 SEC. 563. CERTAIN LARGE OR PUBLICLY TRADED PERSONS 

2 MADE SUBJECT TO A MORE LIKELY THAN 

3 NOT STANDARD FOR AVOIDING PENALTIES 

4 ON UNDERPAYMENTS. 

5 (a) IN GENERAL.—Subsection (c) of section 6664 of 

6 the Internal Revenue Code of 1986, as amended by section 

7 562, is amended— 

8 (1) by redesignating paragraphs (3) and (4) as 

9 paragraphs (4) and (5), respectively; 

10 (2) by striking ‘‘paragraph (3)’’ in paragraph 

11 (4)(A), as so redesignated, and inserting ‘‘paragraph 

12 (4)’’; and 

13 (3) by inserting after paragraph (2) the fol14 lowing new paragraph: 

15 ‘‘(3) SPECIAL RULE FOR CERTAIN LARGE OR

16 PUBLICLY TRADED PERSONS.— 

17 ‘‘(A) IN GENERAL.—In the case of any 

18 specified person, paragraph (1) shall apply to 

19 the portion of an underpayment which is attrib20 utable to any item only if such person has a 

21 reasonable belief that the tax treatment of such 

22 item by such person is more likely than not the 

23 proper tax treatment of such item. 

24 ‘‘(B) SPECIFIED PERSON.—For purposes 

25 of this paragraph, the term ‘specified person’ 

26 means— 
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1 ‘‘(i) any person required to file peri2 odic or other reports under section 13 of 

3 the Securities Exchange Act of 1934, and 

4 ‘‘(ii) any corporation with gross re5 ceipts in excess of $100,000,000 for the 

6 taxable year involved. 

7 All persons treated as a single employer under 

8 section 52(a) shall be treated as one person for 

9 purposes of clause (ii).’’. 

10 (b) NONAPPLICATION OF SUBSTANTIAL AUTHORITY

11 AND REASONABLE BASIS STANDARDS FOR REDUCING

12 UNDERSTATEMENTS.—Paragraph (2) of section 6662(d) 

13 of such Code is amended by adding at the end the fol14 lowing new subparagraph: 

15 ‘‘(D) REDUCTION NOT TO APPLY TO CER16 TAIN LARGE OR PUBLICLY TRADED PERSONS.— 

17 Subparagraph (B) shall not apply to any speci18 fied person (as defined in section 

19 6664(c)(3)(B)).’’. 

20 (c) EFFECTIVE DATE.— 

21 (1) IN GENERAL.—Except as provided in para22 graph (2), the amendments made by this section 

23 shall apply to underpayments attributable to trans24 actions entered into after the date of the enactment 

25 of this Act. 
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1 (2) NONAPPLICATION OF UNDERSTATEMENT

2 REDUCTION.—The amendment made by subsection 

3 (b) shall apply to understatements attributable to 

4 transactions entered into after the date of the enact5 ment of this Act. 

6 PART 3—PARITY IN HEALTH BENEFITS 

7 SEC. 571. CERTAIN HEALTH RELATED BENEFITS APPLICA8 BLE TO SPOUSES AND DEPENDENTS EX9 TENDED TO ELIGIBLE BENEFICIARIES. 

10 (a) APPLICATION OF ACCIDENT AND HEALTH PLANS

11 TO ELIGIBLE BENEFICIARIES.— 

12 (1) EXCLUSION OF CONTRIBUTIONS.—Section 

13 106 of the Internal Revenue Code of 1986 (relating 

14 to contributions by employer to accident and health 

15 plans), as amended by section 531, is amended by 

16 adding at the end the following new subsection: 

17 ‘‘(g) COVERAGE PROVIDED FOR ELIGIBLE BENE18 FICIARIES OF EMPLOYEES.— 

19 ‘‘(1) IN GENERAL.—Subsection (a) shall apply 

20 with respect to any eligible beneficiary of the em21 ployee. 

22 ‘‘(2) ELIGIBLE BENEFICIARY.—For purposes of 

23 this subsection, the term ‘eligible beneficiary’ means 

24 any individual who is eligible to receive benefits or 

25 coverage under an accident or health plan.’’. 
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1 (2) EXCLUSION OF AMOUNTS EXPENDED FOR

2 MEDICAL CARE.—The first sentence of section 

3 105(b) of such Code (relating to amounts expended 

4 for medical care) is amended— 

5 (A) by striking ‘‘and his dependents’’ and 

6 inserting ‘‘his dependents’’; and 

7 (B) by inserting before the period the fol8 lowing: ‘‘and any eligible beneficiary (within the 

9 meaning of section 106(g)) with respect to the 

10 taxpayer’’. 

11 (3) PAYROLL TAXES.— 

12 (A) Section 3121(a)(2) of such Code is 

13 amended— 

14 (i) by striking ‘‘or any of his depend15 ents’’ in the matter preceding subpara16 graph (A) and inserting ‘‘, any of his de17 pendents, or any eligible beneficiary (with18 in the meaning of section 106(g)) with re19 spect to the employee’’; 

20 (ii) by striking ‘‘or any of his depend21 ents,’’ in subparagraph (A) and inserting 

22 ‘‘, any of his dependents, or any eligible 

23 beneficiary (within the meaning of section 

24 106(g)) with respect to the employee,’’; 

25 and 
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1 (iii) by striking ‘‘and their depend2 ents’’ both places it appears and inserting 

3 ‘‘and such employees’ dependents and eligi4 ble beneficiaries (within the meaning of 

5 section 106(g))’’. 

6 (B) Section 3231(e)(1) of such Code is 

7 amended— 

8 (i) by striking ‘‘or any of his depend9 ents’’ and inserting ‘‘, any of his depend10 ents, or any eligible beneficiary (within the 

11 meaning of section 106(g)) with respect to 

12 the employee,’’; and 

13 (ii) by striking ‘‘and their depend14 ents’’ both places it appears and inserting 

15 ‘‘and such employees’ dependents and eligi16 ble beneficiaries (within the meaning of 

17 section 106(g))’’. 

18 (C) Section 3306(b)(2) of such Code is 

19 amended— 

20 (i) by striking ‘‘or any of his depend21 ents’’ in the matter preceding subpara22 graph (A) and inserting ‘‘, any of his de23 pendents, or any eligible beneficiary (with24 in the meaning of section 106(g)) with re25 spect to the employee,’’; 
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1 (ii) by striking ‘‘or any of his depend2 ents’’ in subparagraph (A) and inserting ‘‘, 

3 any of his dependents, or any eligible bene4 ficiary (within the meaning of section 

5 106(g)) with respect to the employee’’; and 

6 (iii) by striking ‘‘and their depend7 ents’’ both places it appears and inserting 

8 ‘‘and such employees’ dependents and eligi9 ble beneficiaries (within the meaning of 

10 section 106(g))’’. 

11 (D) Section 3401(a) of such Code is 

12 amended by striking ‘‘or’’ at the end of para13 graph (22), by striking the period at the end of 

14 paragraph (23) and inserting ‘‘; or’’, and by in15 serting after paragraph (23) the following new 

16 paragraph: 

17 ‘‘(24) for any payment made to or for the ben18 efit of an employee or any eligible beneficiary (within 

19 the meaning of section 106(g)) if at the time of such 

20 payment it is reasonable to believe that the employee 

21 will be able to exclude such payment from income 

22 under section 106 or under section 105 by reference 

23 in section 105(b) to section 106(g).’’. 
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1 (b) EXPANSION OF DEPENDENCY FOR PURPOSES OF

2 DEDUCTION FOR HEALTH INSURANCE COSTS OF SELF3 EMPLOYED INDIVIDUALS.— 

4 (1) IN GENERAL.—Paragraph (1) of section 

5 162(l) of the Internal Revenue Code of 1986 (relat6 ing to special rules for health insurance costs of self7 employed individuals) is amended to read as follows: 

8 ‘‘(1) ALLOWANCE OF DEDUCTION.—In the case 

9 of a taxpayer who is an employee within the mean10 ing of section 401(c)(1), there shall be allowed as a 

11 deduction under this section an amount equal to the 

12 amount paid during the taxable year for insurance 

13 which constitutes medical care for— 

14 ‘‘(A) the taxpayer, 

15 ‘‘(B) the taxpayer’s spouse, 

16 ‘‘(C) the taxpayer’s dependents, 

17 ‘‘(D) any individual who— 

18 ‘‘(i) satisfies the age requirements of 

19 section 152(c)(3)(A), 

20 ‘‘(ii) bears a relationship to the tax21 payer described in section 152(d)(2)(H), 

22 and 

23 ‘‘(iii) meets the requirements of sec24 tion 152(d)(1)(C), and 

25 ‘‘(E) one individual who— 
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1 ‘‘(i) does not satisfy the age require2 ments of section 152(c)(3)(A), 

3 ‘‘(ii) bears a relationship to the tax4 payer described in section 152(d)(2)(H), 

5 ‘‘(iii) meets the requirements of sec6 tion 152(d)(1)(D), and 

7 ‘‘(iv) is not the spouse of the taxpayer 

8 and does not bear any relationship to the 

9 taxpayer described in subparagraphs (A) 

10 through (G) of section 152(d)(2).’’. 

11 (2) CONFORMING AMENDMENT.—Subparagraph 

12 (B) of section 162(l)(2) of such Code is amended by 

13 inserting ‘‘, any dependent, or individual described 

14 in subparagraph (D) or (E) of paragraph (1) with 

15 respect to’’ after ‘‘spouse’’. 

16 (c) EXTENSION TO ELIGIBLE BENEFICIARIES OF

17 SICK AND ACCIDENT BENEFITS PROVIDED TO MEMBERS

18 OF A VOLUNTARY EMPLOYEES’ BENEFICIARY ASSOCIA19 TION AND THEIR DEPENDENTS.—Section 501(c)(9) of 

20 the Internal Revenue Code of 1986 (relating to list of ex21 empt organizations) is amended by adding at the end the 

22 following new sentence: ‘‘For purposes of providing for the 

23 payment of sick and accident benefits to members of such 

24 an association and their dependents, the term ‘dependents’ 

25 shall include any individual who is an eligible beneficiary 
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1 (within the meaning of section 106(g)), as determined 

2 under the terms of a medical benefit, health insurance, 

3 or other program under which members and their depend4 ents are entitled to sick and accident benefits.’’. 

5 (d) FLEXIBLE SPENDING ARRANGEMENTS AND

6 HEALTH REIMBURSEMENT ARRANGEMENTS.—The Sec7 retary of Treasury shall issue guidance of general applica8 bility providing that medical expenses that otherwise qual9 ify— 

10 (1) for reimbursement from a flexible spending 

11 arrangement under regulations in effect on the date 

12 of the enactment of this Act may be reimbursed 

13 from an employee’s flexible spending arrangement, 

14 notwithstanding the fact that such expenses are at15 tributable to any individual who is not the employ16 ee’s spouse or dependent (within the meaning of sec17 tion 105(b) of the Internal Revenue Code of 1986) 

18 but is an eligible beneficiary (within the meaning of 

19 section 106(g) of such Code) under the flexible 

20 spending arrangement with respect to the employee; 

21 and 

22 (2) for reimbursement from a health reimburse23 ment arrangement under regulations in effect on the 

24 date of the enactment of this Act may be reimbursed 

25 from an employee’s health reimbursement arrange-
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1 ment, notwithstanding the fact that such expenses 

2 are attributable to an individual who is not a spouse 

3 or dependent (within the meaning of section 105(b) 

4 of such Code) but is an eligible beneficiary (within 

5 the meaning of section 106(g) of such Code) under 

6 the health reimbursement arrangement with respect 

7 to the employee. 

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

9 this section shall apply to taxable years beginning after 

10 December 31, 2009. 

11 DIVISION B—MEDICARE AND 

12 MEDICAID IMPROVEMENTS 

13 SEC. 1001. TABLE OF CONTENTS OF DIVISION. 

14 The table of contents of this division is as follows: 

Sec. 1001. Table of contents of division. 

TITLE I—IMPROVING HEALTH CARE VALUE 

Subtitle A—Provisions Related to Medicare Part A 

PART 1—MARKET BASKET UPDATES

Sec. 1101. Skilled nursing facility payment update. 

Sec. 1102. Inpatient rehabilitation facility payment update. 

Sec. 1103. Incorporating productivity improvements into market basket updates 

that do not already incorporate such improvements. 

PART 2—OTHER MEDICARE PART A PROVISIONS

Sec. 1111. Payments to skilled nursing facilities. 

Sec. 1112. Medicare DSH report and payment adjustments in response to coverage expansion. 

Sec. 1113. Extension of hospice regulation moratorium. 

Sec. 1114. Permitting physician assistants to order post-hospital extended care 

services and to provide for recognition of attending physician 

assistants as attending physicians to serve hospice patients. 

Subtitle B—Provisions Related to Part B 

PART 1—PHYSICIANS’ SERVICES
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Sec. 1121. Resource-based feedback program for physicians in Medicare. 

Sec. 1122. Misvalued codes under the physician fee schedule. 

Sec. 1123. Payments for efficient areas. 

Sec. 1124. Modifications to the Physician Quality Reporting Initiative (PQRI). 

Sec. 1125. Adjustment to Medicare payment localities. 

PART 2—MARKET BASKET UPDATES

Sec. 1131. Incorporating productivity improvements into market basket updates 

that do not already incorporate such improvements. 

PART 3—OTHER PROVISIONS

Sec. 1141. Rental and purchase of power-driven wheelchairs. 

Sec. 1141A. Election to take ownership, or to decline ownership, of a certain 

item of complex durable medical equipment after the 13-month 

capped rental period ends. 

Sec. 1142. Extension of payment rule for brachytherapy. 

Sec. 1143. Home infusion therapy report to Congress. 

Sec. 1144. Require ambulatory surgical centers (ASCs) to submit cost data and 

other data. 

Sec. 1145. Treatment of certain cancer hospitals. 

Sec. 1146. Payment for imaging services. 

Sec. 1147. Durable medical equipment program improvements. 

Sec. 1148. MedPAC study and report on bone mass measurement. 

Sec. 1149. Timely access to post-mastectomy items. 

Sec. 1149A. Payment for biosimilar biological products. 

Sec. 1149B. Study and report on DME competitive bidding process. 

Subtitle C—Provisions Related to Medicare Parts A and B 

Sec. 1151. Reducing potentially preventable hospital readmissions. 

Sec. 1152. Post acute care services payment reform plan and bundling pilot 

program. 

Sec. 1153. Home health payment update for 2010. 

Sec. 1154. Payment adjustments for home health care. 

Sec. 1155. Incorporating productivity improvements into market basket update 

for home health services. 

Sec. 1155A. MedPAC study on variation in home health margins. 

Sec. 1155B. Permitting home health agencies to assign the most appropriate 

skilled service to make the initial assessment visit under a 

Medicare home health plan of care for rehabilitation cases. 

Sec. 1156. Limitation on Medicare exceptions to the prohibition on certain physician referrals made to hospitals. 

Sec. 1157. Institute of Medicine study of geographic adjustment factors under 

Medicare. 

Sec. 1158. Revision of medicare payment systems to address geographic inequities. 

Sec. 1159. Institute of Medicine study of geographic variation in health care 

spending and promoting high-value health care. 

Sec. 1160. Implementation, and Congressional review, of proposal to revise 

Medicare payments to promote high value health care. 

Subtitle D—Medicare Advantage Reforms 

PART 1—PAYMENT AND ADMINISTRATION
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Sec. 1161. Phase-in of payment based on fee-for-service costs; quality bonus 

payments. 

Sec. 1162. Authority for Secretarial coding intensity adjustment authority. 

Sec. 1163. Simplification of annual beneficiary election periods. 

Sec. 1164. Extension of reasonable cost contracts. 

Sec. 1165. Limitation of waiver authority for employer group plans. 

Sec. 1166. Improving risk adjustment for payments. 

Sec. 1167. Elimination of MA Regional Plan Stabilization Fund. 

Sec. 1168. Study regarding the effects of calculating Medicare Advantage payment rates on a regional average of Medicare fee for service 

rates. 

PART 2—BENEFICIARY PROTECTIONS AND ANTI-FRAUD

Sec. 1171. Limitation on cost-sharing for individual health services. 

Sec. 1172. Continuous open enrollment for enrollees in plans with enrollment 

suspension. 

Sec. 1173. Information for beneficiaries on MA plan administrative costs. 

Sec. 1174. Strengthening audit authority. 

Sec. 1175. Authority to deny plan bids. 

Sec. 1175A. State authority to enforce standardized marketing requirements. 

PART 3—TREATMENT OF SPECIAL NEEDS PLANS

Sec. 1176. Limitation on enrollment outside open enrollment period of individuals into chronic care specialized MA plans for special needs 

individuals. 

Sec. 1177. Extension of authority of special needs plans to restrict enrollment; 

service area moratorium for certain SNPs. 

Sec. 1178. Extension of Medicare senior housing plans. 

Subtitle E—Improvements to Medicare Part D 

Sec. 1181. Elimination of coverage gap. 

Sec. 1182. Discounts for certain part D drugs in original coverage gap. 

Sec. 1183. Repeal of provision relating to submission of claims by pharmacies 

located in or contracting with long-term care facilities. 

Sec. 1184. Including costs incurred by AIDS drug assistance programs and Indian Health Service in providing prescription drugs toward the 

annual out-of-pocket threshold under part D. 

Sec. 1185. No mid-year formulary changes permitted. 

Sec. 1186. Negotiation of lower covered part D drug prices on behalf of Medicare beneficiaries. 

Sec. 1187. Accurate dispensing in long-term care facilities. 

Sec. 1188. Free generic fill. 

Sec. 1189. State certification prior to waiver of licensure requirements under 

Medicare prescription drug program. 

Subtitle F—Medicare Rural Access Protections 

Sec. 1191. Telehealth expansion and enhancements. 

Sec. 1192. Extension of outpatient hold harmless provision. 

Sec. 1193. Extension of section 508 hospital reclassifications. 

Sec. 1194. Extension of geographic floor for work. 

Sec. 1195. Extension of payment for technical component of certain physician 

pathology services. 

Sec. 1196. Extension of ambulance add-ons. 
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TITLE II—MEDICARE BENEFICIARY IMPROVEMENTS 

Subtitle A—Improving and Simplifying Financial Assistance for Low Income 

Medicare Beneficiaries 

Sec. 1201. Improving assets tests for Medicare Savings Program and low-income subsidy program. 

Sec. 1202. Elimination of part D cost-sharing for certain non-institutionalized 

full-benefit dual eligible individuals. 

Sec. 1203. Eliminating barriers to enrollment. 

Sec. 1204. Enhanced oversight relating to reimbursements for retroactive low 

income subsidy enrollment. 

Sec. 1205. Intelligent assignment in enrollment. 

Sec. 1206. Special enrollment period and automatic enrollment process for certain subsidy eligible individuals. 

Sec. 1207. Application of MA premiums prior to rebate and quality bonus payments in calculation of low income subsidy benchmark. 

Subtitle B—Reducing Health Disparities 

Sec. 1221. Ensuring effective communication in Medicare. 

Sec. 1222. Demonstration to promote access for Medicare beneficiaries with 

limited English proficiency by providing reimbursement for culturally and linguistically appropriate services. 

Sec. 1223. IOM report on impact of language access services. 

Sec. 1224. Definitions. 

Subtitle C—Miscellaneous Improvements 

Sec. 1231. Extension of therapy caps exceptions process. 

Sec. 1232. Extended months of coverage of immunosuppressive drugs for kidney transplant patients and other renal dialysis provisions. 

Sec. 1233. Voluntary advance care planning consultation. 

Sec. 1234. Part B special enrollment period and waiver of limited enrollment 

penalty for TRICARE beneficiaries. 

Sec. 1235. Exception for use of more recent tax year in case of gains from sale 

of primary residence in computing part B income-related premium. 

Sec. 1236. Demonstration program on use of patient decisions aids. 

TITLE III—PROMOTING PRIMARY CARE, MENTAL HEALTH 

SERVICES, AND COORDINATED CARE 

Sec. 1301. Accountable Care Organization pilot program. 

Sec. 1302. Medical home pilot program. 

Sec. 1303. Payment incentive for selected primary care services. 

Sec. 1304. Increased reimbursement rate for certified nurse-midwives. 

Sec. 1305. Coverage and waiver of cost-sharing for preventive services. 

Sec. 1306. Waiver of deductible for colorectal cancer screening tests regardless 

of coding, subsequent diagnosis, or ancillary tissue removal. 

Sec. 1307. Excluding clinical social worker services from coverage under the 

medicare skilled nursing facility prospective payment system 

and consolidated payment. 

Sec. 1308. Coverage of marriage and family therapist services and mental 

health counselor services. 

Sec. 1309. Extension of physician fee schedule mental health add-on. 

Sec. 1310. Expanding access to vaccines. 
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Sec. 1311. Expansion of Medicare-Covered Preventive Services at Federally 

Qualified Health Centers. 

Sec. 1312. Independence at home demonstration program. 

Sec. 1313. Recognition of certified diabetes educators as certified providers for 

purposes of Medicare diabetes outpatient self-management 

training services. 

TITLE IV—QUALITY 

Subtitle A—Comparative Effectiveness Research 

Sec. 1401. Comparative effectiveness research. 

Subtitle B—Nursing Home Transparency 

PART 1—IMPROVING TRANSPARENCY OF INFORMATION ON SKILLED NURSING FACILITIES, NURSING FACILITIES, AND OTHER LONG-TERM CARE FACILITIES

Sec. 1411. Required disclosure of ownership and additional disclosable parties 

information. 

Sec. 1412. Accountability requirements. 

Sec. 1413. Nursing home compare Medicare website. 

Sec. 1414. Reporting of expenditures. 

Sec. 1415. Standardized complaint form. 

Sec. 1416. Ensuring staffing accountability. 

Sec. 1417. Nationwide program for national and State background checks on 

direct patient access employees of long-term care facilities and 

providers. 

PART 2—TARGETING ENFORCEMENT

Sec. 1421. Civil money penalties. 

Sec. 1422. National independent monitor pilot program. 

Sec. 1423. Notification of facility closure. 

PART 3—IMPROVING STAFF TRAINING

Sec. 1431. Dementia and abuse prevention training. 

Sec. 1432. Study and report on training required for certified nurse aides and 

supervisory staff. 

Sec. 1433. Qualification of director of food services of a skilled nursing facility 

or nursing facility. 

Subtitle C—Quality Measurements 

Sec. 1441. Establishment of national priorities for quality improvement. 

Sec. 1442. Development of new quality measures; GAO evaluation of data collection process for quality measurement. 

Sec. 1443. Multi-stakeholder pre-rulemaking input into selection of quality 

measures. 

Sec. 1444. Application of quality measures. 

Sec. 1445. Consensus-based entity funding. 

Sec. 1446. Quality indicators for care of people with Alzheimer’s Disease. 

Subtitle D—Physician Payments Sunshine Provision 
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Sec. 1451. Reports on financial relationships between manufacturers and distributors of covered drugs, devices, biologicals, or medical supplies under Medicare, Medicaid, or CHIP and physicians and 

other health care entities and between physicians and other 

health care entities. 

Subtitle E—Public Reporting on Health Care-Associated Infections 

Sec. 1461. Requirement for public reporting by hospitals and ambulatory surgical centers on health care-associated infections. 

TITLE V—MEDICARE GRADUATE MEDICAL EDUCATION 

Sec. 1501. Distribution of unused residency positions. 

Sec. 1502. Increasing training in nonprovider settings. 

Sec. 1503. Rules for counting resident time for didactic and scholarly activities 

and other activities. 

Sec. 1504. Preservation of resident cap positions from closed hospitals. 

Sec. 1505. Improving accountability for approved medical residency training. 

TITLE VI—PROGRAM INTEGRITY 

Subtitle A—Increased Funding to Fight Waste, Fraud, and Abuse 

Sec. 1601. Increased funding and flexibility to fight fraud and abuse. 

Subtitle B—Enhanced Penalties for Fraud and Abuse 

Sec. 1611. Enhanced penalties for false statements on provider or supplier enrollment applications. 

Sec. 1612. Enhanced penalties for submission of false statements material to 

a false claim. 

Sec. 1613. Enhanced penalties for delaying inspections. 

Sec. 1614. Enhanced hospice program safeguards. 

Sec. 1615. Enhanced penalties for individuals excluded from program participation. 

Sec. 1616. Enhanced penalties for provision of false information by Medicare 

Advantage and part D plans. 

Sec. 1617. Enhanced penalties for Medicare Advantage and part D marketing 

violations. 

Sec. 1618. Enhanced penalties for obstruction of program audits. 

Sec. 1619. Exclusion of certain individuals and entities from participation in 

Medicare and State health care programs. 

Sec. 1620. OIG authority to exclude from Federal health care programs officers and owners of entities convicted of fraud. 

Sec. 1621. Self-referral disclosure protocol. 

Subtitle C—Enhanced Program and Provider Protections 

Sec. 1631. Enhanced CMS program protection authority. 

Sec. 1632. Enhanced Medicare, Medicaid, and CHIP program disclosure requirements relating to previous affiliations. 

Sec. 1633. Required inclusion of payment modifier for certain evaluation and 

management services. 

Sec. 1634. Evaluations and reports required under Medicare Integrity Program. 

Sec. 1635. Require providers and suppliers to adopt programs to reduce waste, 

fraud, and abuse. 
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Sec. 1636. Maximum period for submission of Medicare claims reduced to not 

more than 12 months. 

Sec. 1637. Physicians who order durable medical equipment or home health 

services required to be Medicare enrolled physicians or eligible 

professionals. 

Sec. 1638. Requirement for physicians to provide documentation on referrals to 

programs at high risk of waste and abuse. 

Sec. 1639. Face-to-face encounter with patient required before eligibility certifications for home health services or durable medical equipment. 

Sec. 1640. Extension of testimonial subpoena authority to program exclusion 

investigations. 

Sec. 1641. Required repayments of Medicare and Medicaid overpayments. 

Sec. 1642. Expanded application of hardship waivers for OIG exclusions to 

beneficiaries of any Federal health care program. 

Sec. 1643. Access to certain information on renal dialysis facilities. 

Sec. 1644. Billing agents, clearinghouses, or other alternate payees required to 

register under Medicare. 

Sec. 1645. Conforming civil monetary penalties to False Claims Act amendments. 

Sec. 1646. Requiring provider and supplier payments under Medicare to be 

made through direct deposit or electronic funds transfer (EFT) 

at insured depository institutions. 

Sec. 1647. Inspector General for the Health Choices Administration. 

Subtitle D—Access to Information Needed to Prevent Fraud, Waste, and 

Abuse 

Sec. 1651. Access to Information Necessary to Identify Fraud, Waste, and 

Abuse. 

Sec. 1652. Elimination of duplication between the Healthcare Integrity and 

Protection Data Bank and the National Practitioner Data 

Bank. 

Sec. 1653. Compliance with HIPAA privacy and security standards. 

Sec. 1654. Disclosure of Medicare fraud and abuse hotline number on explanation of benefits. 

TITLE VII—MEDICAID AND CHIP 

Subtitle A—Medicaid and Health Reform 

Sec. 1701. Eligibility for individuals with income below 150 percent of the Federal poverty level. 

Sec. 1702. Requirements and special rules for certain Medicaid eligible individuals. 

Sec. 1703. CHIP and Medicaid maintenance of eligibility. 

Sec. 1704. Reduction in Medicaid DSH. 

Sec. 1705. Expanded outstationing. 

Subtitle B—Prevention 

Sec. 1711. Required coverage of preventive services. 

Sec. 1712. Tobacco cessation. 

Sec. 1713. Optional coverage of nurse home visitation services. 

Sec. 1714. State eligibility option for family planning services. 

Subtitle C—Access 
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Sec. 1721. Payments to primary care practitioners. 

Sec. 1722. Medical home pilot program. 

Sec. 1723. Translation or interpretation services. 

Sec. 1724. Optional coverage for freestanding birth center services. 

Sec. 1725. Inclusion of public health clinics under the vaccines for children program. 

Sec. 1726. Requiring coverage of services of podiatrists. 

Sec. 1726A. Requiring coverage of services of optometrists. 

Sec. 1727. Therapeutic foster care. 

Sec. 1728. Assuring adequate payment levels for services. 

Sec. 1729. Preserving Medicaid coverage for youths upon release from public 

institutions. 

Sec. 1730. Quality measures for maternity and adult health services under 

Medicaid and CHIP. 

Sec. 1730A. Accountable care organization pilot program. 

Sec. 1730B. FQHC coverage. 

Subtitle D—Coverage 

Sec. 1731. Optional Medicaid coverage of low-income HIV-infected individuals. 

Sec. 1732. Extending transitional Medicaid Assistance (TMA). 

Sec. 1733. Requirement of 12-month continuous coverage under certain CHIP 

programs. 

Sec. 1734. Preventing the application under CHIP of coverage waiting periods 

for certain children. 

Sec. 1735. Adult day health care services. 

Sec. 1736. Medicaid coverage for citizens of Freely Associated States. 

Sec. 1737. Continuing requirement of Medicaid coverage of nonemergency 

transportation to medically necessary services. 

Sec. 1738. State option to disregard certain income in providing continued 

Medicaid coverage for certain individuals with extremely high 

prescription costs. 

Sec. 1739. Provisions relating to community living assistance services and supports (CLASS). 

Sec. 1739A. Sense of Congress regarding Community First Choice Option to 

provide medicaid coverage of community-based attendant services and supports. 

Subtitle E—Financing 

Sec. 1741. Payments to pharmacists. 

Sec. 1742. Prescription drug rebates. 

Sec. 1743. Extension of prescription drug discounts to enrollees of Medicaid 

managed care organizations. 

Sec. 1744. Payments for graduate medical education. 

Sec. 1745. Nursing Facility Supplemental Payment Program. 

Sec. 1746. Report on Medicaid payments. 

Sec. 1747. Reviews of Medicaid. 

Sec. 1748. Extension of delay in managed care organization provider tax elimination. 

Sec. 1749. Extension of ARRA increase in FMAP. 

Subtitle F—Waste, Fraud, and Abuse 

Sec. 1751. Health care acquired conditions. 

Sec. 1752. Evaluations and reports required under Medicaid Integrity Program. 
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Sec. 1753. Require providers and suppliers to adopt programs to reduce waste, 

fraud, and abuse. 

Sec. 1754. Overpayments. 

Sec. 1755. Managed care organizations. 

Sec. 1756. Termination of provider participation under Medicaid and CHIP if 

terminated under Medicare or other State plan or child health 

plan. 

Sec. 1757. Medicaid and CHIP exclusion from participation relating to certain 

ownership, control, and management affiliations. 

Sec. 1758. Requirement to report expanded set of data elements under MMIS 

to detect fraud and abuse. 

Sec. 1759. Billing agents, clearinghouses, or other alternate payees required to 

register under Medicaid. 

Sec. 1760. Denial of payments for litigation-related misconduct. 

Sec. 1761. Mandatory State use of national correct coding initiative. 

Subtitle G—Payments to the Territories 

Sec. 1771. Payment to territories. 

Subtitle H—Miscellaneous 

Sec. 1781. Technical corrections. 

Sec. 1782. Extension of QI program. 

Sec. 1783. Assuring transparency of information. 

Sec. 1784. Medicaid and CHIP Payment and Access Commission. 

Sec. 1785. Outreach and enrollment of Medicaid and CHIP eligible individuals. 

Sec. 1786. Prohibitions on Federal Medicaid and CHIP payment for undocumented aliens. 

Sec. 1787. Demonstration project for stabilization of emergency medical conditions by institutions for mental diseases. 

Sec. 1788. Application of Medicaid Improvement Fund. 

Sec. 1789. Treatment of certain Medicaid brokers. 

Sec. 1790. Rule for changes requiring State legislation. 

TITLE VIII—REVENUE-RELATED PROVISIONS 

Sec. 1801. Disclosures to facilitate identification of individuals likely to be ineligible for the low-income assistance under the Medicare prescription drug program to assist Social Security Administration’s outreach to eligible individuals. 

Sec. 1802. Comparative Effectiveness Research Trust Fund; financing for 

Trust Fund. 

TITLE IX—MISCELLANEOUS PROVISIONS 

Sec. 1901. Repeal of trigger provision. 

Sec. 1902. Repeal of comparative cost adjustment (CCA) program. 

Sec. 1903. Extension of gainsharing demonstration. 

Sec. 1904. Grants to States for quality home visitation programs for families 

with young children and families expecting children. 

Sec. 1905. Improved coordination and protection for dual eligibles. 

Sec. 1906. Assessment of medicare cost-intensive diseases and conditions. 

Sec. 1907. Establishment of Center for Medicare and Medicaid Innovation 

within CMS. 

Sec. 1908. Application of emergency services laws. 
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Sec. 1909. Disregard under the Supplemental Security Income program of compensation for participation in clinical trials for rare diseases or 

conditions. 

1 TITLE I—IMPROVING HEALTH 

2 CARE VALUE 

3 Subtitle A—Provisions Related to 

4 Medicare Part A 

5 PART 1—MARKET BASKET UPDATES 

6 SEC. 1101. SKILLED NURSING FACILITY PAYMENT UPDATE. 

7 (a) IN GENERAL.—Section 1888(e)(4)(E)(ii) of the 

8 Social Security Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is 

9 amended— 

10 (1) in subclause (III), by striking ‘‘and’’ at the 

11 end; 

12 (2) by redesignating subclause (IV) as sub13 clause (VI); and 

14 (3) by inserting after subclause (III) the fol15 lowing new subclauses: 

16 ‘‘(IV) for each of fiscal years 

17 2004 through 2009, the rate com18 puted for the previous fiscal year in19 creased by the skilled nursing facility 

20 market basket percentage change for 

21 the fiscal year involved; 

22 ‘‘(V) for fiscal year 2010, the 

23 rate computed for the previous fiscal 

24 year; and’’. 
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1 (b) DELAYED EFFECTIVE DATE.—Section 

2 1888(e)(4)(E)(ii)(V) of the Social Security Act, as in3 serted by subsection (a)(3), shall not apply to payment 

4 for days before January 1, 2010. 

5 SEC. 1102. INPATIENT REHABILITATION FACILITY PAY6 MENT UPDATE. 

7 (a) IN GENERAL.—Section 1886(j)(3)(C) of the So8 cial Security Act (42 U.S.C. 1395ww(j)(3)(C)) is amended 

9 by striking ‘‘and 2009’’ and inserting ‘‘through 2010’’. 

10 (b) DELAYED EFFECTIVE DATE.—The amendment 

11 made by subsection (a) shall not apply to payment units 

12 occurring before January 1, 2010. 

13 SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVE14 MENTS INTO MARKET BASKET UPDATES 

15 THAT DO NOT ALREADY INCORPORATE SUCH 

16 IMPROVEMENTS. 

17 (a) INPATIENT ACUTE HOSPITALS.—Section 

18 1886(b)(3)(B) of the Social Security Act (42 U.S.C. 

19 1395ww(b)(3)(B)) is amended— 

20 (1) in clause (iii)— 

21 (A) by striking ‘‘(iii) For purposes of this 

22 subparagraph,’’ and inserting ‘‘(iii)(I) For pur23 poses of this subparagraph, subject to the pro24 ductivity adjustment described in subclause 

25 (II),’’; and 
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1 (B) by adding at the end the following new 

2 subclause: 

3 ‘‘(II) The productivity adjustment described in this 

4 subclause, with respect to an increase or change for a fis5 cal year or year or cost reporting period, or other annual 

6 period, is a productivity offset in the form of a reduction 

7 in such increase or change equal to the percentage change 

8 in the 10-year moving average of annual economy-wide 

9 private nonfarm business multi-factor productivity (as re10 cently published in final form before the promulgation or 

11 publication of such increase for the year or period in12 volved). Except as otherwise provided, any reference to the 

13 increase described in this clause shall be a reference to 

14 the percentage increase described in subclause (I) minus 

15 the percentage change under this subclause.’’; 

16 (2) in the first sentence of clause (viii)(I), by 

17 inserting ‘‘(but not below zero)’’ after ‘‘shall be re18 duced’’; and 

19 (3) in the first sentence of clause (ix)(I)— 

20 (A) by inserting ‘‘(determined without re21 gard to clause (iii)(II))’’ after ‘‘clause (i)’’ the 

22 second time it appears; and 

23 (B) by inserting ‘‘(but not below zero)’’ 

24 after ‘‘reduced’’. 
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1 (b) SKILLED NURSING FACILITIES.—Section 

2 1888(e)(5)(B) of such Act (42 U.S.C. 1395yy(e)(5)(B)) 

3 is amended by inserting ‘‘subject to the productivity ad4 justment described in section 1886(b)(3)(B)(iii)(II)’’ after 

5 ‘‘as calculated by the Secretary’’. 

6 (c) LONG TERM CARE HOSPITALS.—Section 

7 1886(m) of the Social Security Act (42 U.S.C. 

8 1395ww(m)) is amended by adding at the end the fol9 lowing new paragraph: 

10 ‘‘(3) PRODUCTIVITY ADJUSTMENT.—In imple11 menting the system described in paragraph (1) for 

12 discharges occurring on or after January 1, 2010, 

13 during the rate year ending in 2010 or any subse14 quent rate year for a hospital, to the extent that an 

15 annual percentage increase factor applies to a stand16 ard Federal rate for such discharges for the hos17 pital, such factor shall be subject to the productivity 

18 adjustment described in subsection 

19 (b)(3)(B)(iii)(II).’’. 

20 (d) INPATIENT REHABILITATION FACILITIES.—The 

21 second sentence of section 1886(j)(3)(C) of the Social Se22 curity Act (42 U.S.C. 1395ww(j)(3)(C)) is amended by in23 serting ‘‘(subject to the productivity adjustment described 

24 in subsection (b)(3)(B)(iii)(II))’’ after ‘‘appropriate per25 centage increase’’. 
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1 (e) PSYCHIATRIC HOSPITALS.—Section 1886 of the 

2 Social Security Act (42 U.S.C. 1395ww) is amended by 

3 adding at the end the following new subsection: 

4 ‘‘(o) PROSPECTIVE PAYMENT FOR PSYCHIATRIC

5 HOSPITALS.— 

6 ‘‘(1) REFERENCE TO ESTABLISHMENT AND IM7 PLEMENTATION OF SYSTEM.—For provisions related 

8 to the establishment and implementation of a pro9 spective payment system for payments under this 

10 title for inpatient hospital services furnished by psy11 chiatric hospitals (as described in clause (i) of sub12 section (d)(1)(B) and psychiatric units (as described 

13 in the matter following clause (v) of such sub14 section), see section 124 of the Medicare, Medicaid, 

15 and SCHIP Balanced Budget Refinement Act of 

16 1999. 

17 ‘‘(2) PRODUCTIVITY ADJUSTMENT.—In imple18 menting the system described in paragraph (1) for 

19 days occurring during the rate year ending in 2011 

20 or any subsequent rate year for a psychiatric hos21 pital or unit described in such paragraph, to the ex22 tent that an annual percentage increase factor ap23 plies to a base rate for such days for the hospital 

24 or unit, respectively, such factor shall be subject to 
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1 the productivity adjustment described in subsection 

2 (b)(3)(B)(iii)(II).’’. 

3 (f) HOSPICE CARE.—Subclause (VII) of section 

4 1814(i)(1)(C)(ii) of the Social Security Act (42 U.S.C. 

5 1395f(i)(1)(C)(ii)) is amended by inserting after ‘‘the 

6 market basket percentage increase’’ the following: ‘‘(which 

7 is subject to the productivity adjustment described in sec8 tion 1886(b)(3)(B)(iii)(II))’’. 

9 (g) EFFECTIVE DATES.— 

10 (1) IPPS.—The amendments made by sub11 section (a) shall apply to annual increases effected 

12 for fiscal years beginning with fiscal year 2010, but 

13 only with respect to discharges occurring on or after 

14 January 1, 2010. 

15 (2) SNF AND IRF.—The amendments made by 

16 subsections (b) and (d) shall apply to annual in17 creases effected for fiscal years beginning with fiscal 

18 year 2011. 

19 (3) HOSPICE CARE.—The amendment made by 

20 subsection (f) shall apply to annual increases ef21 fected for fiscal years beginning with fiscal year 

22 2010, but only with respect to days of care occurring 

23 on or after January 1, 2010. 
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1 PART 2—OTHER MEDICARE PART A PROVISIONS 

2 SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES. 

3 (a) CHANGE IN RECALIBRATION FACTOR.— 

4 (1) ANALYSIS.—The Secretary of Health and 

5 Human Services shall conduct, using calendar year 

6 2006 claims data, an initial analysis comparing total 

7 payments under title XVIII of the Social Security 

8 Act for skilled nursing facility services under the 

9 RUG–53 and under the RUG–44 classification sys10 tems. 

11 (2) ADJUSTMENT IN RECALIBRATION FAC12 TOR.—Based on the initial analysis under paragraph 

13 (1), the Secretary shall adjust the case mix indexes 

14 under section 1888(e)(4)(G)(i) of the Social Security 

15 Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for fiscal year 

16 2010 by the appropriate recalibration factor as pro17 posed in the final rule for Medicare skilled nursing 

18 facilities issued by such Secretary on August 11, 

19 2009 (74 Fed. Reg. 40287 et seq.). 

20 (b) CHANGE IN PAYMENT FOR NONTHERAPY ANCIL21 LARY (NTA) SERVICES AND THERAPY SERVICES.— 

22 (1) CHANGES UNDER CURRENT SNF CLASSI23 FICATION SYSTEM.— 

24 (A) IN GENERAL.—Subject to subpara25 graph (B), the Secretary of Health and Human 

26 Services shall, under the system for payment of 
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1 skilled nursing facility services under section 

2 1888(e) of the Social Security Act (42 U.S.C. 

3 1395yy(e)), increase payment by 10 percent for 

4 non-therapy ancillary services (as specified by 

5 the Secretary in the notice issued on November 

6 27, 1998 (63 Fed. Reg. 65561 et seq.)) and 

7 shall decrease payment for the therapy case mix 

8 component of such rates by 5.5 percent. 

9 (B) EFFECTIVE DATE.—The changes in 

10 payment described in subparagraph (A) shall 

11 apply for days on or after April 1, 2010, and 

12 until the Secretary implements an alternative 

13 case mix classification system for payment of 

14 skilled nursing facility services under section 

15 1888(e) of the Social Security Act (42 U.S.C. 

16 1395yy(e)). 

17 (C) IMPLEMENTATION.—Notwithstanding 

18 any other provision of law, the Secretary may 

19 implement by program instruction or otherwise 

20 the provisions of this paragraph. 

21 (2) CHANGES UNDER A FUTURE SNF CASE MIX

22 CLASSIFICATION SYSTEM.— 

23 (A) ANALYSIS.— 

24 (i) IN GENERAL.—The Secretary of 

25 Health and Human Services shall analyze 
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1 payments for non-therapy ancillary services 

2 under a future skilled nursing facility clas3 sification system to ensure the accuracy of 

4 payment for non-therapy ancillary services. 

5 Such analysis shall consider use of appro6 priate predictors which may include age, 

7 physical and mental status, ability to per8 form activities of daily living, prior nursing 

9 home stay, diagnoses, broad RUG cat10 egory, and a proxy for length of stay. 

11 (ii) APPLICATION.—Such analysis 

12 shall be conducted in a manner such that 

13 the future skilled nursing facility classifica14 tion system is implemented to apply to 

15 services furnished during a fiscal year be16 ginning with fiscal year 2011. 

17 (B) CONSULTATION.—In conducting the 

18 analysis under subparagraph (A), the Secretary 

19 shall consult with interested parties, including 

20 the Medicare Payment Advisory Commission 

21 and other interested stakeholders, to identify 

22 appropriate predictors of nontherapy ancillary 

23 costs. 

24 (C) RULEMAKING.—The Secretary shall 

25 include the result of the analysis under sub-
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1 paragraph (A) in the fiscal year 2011 rule2 making cycle for purposes of implementation 

3 beginning for such fiscal year. 

4 (D) IMPLEMENTATION.—Subject to sub5 paragraph (E) and consistent with subpara6 graph (A)(ii), the Secretary shall implement 

7 changes to payments for non-therapy ancillary 

8 services (which shall include a separate rate 

9 component for non-therapy ancillary services 

10 and may include use of a model that predicts 

11 payment amounts applicable for non-therapy 

12 ancillary services) under such future skilled 

13 nursing facility services classification system as 

14 the Secretary determines appropriate based on 

15 the analysis conducted pursuant to subpara16 graph (A). 

17 (E) BUDGET NEUTRALITY.—The Secretary 

18 shall implement changes described in subpara19 graph (D) in a manner such that the estimated 

20 expenditures under such future skilled nursing 

21 facility services classification system for a fiscal 

22 year beginning with fiscal year 2011 with such 

23 changes would be equal to the estimated ex24 penditures that would otherwise occur under 

25 title XVIII of the Social Security Act under 
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1 such future skilled nursing facility services clas2 sification system for such year without such 

3 changes. 

4 (c) OUTLIER POLICY FOR NTA AND THERAPY.—Sec5 tion 1888(e) of the Social Security Act (42 U.S.C. 

6 1395yy(e)) is amended by adding at the end the following 

7 new paragraph: 

8 ‘‘(13) OUTLIERS FOR NTA AND THERAPY.— 

9 ‘‘(A) IN GENERAL.—With respect to 

10 outliers because of unusual variations in the 

11 type or amount of medically necessary care, be12 ginning with October 1, 2010, the Secretary— 

13 ‘‘(i) shall provide for an addition or 

14 adjustment to the payment amount other15 wise made under this section with respect 

16 to non-therapy ancillary services in the 

17 case of such outliers; and 

18 ‘‘(ii) may provide for such an addition 

19 or adjustment to the payment amount oth20 erwise made under this section with re21 spect to therapy services in the case of 

22 such outliers. 

23 ‘‘(B) OUTLIERS BASED ON AGGREGATE

24 COSTS.—Outlier adjustments or additional pay25 ments described in subparagraph (A) shall be 
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1 based on aggregate costs during a stay in a 

2 skilled nursing facility and not on the number 

3 of days in such stay. 

4 ‘‘(C) BUDGET NEUTRALITY.—The Sec5 retary shall reduce estimated payments that 

6 would otherwise be made under the prospective 

7 payment system under this subsection with re8 spect to a fiscal year by 2 percent. The total 

9 amount of the additional payments or payment 

10 adjustments for outliers made under this para11 graph with respect to a fiscal year may not ex12 ceed 2 percent of the total payments projected 

13 or estimated to be made based on the prospec14 tive payment system under this subsection for 

15 the fiscal year.’’. 

16 (d) CONFORMING AMENDMENTS.—Section 

17 1888(e)(8) of such Act (42 U.S.C. 1395yy(e)(8)) is 

18 amended— 

19 (1) in subparagraph (A)— 

20 (A) by striking ‘‘and’’ before ‘‘adjust21 ments’’; and 

22 (B) by inserting ‘‘, and adjustment under 

23 section 1111(b) of the Affordable Health Care 

24 for America Act’’ before the semicolon at the 

25 end; 
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1 (2) in subparagraph (B), by striking ‘‘and’’; 

2 (3) in subparagraph (C), by striking the period 

3 and inserting ‘‘; and’’; and 

4 (4) by adding at the end the following new sub5 paragraph: 

6 ‘‘(D) the establishment of outliers under 

7 paragraph (13).’’. 

8 SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUST9 MENTS IN RESPONSE TO COVERAGE EXPAN10 SION. 

11 (a) DSH REPORT.— 

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

13 2016, the Secretary of Health and Human Services 

14 shall submit to Congress a report on Medicare DSH 

15 taking into account the impact of the health care re16 forms carried out under division A in reducing the 

17 number of uninsured individuals. The report shall 

18 include recommendations relating to the following: 

19 (A) The appropriate amount, targeting, 

20 and distribution of Medicare DSH to com21 pensate for higher Medicare costs associated 

22 with serving low-income beneficiaries (taking 

23 into account variations in the empirical jus24 tification for Medicare DSH attributable to hos25 pital characteristics, including bed size), con-
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1 sistent with the original intent of Medicare 

2 DSH. 

3 (B) The appropriate amount, targeting, 

4 and distribution of Medicare DSH to hospitals 

5 given their continued uncompensated care costs, 

6 to the extent such costs remain. 

7 (2) COORDINATION WITH MEDICAID DSH RE8 PORT.—The Secretary shall coordinate the report 

9 under this subsection with the report on Medicaid 

10 DSH under section 1704(a). 

11 (b) PAYMENT ADJUSTMENTS IN RESPONSE TO COV12 ERAGE EXPANSION.— 

13 (1) IN GENERAL.—If there is a significant de14 crease in the national rate of uninsurance as a result 

15 of this Act (as determined under paragraph (2)(A)), 

16 then the Secretary of Health and Human Services 

17 shall, beginning in fiscal year 2017, implement the 

18 following adjustments to Medicare DSH: 

19 (A) In lieu of the amount of Medicare 

20 DSH payment that would otherwise be made 

21 under section 1886(d)(5)(F) of the Social Secu22 rity Act, the amount of Medicare DSH payment 

23 shall be an amount based on the recommenda24 tions of the report under subsection (a)(1)(A) 

25 and shall take into account variations in the 
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1 empirical justification for Medicare DSH attrib2 utable to hospital characteristics, including bed 

3 size. 

4 (B) Subject to paragraph (3), make an ad5 ditional payment to a hospital by an amount 

6 that is estimated based on the amount of un7 compensated care provided by the hospital 

8 based on criteria for uncompensated care as de9 termined by the Secretary, which shall exclude 

10 bad debt. 

11 (2) SIGNIFICANT DECREASE IN NATIONAL RATE

12 OF UNINSURANCE AS A RESULT OF THIS ACT.—For 

13 purposes of this subsection— 

14 (A) IN GENERAL.—There is a ‘‘significant 

15 decrease in the national rate of uninsurance as 

16 a result of this Act’’ if there is a decrease in 

17 the national rate of uninsurance (as defined in 

18 subparagraph (B)) from 2012 to 2014 that ex19 ceeds 8 percentage points. 

20 (B) NATIONAL RATE OF UNINSURANCE

21 DEFINED.—The term ‘‘national rate of 

22 uninsurance’’ means, for a year, such rate for 

23 the under-65 population for the year as deter24 mined and published by the Bureau of the Cen-
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1 sus in its Current Population Survey in or 

2 about September of the succeeding year. 

3 (3) UNCOMPENSATED CARE INCREASE.— 

4 (A) COMPUTATION OF DSH SAVINGS.—For 

5 each fiscal year (beginning with fiscal year 

6 2017), the Secretary shall estimate the aggre7 gate reduction in the amount of Medicare DSH 

8 payment that would be expected to result from 

9 the adjustment under paragraph (1)(A). 

10 (B) STRUCTURE OF PAYMENT IN11 CREASE.—The Secretary shall compute the ad12 ditional payment to a hospital as described in 

13 paragraph (1)(B) for a fiscal year in accordance 

14 with a formula established by the Secretary 

15 that provides that— 

16 (i) the estimated aggregate amount of 

17 such increase for the fiscal year does not 

18 exceed 50 percent of the aggregate reduc19 tion in Medicare DSH estimated by the 

20 Secretary for such fiscal year; and 

21 (ii) hospitals with higher levels of un22 compensated care receive a greater in23 crease. 

24 (c) MEDICARE DSH.—In this section, the term 

25 ‘‘Medicare DSH’’ means adjustments in payments under 
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1 section 1886(d)(5)(F) of the Social Security Act (42 

2 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital services 

3 furnished by disproportionate share hospitals. 

4 SEC. 1113. EXTENSION OF HOSPICE REGULATION MORATO5 RIUM. 

6 Section 4301(a) of division B of the American Recov7 ery and Reinvestment Act of 2009 (Public Law 111–5) 

8 is amended— 

9 (1) by striking ‘‘October 1, 2009’’ and inserting 

10 ‘‘October 1, 2010’’; and 

11 (2) by striking ‘‘for fiscal year 2009’’ and in12 serting ‘‘for fiscal years 2009 and 2010’’. 

13 SEC. 1114. PERMITTING PHYSICIAN ASSISTANTS TO ORDER 

14 POST-HOSPITAL EXTENDED CARE SERVICES 

15 AND TO PROVIDE FOR RECOGNITION OF AT16 TENDING PHYSICIAN ASSISTANTS AS AT17 TENDING PHYSICIANS TO SERVE HOSPICE 

18 PATIENTS. 

19 (a) ORDERING POST-HOSPITAL EXTENDED CARE

20 SERVICES.—Section 1814(a) of the Social Security Act 

21 (42 U.S.C. 1395f(a)) is amended— 

22 (1) in paragraph (2) in the matter preceding 

23 subparagraph (A), is amended by striking ‘‘nurse 

24 practitioner or clinical nurse specialist’’ and insert-
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1 ing ‘‘nurse practitioner, a clinical nurse specialist, or 

2 a physician assistant’’. 

3 (2) in the second sentence, by striking ‘‘or clin4 ical nurse specialist’’ and inserting ‘‘clinical nurse 

5 specialist, or physician assistant’’. 

6 (b) RECOGNITION OF ATTENDING PHYSICIAN AS7 SISTANTS AS ATTENDING PHYSICIANS TO SERVE HOSPICE

8 PATIENTS.— 

9 (1) IN GENERAL.—Section 1861(dd)(3)(B) of 

10 such Act (42 U.S.C. 1395x(dd)(3)(B)) is amended— 

11 (A) by striking ‘‘or nurse’’ and inserting ‘‘, 

12 the nurse’’; and 

13 (B) by inserting ‘‘or the physician assist14 ant (as defined in such subsection),’’ after 

15 ‘‘subsection (aa)(5)),’’. 

16 (2) CONFORMING AMENDMENT.—Section 

17 1814(a)(7)(A)(i)(I) of such Act (42 U.S.C. 

18 1395f(a)(7)(A)(i)(I)) is amended by inserting ‘‘or a 

19 physician assistant’’ after ‘‘a nurse practitioner’’. 

20 (3) CONSTRUCTION.—Nothing in the amend21 ments made by this subsection shall be construed as 

22 changing the requirements of section 1842(b)(6)(C) 

23 of the Social Security Act (42 U.S.C. 

24 1395u(b)(6)(C)) with respect to payment for serv-
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1 ices of physician assistants under part B of title 

2 XVIII of such Act. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 this section shall apply to items and services furnished on 

5 or after January 1, 2010. 

6 Subtitle B—Provisions Related to 

7 Part B 

8 PART 1—PHYSICIANS’ SERVICES 

9 SEC. 1121. RESOURCE-BASED FEEDBACK PROGRAM FOR 

10 PHYSICIANS IN MEDICARE. 

11 Section 1848(n) of the Social Security Act (42 U.S.C. 

12 1395w–4(n)) is amended by adding at the end the fol13 lowing new paragraph: 

14 ‘‘(9) FEEDBACK IMPLEMENTATION PLAN.— 

15 ‘‘(A) TIMELINE FOR FEEDBACK PRO16 GRAM.— 

17 ‘‘(i) EVALUATION.—During 2011 the 

18 Secretary shall conduct the evaluation 

19 specified in subparagraph (E)(i). 

20 ‘‘(ii) EXPANSION.—The Secretary 

21 shall expand the Program under this sub22 section as specified in subparagraph 

23 (E)(ii). 

24 ‘‘(B) ESTABLISHMENT OF NATURE OF RE25 PORTS.— 
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1 ‘‘(i) IN GENERAL.—The Secretary 

2 shall develop and specify the nature of the 

3 reports that will be disseminated under 

4 this subsection, based on results and find5 ings from the Program under this sub6 section as in existence before the date of 

7 the enactment of this paragraph. Such re8 ports may be based on a per capita basis, 

9 an episode basis that combines separate 

10 but clinically related physicians’ services 

11 and other items and services furnished or 

12 ordered by a physician into an episode of 

13 care, as appropriate, or both. 

14 ‘‘(ii) TIMELINE FOR DEVELOP15 MENT.—The nature of the reports de16 scribed in clause (i) shall be developed by 

17 not later than January 1, 2012. 

18 ‘‘(iii) PUBLIC AVAILABILITY.—The 

19 Secretary shall make the details of the na20 ture of the reports developed under clause 

21 (i) available to the public. 

22 ‘‘(C) ANALYSIS OF DATA.—The Secretary 

23 shall, for purposes of preparing reports under 

24 this subsection, establish methodologies as ap25 propriate such as to— 
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1 ‘‘(i) attribute items and services, in 

2 whole or in part, to physicians; 

3 ‘‘(ii) identify appropriate physicians 

4 for purposes of comparison under subpara5 graph (B)(i); and 

6 ‘‘(iii) aggregate items and services at7 tributed to a physician under clause (i) 

8 into a composite measure per individual. 

9 ‘‘(D) FEEDBACK PROGRAM.—The Sec10 retary shall engage in efforts to disseminate re11 ports under this subsection. In disseminating 

12 such reports, the Secretary shall consider the 

13 following: 

14 ‘‘(i) Direct meetings between con15 tracted physicians, facilitated by the Sec16 retary, to discuss the contents of reports 

17 under this subsection, including any rea18 sons for divergence from local or national 

19 averages. 

20 ‘‘(ii) Contract with local, non-profit 

21 entities engaged in quality improvement ef22 forts at the community level. Such entities 

23 shall use the reports under this subsection, 

24 or such equivalent tool as specified by the 

25 Secretary. Any exchange of data under this 
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1 paragraph shall be protected by appro2 priate privacy safeguards. 

3 ‘‘(iii) Mailings or other methods of 

4 communication that facilitate large-scale 

5 dissemination. 

6 ‘‘(iv) Other methods specified by the 

7 Secretary. 

8 ‘‘(E) EVALUATION AND EXPANSION.— 

9 ‘‘(i) EVALUATION.—The Secretary 

10 shall evaluate the methods specified in sub11 paragraph (D) with regard to their efficacy 

12 in changing practice patterns to improve 

13 quality and decrease costs. 

14 ‘‘(ii) EXPANSION.—Taking into ac15 count the cost of each method specified in 

16 subparagraph (D), the Secretary shall de17 velop a plan to disseminate reports under 

18 this subsection in a significant manner in 

19 the regions and cities of the country with 

20 the highest utilization of services under 

21 this title. To the extent practicable, reports 

22 under this subsection shall be disseminated 

23 to increasing numbers of physicians each 

24 year, such that during 2014 and subse25 quent years, reports are disseminated at 
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1 least to physicians with utilization rates 

2 among the highest 5 percent of the nation, 

3 subject the authority to focus under para4 graph (4). 

5 ‘‘(F) ADMINISTRATION.— 

6 ‘‘(i) Chapter 35 of title 44, United 

7 States Code, shall not apply to this para8 graph. 

9 ‘‘(ii) Notwithstanding any other provi10 sion of law, the Secretary may implement 

11 the provisions of this paragraph by pro12 gram instruction or otherwise.’’. 

13 SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE 

14 SCHEDULE. 

15 (a) IN GENERAL.—Section 1848(c)(2) of the Social 

16 Security Act (42 U.S.C. 1395w–4(c)(2)) is amended by 

17 adding at the end the following new subparagraphs: 

18 ‘‘(K) POTENTIALLY MISVALUED CODES.— 

19 ‘‘(i) IN GENERAL.—The Secretary 

20 shall— 

21 ‘‘(I) periodically identify services 

22 as being potentially misvalued using 

23 criteria specified in clause (ii); and 

24 ‘‘(II) review and make appro25 priate adjustments to the relative val-
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1 ues established under this paragraph 

2 for services identified as being poten3 tially misvalued under subclause (I). 

4 ‘‘(ii) IDENTIFICATION OF POTEN5 TIALLY MISVALUED CODES.—For purposes 

6 of identifying potentially misvalued services 

7 pursuant to clause (i)(I), the Secretary 

8 shall examine (as the Secretary determines 

9 to be appropriate) codes (and families of 

10 codes as appropriate) for which there has 

11 been the fastest growth; codes (and fami12 lies of codes as appropriate) that have ex13 perienced substantial changes in practice 

14 expenses; codes for new technologies or 

15 services within an appropriate period (such 

16 as three years) after the relative values are 

17 initially established for such codes; mul18 tiple codes that are frequently billed in 

19 conjunction with furnishing a single serv20 ice; codes with low relative values, particu21 larly those that are often billed multiple 

22 times for a single treatment; codes which 

23 have not been subject to review since the 

24 implementation of the RBRVS (the so25 called ‘Harvard-valued codes’); and such 
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1 other codes determined to be appropriate 

2 by the Secretary. 

3 ‘‘(iii) REVIEW AND ADJUSTMENTS.— 

4 ‘‘(I) The Secretary may use ex5 isting processes to receive rec6 ommendations on the review and ap7 propriate adjustment of potentially 

8 misvalued services described clause 

9 (i)(II). 

10 ‘‘(II) The Secretary may conduct 

11 surveys, other data collection activi12 ties, studies, or other analyses as the 

13 Secretary determines to be appro14 priate to facilitate the review and ap15 propriate adjustment described in 

16 clause (i)(II). 

17 ‘‘(III) The Secretary may use 

18 analytic contractors to identify and 

19 analyze services identified under 

20 clause (i)(I), conduct surveys or col21 lect data, and make recommendations 

22 on the review and appropriate adjust23 ment of services described in clause 

24 (i)(II). 
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1 ‘‘(IV) The Secretary may coordi2 nate the review and appropriate ad3 justment described in clause (i)(II) 

4 with the periodic review described in 

5 subparagraph (B). 

6 ‘‘(V) As part of the review and 

7 adjustment described in clause (i)(II), 

8 including with respect to codes with 

9 low relative values described in clause 

10 (ii), the Secretary may make appro11 priate coding revisions (including 

12 using existing processes for consider13 ation of coding changes) which may 

14 include consolidation of individual 

15 services into bundled codes for pay16 ment under the fee schedule under 

17 subsection (b). 

18 ‘‘(VI) The provisions of subpara19 graph (B)(ii)(II) shall apply to adjust20 ments to relative value units made 

21 pursuant to this subparagraph in the 

22 same manner as such provisions apply 

23 to adjustments under subparagraph 

24 (B)(ii)(II). 
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1 ‘‘(L) VALIDATING RELATIVE VALUE

2 UNITS.— 

3 ‘‘(i) IN GENERAL.—The Secretary 

4 shall establish a process to validate relative 

5 value units under the fee schedule under 

6 subsection (b). 

7 ‘‘(ii) COMPONENTS AND ELEMENTS

8 OF WORK.—The process described in 

9 clause (i) may include validation of work 

10 elements (such as time, mental effort and 

11 professional judgment, technical skill and 

12 physical effort, and stress due to risk) in13 volved with furnishing a service and may 

14 include validation of the pre, post, and 

15 intra-service components of work. 

16 ‘‘(iii) SCOPE OF CODES.—The valida17 tion of work relative value units shall in18 clude a sampling of codes for services that 

19 is the same as the codes listed under sub20 paragraph (K)(ii) 

21 ‘‘(iv) METHODS.—The Secretary may 

22 conduct the validation under this subpara23 graph using methods described in sub24 clauses (I) through (V) of subparagraph 
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1 (K)(iii) as the Secretary determines to be 

2 appropriate. 

3 ‘‘(v) ADJUSTMENTS.—The Secretary 

4 shall make appropriate adjustments to the 

5 work relative value units under the fee 

6 schedule under subsection (b). The provi7 sions of subparagraph (B)(ii)(II) shall 

8 apply to adjustments to relative value units 

9 made pursuant to this subparagraph in the 

10 same manner as such provisions apply to 

11 adjustments under subparagraph 

12 (B)(ii)(II).’’. 

13 (b) IMPLEMENTATION.— 

14 (1) FUNDING.—For purposes of carrying out 

15 the provisions of subparagraphs (K) and (L) of 

16 1848(c)(2) of the Social Security Act, as added by 

17 subsection (a), in addition to funds otherwise avail18 able, out of any funds in the Treasury not otherwise 

19 appropriated, there are appropriated to the Sec20 retary of Health and Human Services for the Center 

21 for Medicare & Medicaid Services Program Manage22 ment Account $20,000,000 for fiscal year 2010 and 

23 each subsequent fiscal year. Amounts appropriated 

24 under this paragraph for a fiscal year shall be avail25 able until expended. 
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1 (2) ADMINISTRATION.— 

2 (A) Chapter 35 of title 44, United States 

3 Code, and the provisions of the Federal Advi4 sory Committee Act (5 U.S.C. App.) shall not 

5 apply to this section or the amendment made by 

6 this section. 

7 (B) Notwithstanding any other provision of 

8 law, the Secretary may implement subpara9 graphs (K) and (L) of 1848(c)(2) of the Social 

10 Security Act, as added by subsection (a), by 

11 program instruction or otherwise. 

12 (C) Section 4505(d) of the Balanced 

13 Budget Act of 1997 is repealed. 

14 (D) Except for provisions related to con15 fidentiality of information, the provisions of the 

16 Federal Acquisition Regulation shall not apply 

17 to this section or the amendment made by this 

18 section. 

19 (3) FOCUSING CMS RESOURCES ON POTEN20 TIALLY OVERVALUED CODES.—Section 1868(a) of 

21 the Social Security Act (42 U.S.C. 1395ee(a)) is re22 pealed. 
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1 SEC. 1123. PAYMENTS FOR EFFICIENT AREAS. 

2 Section 1833 of the Social Security Act (42 U.S.C. 

3 1395l) is amended by adding at the end the following new 

4 subsection: 

5 ‘‘(x) INCENTIVE PAYMENTS FOR EFFICIENT

6 AREAS.— 

7 ‘‘(1) IN GENERAL.—In the case of services fur8 nished under the physician fee schedule under sec9 tion 1848 on or after January 1, 2011, and before 

10 January 1, 2013, by a supplier that is paid under 

11 such fee schedule in an efficient area (as identified 

12 under paragraph (2)), in addition to the amount of 

13 payment that would otherwise be made for such 

14 services under this part, there also shall be paid (on 

15 a monthly or quarterly basis) an amount equal to 5 

16 percent of the payment amount for the services 

17 under this part. 

18 ‘‘(2) IDENTIFICATION OF EFFICIENT AREAS.— 

19 ‘‘(A) IN GENERAL.—Based upon available 

20 data, the Secretary shall identify those counties 

21 or equivalent areas in the United States in the 

22 lowest fifth percentile of utilization based on 

23 per capita spending under this part and part A 

24 for services provided in the most recent year for 

25 which data are available as of the date of the 

26 enactment of this subsection, as standardized to 
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1 eliminate the effect of geographic adjustments 

2 in payment rates. 

3 ‘‘(B) IDENTIFICATION OF COUNTIES

4 WHERE SERVICE IS FURNISHED..—For pur5 poses of paying the additional amount specified 

6 in paragraph (1), if the Secretary uses the 5- 

7 digit postal ZIP Code where the service is fur8 nished, the dominant county of the postal ZIP 

9 Code (as determined by the United States Post10 al Service, or otherwise) shall be used to deter11 mine whether the postal ZIP Code is in a coun12 ty described in subparagraph (A). 

13 ‘‘(C) LIMITATION ON REVIEW.—There 

14 shall be no administrative or judicial review 

15 under section 1869, 1878, or otherwise, respect16 ing— 

17 ‘‘(i) the identification of a county or 

18 other area under subparagraph (A); or 

19 ‘‘(ii) the assignment of a postal ZIP 

20 Code to a county or other area under sub21 paragraph (B). 

22 ‘‘(D) PUBLICATION OF LIST OF COUNTIES; 

23 POSTING ON WEBSITE.—With respect to a year 

24 for which a county or area is identified under 

25 this paragraph, the Secretary shall identify 
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1 such counties or areas as part of the proposed 

2 and final rule to implement the physician fee 

3 schedule under section 1848 for the applicable 

4 year. The Secretary shall post the list of coun5 ties identified under this paragraph on the 

6 Internet website of the Centers for Medicare & 

7 Medicaid Services.’’. 

8 SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY 

9 REPORTING INITIATIVE (PQRI). 

10 (a) FEEDBACK.—Section 1848(m)(5) of the Social 

11 Security Act (42 U.S.C. 1395w–4(m)(5)) is amended by 

12 adding at the end the following new subparagraph: 

13 ‘‘(H) FEEDBACK.—The Secretary shall 

14 provide timely feedback to eligible professionals 

15 on the performance of the eligible professional 

16 with respect to satisfactorily submitting data on 

17 quality measures under this subsection.’’. 

18 (b) APPEALS.—Such section is further amended— 

19 (1) in subparagraph (E), by striking ‘‘There 

20 shall be’’ and inserting ‘‘Except as provided in sub21 paragraph (I), there shall be’’; and 

22 (2) by adding at the end the following new sub23 paragraph: 

24 ‘‘(I) INFORMAL APPEALS PROCESS.—By 

25 not later than January 1, 2011, the Secretary 
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1 shall establish and have in place an informal 

2 process for eligible professionals to seek a re3 view of the determination that an eligible pro4 fessional did not satisfactorily submit data on 

5 quality measures under this subsection.’’. 

6 (c) INTEGRATION OF PHYSICIAN QUALITY REPORT7 ING AND EHR REPORTING.—Section 1848(m) of such 

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

9 paragraph: 

10 ‘‘(7) INTEGRATION OF PHYSICIAN QUALITY RE11 PORTING AND EHR REPORTING.—Not later than 

12 January 1, 2012, the Secretary shall develop a plan 

13 to integrate clinical reporting on quality measures 

14 under this subsection with reporting requirements 

15 under subsection (o) relating to the meaningful use 

16 of electronic health records. Such integration shall 

17 consist of the following: 

18 ‘‘(A) The development of measures, the re19 porting of which would both demonstrate— 

20 ‘‘(i) meaningful use of an electronic 

21 health record for purposes of subsection 

22 (o); and 

23 ‘‘(ii) clinical quality of care furnished 

24 to an individual. 
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1 ‘‘(B) The collection of health data to iden2 tify deficiencies in the quality and coordination 

3 of care for individuals eligible for benefits under 

4 this part. 

5 ‘‘(C) Such other activities as specified by 

6 the Secretary.’’. 

7 (d) EXTENSION OF INCENTIVE PAYMENTS.—Section 

8 1848(m)(1) of such Act (42 U.S.C. 1395w–4(m)(1)) is 

9 amended— 

10 (1) in subparagraph (A), by striking ‘‘2010’’ 

11 and inserting ‘‘2012’’; and 

12 (2) in subparagraph (B)(ii), by striking ‘‘2009 

13 and 2010’’ and inserting ‘‘for each of the years 2009 

14 through 2012’’. 

15 SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCAL16 ITIES. 

17 (a) IN GENERAL.—Section 1848(e) of the Social Se18 curity Act (42 U.S.C.1395w–4(e)) is amended by adding 

19 at the end the following new paragraph: 

20 ‘‘(6) TRANSITION TO USE OF MSAS AS FEE

21 SCHEDULE AREAS IN CALIFORNIA.— 

22 ‘‘(A) IN GENERAL.— 

23 ‘‘(i) REVISION.—Subject to clause (ii) 

24 and notwithstanding the previous provi25 sions of this subsection, for services fur-
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1 nished on or after January 1, 2011, the 

2 Secretary shall revise the fee schedule 

3 areas used for payment under this section 

4 applicable to the State of California using 

5 the Metropolitan Statistical Area (MSA) 

6 iterative Geographic Adjustment Factor 

7 methodology as follows: 

8 ‘‘(I) The Secretary shall con9 figure the physician fee schedule areas 

10 using the Metropolitan Statistical 

11 Areas (each in this paragraph referred 

12 to as an ‘MSA’), as defined by the Di13 rector of the Office of Management 

14 and Budget and published in the Fed15 eral Register, using the most recent 

16 available decennial population data as 

17 of the date of the enactment of the 

18 Affordable Health Care for America 

19 Act, as the basis for the fee schedule 

20 areas. 

21 ‘‘(II) For purposes of this clause, 

22 the Secretary shall treat all areas not 

23 included in an MSA as a single rest of 

24 the State MSA. 
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1 ‘‘(III) The Secretary shall list all 

2 MSAs within the State by Geographic 

3 Adjustment Factor described in para4 graph (2) (in this paragraph referred 

5 to as a ‘GAF’) in descending order. 

6 ‘‘(IV) In the first iteration, the 

7 Secretary shall compare the GAF of 

8 the highest cost MSA in the State to 

9 the weighted-average GAF of all the 

10 remaining MSAs in the State (includ11 ing the rest of State MSA described 

12 in subclause (II)). If the ratio of the 

13 GAF of the highest cost MSA to the 

14 weighted-average of the GAF of re15 maining lower cost MSAs is 1.05 or 

16 greater, the highest cost MSA shall be 

17 a separate fee schedule area. 

18 ‘‘(V) In the next iteration, the 

19 Secretary shall compare the GAF of 

20 the MSA with the second-highest 

21 GAF to the weighted-average GAF of 

22 the all the remaining MSAs (excluding 

23 MSAs that become separate fee sched24 ule areas). If the ratio of the second25 highest MSA’s GAF to the weighted- 
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1 average of the remaining lower cost 

2 MSAs is 1.05 or greater, the second3 highest MSA shall be a separate fee 

4 schedule area. 

5 ‘‘(VI) The iterative process shall 

6 continue until the ratio of the GAF of 

7 the MSA with highest remaining GAF 

8 to the weighted-average of the remain9 ing MSAs with lower GAFS is less 

10 than 1.05, and the remaining group of 

11 MSAs with lower GAFS shall be 

12 treated as a single fee schedule area. 

13 ‘‘(VII) For purposes of the 

14 iterative process described in this 

15 clause, if two MSAs have identical 

16 GAFs, they shall be combined. 

17 ‘‘(ii) TRANSITION.—For services fur18 nished on or after January 1, 2011, and 

19 before January 1, 2016, in the State of 

20 California, after calculating the work, prac21 tice expense, and malpractice geographic 

22 indices that would otherwise be determined 

23 under clauses (i), (ii), and (iii) of para24 graph (1)(A) for a fee schedule area deter25 mined under clause (i), if the index for a 
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1 county within a fee schedule area is less 

2 than the index in effect for such county on 

3 December 31, 2010, the Secretary shall in4 stead apply the index in effect for such 

5 county on such date. 

6 ‘‘(B) SUBSEQUENT REVISIONS.—After the 

7 transition described in subparagraph (A)(ii), 

8 not less than every 3 years the Secretary shall 

9 review and update the fee schedule areas using 

10 the methodology described in subparagraph 

11 (A)(i) and any updated MSAs as defined by the 

12 Director of the Office of Management and 

13 Budget and published in the Federal Register. 

14 The Secretary shall review and make any 

15 changes pursuant to such reviews concurrent 

16 with the application of the periodic review of 

17 the adjustment factors required under para18 graph (1)(C) for California. 

19 ‘‘(C) REFERENCES TO FEE SCHEDULE

20 AREAS.—Effective for services furnished on or 

21 after January 1, 2011, for the State of Cali22 fornia, any reference in this section to a fee 

23 schedule area shall be deemed a reference to an 

24 MSA in the State (including the single rest of 
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1 state MSA described in subparagraph 

2 (A)(i)(II)).’’. 

3 (b) CONFORMING AMENDMENT TO DEFINITION OF

4 FEE SCHEDULE AREA.—Section 1848(j)(2) of the Social 

5 Security Act (42 U.S.C. 1395w(j)(2)) is amended by strik6 ing ‘‘The term’’ and inserting ‘‘Except as provided in sub7 section (e)(6)(C), the term’’. 

8 PART 2—MARKET BASKET UPDATES 

9 SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVE10 MENTS INTO MARKET BASKET UPDATES 

11 THAT DO NOT ALREADY INCORPORATE SUCH 

12 IMPROVEMENTS. 

13 (a) OUTPATIENT HOSPITALS.— 

14 (1) IN GENERAL.—Section 1833(t)(3)(C)(iv) of 

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

16 1395l(t)(3)(C)(iv)) is amended— 

17 (A) in the first sentence— 

18 (i) by inserting ‘‘(which is subject to 

19 the productivity adjustment described in 

20 subclause (II) of such section)’’ after 

21 ‘‘1886(b)(3)(B)(iii)’’; and 

22 (ii) by inserting ‘‘(but not below 0)’’ 

23 after ‘‘reduced’’; and 

24 (B) in the second sentence, by inserting 

25 ‘‘and which is subject, beginning with 2010, to 
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1 the productivity adjustment described in section 

2 1886(b)(3)(B)(iii)(II)’’. 

3 (2) EFFECTIVE DATE.—The amendments made 

4 by this subsection shall apply to increase factors for 

5 services furnished in years beginning with 2010. 

6 (b) AMBULANCE SERVICES.—Section 1834(l)(3)(B) 

7 of such Act (42 U.S.C. 1395m(l)(3)(B))) is amended by 

8 inserting before the period at the end the following: ‘‘and, 

9 in the case of years beginning with 2010, subject to the 

10 productivity adjustment described in section 

11 1886(b)(3)(B)(iii)(II)’’. 

12 (c) AMBULATORY SURGICAL CENTER SERVICES.— 

13 Section 1833(i)(2)(D) of such Act (42 U.S.C. 

14 1395l(i)(2)(D)) is amended— 

15 (1) by redesignating clause (v) as clause (vi); 

16 and 

17 (2) by inserting after clause (iv) the following 

18 new clause: 

19 ‘‘(v) In implementing the system described in clause 

20 (i), for services furnished during 2010 or any subsequent 

21 year, to the extent that an annual percentage change fac22 tor applies, such factor shall be subject to the productivity 

23 adjustment described in section 1886(b)(3)(B)(iii)(II).’’. 

24 (d) LABORATORY SERVICES.—Section 1833(h)(2)(A) 

25 of such Act (42 U.S.C. 1395l(h)(2)(A)) is amended— 
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1 (1) in clause (i), by striking ‘‘for each of the 

2 years 2009 through 2013’’ and inserting ‘‘for 

3 2009’’; and 

4 (2) clause (ii)— 

5 (A) by striking ‘‘and’’ at the end of sub6 clause (III); 

7 (B) by striking the period at the end of 

8 subclause (IV) and inserting ‘‘; and’’; and 

9 (C) by adding at the end the following new 

10 subclause: 

11 ‘‘(V) the annual adjustment in the fee schedules 

12 determined under clause (i) for years beginning with 

13 2010 shall be subject to the productivity adjustment 

14 described in section 1886(b)(3)(B)(iii)(II).’’. 

15 (e) CERTAIN DURABLE MEDICAL EQUIPMENT.—Sec16 tion 1834(a)(14) of such Act (42 U.S.C. 1395m(a)(14)) 

17 is amended— 

18 (1) in subparagraph (K), by inserting before 

19 the semicolon at the end the following: ‘‘, subject to 

20 the productivity adjustment described in section 

21 1886(b)(3)(B)(iii)(II)’’; 

22 (2) in subparagraph (L)(i), by inserting after 

23 ‘‘June 2013,’’ the following: ‘‘subject to the produc24 tivity adjustment described in section 

25 1886(b)(3)(B)(iii)(II),’’; 
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1 (3) in subparagraph (L)(ii), by inserting after 

2 ‘‘June 2013’’ the following: ‘‘, subject to the produc3 tivity adjustment described in section 

4 1886(b)(3)(B)(iii)(II)’’; and 

5 (4) in subparagraph (M), by inserting before 

6 the period at the end the following: ‘‘, subject to the 

7 productivity adjustment described in section 

8 1886(b)(3)(B)(iii)(II)’’. 

9 PART 3—OTHER PROVISIONS 

10 SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN 

11 WHEELCHAIRS. 

12 (a) IN GENERAL.—Section 1834(a)(7)(A)(iii) of the 

13 Social Security Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is 

14 amended— 

15 (1) in the heading, by inserting ‘‘CERTAIN COM16 PLEX REHABILITATIVE’’ after ‘‘OPTION FOR’’; and 

17 (2) by striking ‘‘power-driven wheelchair’’ and 

18 inserting ‘‘complex rehabilitative power-driven wheel19 chair recognized by the Secretary as classified within 

20 group 3 or higher’’. 

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

22 subsection (a) shall take effect on January 1, 2011, and 

23 shall apply to power-driven wheelchairs furnished on or 

24 after such date. Such amendments shall not apply to con25 tracts entered into under section 1847 of the Social Secu-
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1 rity Act (42 U.S.C. 1395w–3) pursuant to a bid submitted 

2 under such section before October 1, 2010, under sub3 section (a)(1)(B)(i)(I) of such section. 

4 SEC. 1141A. ELECTION TO TAKE OWNERSHIP, OR TO DE5 CLINE OWNERSHIP, OF A CERTAIN ITEM OF 

6 COMPLEX DURABLE MEDICAL EQUIPMENT 

7 AFTER THE 13-MONTH CAPPED RENTAL PE8 RIOD ENDS. 

9 (a) IN GENERAL.—Section 1834(a)(7)(A) of the So10 cial Security Act (42 U.S.C. 1395m(a)(7)(A)) is amend11 ed— 

12 (1) in clause (ii)— 

13 (A) by striking ‘‘RENTAL.—On’’ and in14 serting ‘‘RENTAL.— 

15 ‘‘(I) IN GENERAL.—Except as 

16 provided in subclause (II), on’’; and 

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

18 subclause: 

19 ‘‘(II) OPTION TO ACCEPT OR RE20 JECT TRANSFER OF TITLE TO GROUP

21 3 SUPPORT SURFACE.— 

22 ‘‘(aa) IN GENERAL.—During 

23 the 10th continuous month dur24 ing which payment is made for 

25 the rental of a Group 3 Support 
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1 Surface under clause (i), the sup2 plier of such item shall offer the 

3 individual the option to accept or 

4 reject transfer of title to a Group 

5 3 Support Surface after the 13th 

6 continuous month during which 

7 payment is made for the rental of 

8 the Group 3 Support Surface 

9 under clause (i). Such title shall 

10 be transferred to the individual 

11 only if the individual notifies the 

12 supplier not later than 1 month 

13 after the supplier makes such 

14 offer that the individual agrees to 

15 accept transfer of the title to the 

16 Group 3 Support Surface. Unless 

17 the individual accepts transfer of 

18 title to the Group 3 Support Sur19 face in the manner set forth in 

20 this subclause, the individual 

21 shall be deemed to have rejected 

22 transfer of title. If the individual 

23 agrees to accept the transfer of 

24 the title to the Group 3 Support 

25 Surface, the supplier shall trans-
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1 fer such title to the individual on 

2 the first day that begins after the 

3 13th continuous month during 

4 which payment is made for the 

5 rental of the Group 3 Support 

6 Surface under clause (i). 

7 ‘‘(bb) SPECIAL RULE.—If, 

8 on the effective date of this sub9 clause, an individual’s rental pe10 riod for a Group 3 Support Sur11 face has exceeded 10 continuous 

12 months, but the first day that be13 gins after the 13th continuous 

14 month during which payment is 

15 made for the rental under clause 

16 (i) has not been reached, the sup17 plier shall, within 1 month fol18 lowing such effective date, offer 

19 the individual the option to ac20 cept or reject transfer of title to 

21 a Group 3 Support Surface. Such 

22 title shall be transferred to the 

23 individual only if the individual 

24 notifies the supplier not later 

25 than 1 month after the supplier 
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1 makes such offer that the indi2 vidual agrees to accept transfer 

3 of title to the Group 3 Support 

4 Surface. Unless the individual ac5 cepts transfer of title to the 

6 Group 3 Support Surface in the 

7 manner set forth in this sub8 clause, the individual shall be 

9 deemed to have rejected transfer 

10 of title. If the individual agrees 

11 to accept the transfer of the title 

12 to the Group 3 Support Surface, 

13 the supplier shall transfer such 

14 title to the individual on the first 

15 day that begins after the 13th 

16 continuous month during which 

17 payment is made for the rental of 

18 the Group 3 Support Surface 

19 under clause (i) unless that day 

20 has passed, in which case the 

21 supplier shall transfer such title 

22 to the individual not later than 1 

23 month after notification that the 

24 individual accepts transfer of 

25 title. 
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1 ‘‘(cc) TREATMENT OF SUB2 SEQUENT RESUPPLY WITHIN PE3 RIOD OF REASONABLE USEFUL

4 LIFETIME OF GROUP 3 SUPPORT

5 SURFACE IN CASE OF NEED.—If 

6 an individual rejects transfer of 

7 title to a Group 3 Support Sur8 face under this subclause and the 

9 individual requires such Support 

10 Surface at any subsequent time 

11 during the period of the reason12 able useful lifetime of such equip13 ment (as defined by the Sec14 retary) beginning with the first 

15 month for which payment is 

16 made for the rental of such 

17 equipment under clause (i), the 

18 supplier shall supply the equip19 ment without charge to the indi20 vidual or the program under this 

21 title during the remainder of 

22 such period, other than payment 

23 for maintenance and servicing 

24 during such period which would 

25 otherwise have been paid if the 
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1 individual had accepted title to 

2 such equipment. The previous 

3 sentence shall not affect the pay4 ment of amounts under this part 

5 for such equipment after the end 

6 of such period of the reasonable 

7 useful lifetime of the equipment. 

8 ‘‘(dd) PAYMENTS.—Mainte9 nance and servicing payments 

10 shall be made in accordance with 

11 clause (iv), in the case of a sup12 plier that transfers title to the 

13 Group 3 Support Surface under 

14 this subclause, after such trans15 fer and, in the case of an indi16 vidual who rejects transfer of 

17 title under this subclause, after 

18 the end of the period of medical 

19 need during which payment is 

20 made under clause (i).’’; and 

21 (2) in clause (iv), by inserting ‘‘or, in the case 

22 of an individual who rejects transfer of title to a 

23 Group 3 Support Surface under clause (ii), after the 

24 end of the period of medical need during which pay-
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1 ment is made under clause (i),’’ after ‘‘under clause 

2 (ii)’’. 

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

4 this section shall apply with respect to durable medical 

5 equipment not later than January 1, 2011. 

6 SEC. 1142. EXTENSION OF PAYMENT RULE FOR 

7 BRACHYTHERAPY. 

8 Section 1833(t)(16)(C) of the Social Security Act (42 

9 U.S.C. 1395l(t)(16)(C)), as amended by section 142 of the 

10 Medicare Improvements for Patients and Providers Act of 

11 2008 (Public Law 110–275), is amended by striking, the 

12 first place it appears, ‘‘January 1, 2010’’ and inserting 

13 ‘‘January 1, 2012’’. 

14 SEC. 1143. HOME INFUSION THERAPY REPORT TO CON15 GRESS. 

16 Not later than July 1, 2011, the Medicare Payment 

17 Advisory Commission shall submit to Congress a report 

18 on the following: 

19 (1) The scope of coverage for home infusion 

20 therapy in the fee-for-service Medicare program 

21 under title XVIII of the Social Security Act, Medi22 care Advantage under part C of such title, the vet23 eran’s health care program under chapter 17 of title 

24 38, United States Code, and among private payers, 

25 including an analysis of the scope of services pro-
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1 vided by home infusion therapy providers to their 

2 patients in such programs. 

3 (2) The benefits and costs of providing such 

4 coverage under the Medicare program, including a 

5 calculation of the potential savings achieved through 

6 avoided or shortened hospital and nursing home 

7 stays as a result of Medicare coverage of home infu8 sion therapy. 

9 (3) An assessment of sources of data on the 

10 costs of home infusion therapy that might be used 

11 to construct payment mechanisms in the Medicare 

12 program. 

13 (4) Recommendations, if any, on the structure 

14 of a payment system under the Medicare program 

15 for home infusion therapy, including an analysis of 

16 the payment methodologies used under Medicare Ad17 vantage plans and private health plans for the provi18 sion of home infusion therapy and their applicability 

19 to the Medicare program. 

20 SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS 

21 (ASCS) TO SUBMIT COST DATA AND OTHER 

22 DATA. 

23 (a) COST REPORTING.— 
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1 (1) IN GENERAL.—Section 1833(i) of the Social 

2 Security Act (42 U.S.C. 1395l(i)) is amended by 

3 adding at the end the following new paragraph: 

4 ‘‘(8) The Secretary shall require, as a condition of 

5 the agreement described in section 1832(a)(2)(F)(i), the 

6 submission of such cost report as the Secretary may speci7 fy, taking into account the requirements for such reports 

8 under section 1815 in the case of a hospital.’’. 

9 (2) DEVELOPMENT OF COST REPORT.—Not 

10 later than 3 years after the date of the enactment 

11 of this Act, the Secretary of Health and Human 

12 Services shall develop a cost report form for use 

13 under section 1833(i)(8) of the Social Security Act, 

14 as added by paragraph (1). 

15 (3) AUDIT REQUIREMENT.—The Secretary shall 

16 provide for periodic auditing of cost reports sub17 mitted under section 1833(i)(8) of the Social Secu18 rity Act, as added by paragraph (1). 

19 (4) EFFECTIVE DATE.—The amendment made 

20 by paragraph (1) shall apply to agreements applica21 ble to cost reporting periods beginning 18 months 

22 after the date the Secretary develops the cost report 

23 form under paragraph (2). 

24 (b) ADDITIONAL DATA ON QUALITY.— 
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1 (1) IN GENERAL.—Section 1833(i)(7) of such 

2 Act (42 U.S.C. 1395l(i)(7)) is amended— 

3 (A) in subparagraph (B), by inserting 

4 ‘‘subject to subparagraph (C),’’ after ‘‘may oth5 erwise provide,’’; and 

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

7 subparagraph: 

8 ‘‘(C) Under subparagraph (B) the Secretary shall re9 quire the reporting of such additional data relating to 

10 quality of services furnished in an ambulatory surgical fa11 cility, including data on health care associated infections, 

12 as the Secretary may specify.’’. 

13 (2) EFFECTIVE DATE.—The amendment made 

14 by paragraph (1) shall to reporting for years begin15 ning with 2012. 

16 SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS. 

17 Section 1833(t) of the Social Security Act (42 U.S.C. 

18 1395l(t)) is amended by adding at the end the following 

19 new paragraph: 

20 ‘‘(18) AUTHORIZATION OF ADJUSTMENT FOR

21 CANCER HOSPITALS.— 

22 ‘‘(A) STUDY.—The Secretary shall conduct 

23 a study to determine if, under the system under 

24 this subsection, costs incurred by hospitals de25 scribed in section 1886(d)(1)(B)(v) with respect 
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1 to ambulatory payment classification groups ex2 ceed those costs incurred by other hospitals fur3 nishing services under this subsection (as deter4 mined appropriate by the Secretary). 

5 ‘‘(B) AUTHORIZATION OF ADJUSTMENT.— 

6 Insofar as the Secretary determines under sub7 paragraph (A) that costs incurred by hospitals 

8 described in section 1886(d)(1)(B)(v) exceed 

9 those costs incurred by other hospitals fur10 nishing services under this subsection, the Sec11 retary shall provide for an appropriate adjust12 ment under paragraph (2)(E) to reflect those 

13 higher costs effective for services furnished on 

14 or after January 1, 2011.’’. 

15 SEC. 1146. PAYMENT FOR IMAGING SERVICES. 

16 (a) ADJUSTMENT IN PRACTICE EXPENSE TO RE17 FLECT A PRESUMED LEVEL OF UTILIZATION.—Section 

18 1848 of the Social Security Act (42 U.S.C. 1395w–4) is 

19 amended— 

20 (1) in subsection (b)(4)— 

21 (A) in subparagraph (B), by striking ‘‘sub22 paragraph (A)’’ and inserting ‘‘this paragraph’’; 

23 and 

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

25 subparagraph: 
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1 ‘‘(C) ADJUSTMENT IN PRACTICE EXPENSE

2 TO REFLECT A PRESUMED LEVEL OF UTILIZA3 TION.—Consistent with the methodology for 

4 computing the number of practice expense rel5 ative value units under subsection (c)(2)(C)(ii) 

6 with respect to advanced diagnostic imaging 

7 services (as defined in section 1834(e)(1)(B)) 

8 furnished on or after January 1, 2011, the Sec9 retary shall adjust such number of units so it 

10 reflects a presumed rate of utilization of imag11 ing equipment of 75 percent.’’; and 

12 (2) in subsection (c)(2)(B)(v)), by adding at the 

13 end the following new subclause: 

14 ‘‘(III) CHANGE IN PRESUMED

15 UTILIZATION LEVEL OF CERTAIN AD16 VANCED DIAGNOSTIC IMAGING SERV17 ICES.—Effective for fee schedules es18 tablished beginning with 2011, re19 duced expenditures attributable to the 

20 presumed utilization of 75 percent 

21 under subsection (b)(4)(C) instead of 

22 a presumed utilization of imaging 

23 equipment of 50 percent.’’. 

24 (b) ADJUSTMENT IN TECHNICAL COMPONENT ‘‘DIS25 COUNT’’ ON SINGLE-SESSION IMAGING TO CONSECUTIVE
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1 BODY PARTS.—Section 1848 of such Act (42 U.S.C. 

2 1395w–4) is further amended— 

3 (1) in subsection (b)(4), by adding at the end 

4 the following new subparagraph: 

5 ‘‘(D) ADJUSTMENT IN TECHNICAL COMPO6 NENT DISCOUNT ON SINGLE-SESSION IMAGING

7 INVOLVING CONSECUTIVE BODY PARTS.—For 

8 services furnished on or after January 1, 2011, 

9 the Secretary shall increase the reduction in ex10 penditures attributable to the multiple proce11 dure payment reduction applicable to the tech12 nical component for imaging under the final 

13 rule published by the Secretary in the Federal 

14 Register on November 21, 2005 (part 405 of 

15 title 42, Code of Federal Regulations) from 25 

16 percent to 50 percent.’’; and 

17 (2) in subsection (c)(2)(B)(v), by adding at the 

18 end the following new subclause: 

19 ‘‘(III) ADDITIONAL REDUCED

20 PAYMENT FOR MULTIPLE IMAGING

21 PROCEDURES.—Effective for fee 

22 schedules established beginning with 

23 2011, reduced expenditures attrib24 utable to the increase in the multiple 

25 procedure payment reduction from 25 
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1 percent to 50 percent as described in 

2 subsection (b)(4)(D).’’. 

3 SEC. 1147. DURABLE MEDICAL EQUIPMENT PROGRAM IM4 PROVEMENTS. 

5 (a) WAIVER OF SURETY BOND REQUIREMENT.—Sec6 tion 1834(a)(16) of the Social Security Act (42 U.S.C. 

7 1395m(a)(16)) is amended by adding at the end the fol8 lowing sentence: ‘‘The requirement for a surety bond de9 scribed in subparagraph (B) shall not apply in the case 

10 of a pharmacy or supplier that exclusively furnishes eye11 glasses or contact lenses described in section 1861(s)(8) 

12 if the pharmacy or supply has been enrolled under section 

13 1866(j) as a supplier of durable medical equipment, pros14 thetics, orthotics, and supplies and has been issued (which 

15 may include renewal of) a supplier number (as described 

16 in the first sentence of this paragraph) for at least 5 years, 

17 and if a final adverse action (as defined in section 

18 424.57(a) of title 42, Code of Federal Regulations) has 

19 never been imposed for such pharmacy or supplier.’’. 

20 (b) ENSURING SUPPLY OF OXYGEN EQUIPMENT .— 

21 (1) IN GENERAL.—Section 1834(a)(5)(F) of the 

22 Social Security Act (42 U.S.C. 1395m(a)(5)(F)) is 

23 amended— 
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1 (A) in clause (ii), by striking ‘‘After the’’ 

2 and inserting ‘‘Except as provided in clause 

3 (iii), after the’’; and 

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

5 clause: 

6 ‘‘(iii) CONTINUATION OF SUPPLY.—In 

7 the case of a supplier furnishing such 

8 equipment to an individual under this sub9 section as of the 27th month of the 36 

10 months described in clause (i), the supplier 

11 furnishing such equipment as of such 

12 month shall continue to furnish such 

13 equipment to such individual (either di14 rectly or though arrangements with other 

15 suppliers of such equipment) during any 

16 subsequent period of medical need for the 

17 remainder of the reasonable useful lifetime 

18 of the equipment, as determined by the 

19 Secretary, regardless of the location of the 

20 individual, unless another supplier has ac21 cepted responsibility for continuing to fur22 nish such equipment during the remainder 

23 of such period.’’. 

24 (2) EFFECTIVE DATE.—The amendments made 

25 by paragraph (1) shall take effect as of the date of 
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1 the enactment of this Act and shall apply to the fur2 nishing of equipment to individuals for whom the 

3 27th month of a continuous period of use of oxygen 

4 equipment described in section 1834(a)(5)(F) of the 

5 Social Security Act occurs on or after July 1, 2010. 

6 (c) TREATMENT OF CURRENT ACCREDITATION AP7 PLICATIONS.—Section 1834(a)(20)(F) of such Act (42 

8 U.S.C. 1395m(a)(20)(F)) is amended— 

9 (1) in clause (i)— 

10 (A) by striking ‘‘clause (ii)’’ and inserting 

11 ‘‘clauses (ii) and (iii)’’; and 

12 (B) by striking ‘‘and’’ at the end; 

13 (2) by striking the period at the end of clause 

14 (ii)(II) and by inserting a semicolon; 

15 (3) by inserting after clause (ii) the following 

16 new clauses: 

17 ‘‘(iii) the requirement for accredita18 tion described in clause (i) shall not apply 

19 for purposes of supplying diabetic testing 

20 supplies, canes, and crutches in the case of 

21 a pharmacy that is enrolled under section 

22 1866(j) as a supplier of durable medical 

23 equipment, prosthetics, orthotics, and sup24 plies; and 
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1 ‘‘(iv) a supplier that has submitted an 

2 application for accreditation before August 

3 1, 2009, shall retain the supplier’s provider 

4 or supplier number until an independent 

5 accreditation organization determines if 

6 such supplier complies with requirements 

7 under this paragraph.’’; and 

8 (4) by adding at the end the following new sen9 tence: ‘‘Nothing in clauses (iii) and (iv) shall be con10 strued as affecting the application of an accredita11 tion requirement for suppliers to qualify for bidding 

12 in a competitive acquisition area under section 

13 1847,’’. 

14 (d) RESTORING 36-MONTH OXYGEN RENTAL PERIOD

15 IN CASE OF SUPPLIER BANKRUPTCY FOR CERTAIN INDI16 VIDUALS.—Section 1834(a)(5)(F) of such Act (42 U.S.C. 

17 1395m(a)(5)(F)), as amended by subsection (b), is further 

18 amended by adding at the end the following new clause: 

19 ‘‘(iv) EXCEPTION FOR BANK20 RUPTCY.—If a supplier who furnishes oxy21 gen and oxygen equipment to an individual 

22 is declared bankrupt and its assets are liq23 uidated and at the time of such declaration 

24 and liquidation more than 24 months of 

25 rental payments have been made, such in-
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1 dividual may begin a new 36-month rental 

2 period under this subparagraph with an3 other supplier of oxygen.’’. 

4 SEC. 1148. MEDPAC STUDY AND REPORT ON BONE MASS 

5 MEASUREMENT. 

6 (a) IN GENERAL.—The Medicare Payment Advisory 

7 Commission shall conduct a study regarding bone mass 

8 measurement, including computed tomography, duel-en9 ergy x-ray absorptriometry, and vertebral fracture assess10 ment. The study shall focus on the following: 

11 (1) An assessment of the adequacy of Medicare 

12 payment rates for such services, taking into account 

13 costs of acquiring the necessary equipment, profes14 sional work time, and practice expense costs. 

15 (2) The impact of Medicare payment changes 

16 since 2006 on beneficiary access to bone mass meas17 urement benefits in general and in rural and minor18 ity communities specifically. 

19 (3) A review of the clinically appropriate and 

20 recommended use among Medicare beneficiaries and 

21 how usage rates among such beneficiaries compares 

22 to such recommendations. 

23 (4) In conjunction with the findings under (3), 

24 recommendations, if necessary, regarding methods 
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1 for reaching appropriate use of bone mass measure2 ment studies among Medicare beneficiaries. 

3 (b) REPORT.—The Commission shall submit a report 

4 to the Congress, not later than 9 months after the date 

5 of the enactment of this Act, containing a description of 

6 the results of the study conducted under subsection (a) 

7 and the conclusions and recommendations, if any, regard8 ing each of the issues described in paragraphs (1), (2) (3) 

9 and (4) of such subsection. 

10 SEC. 1149. TIMELY ACCESS TO POST-MASTECTOMY ITEMS. 

11 (a) IN GENERAL.—Section 1834(h)(1) of the Social 

12 Security Act (42 U.S.C. 1395m) is amended— 

13 (1) by redesignating subparagraph (H) as sub14 paragraph (I); and 

15 (2) by inserting after subparagraph (G) the fol16 lowing new subparagraph: 

17 ‘‘(H) SPECIAL PAYMENT RULE FOR POST18 MASTECTOMY EXTERNAL BREAST PROSTHESIS

19 GARMENTS.—Payment for post-mastectomy ex20 ternal breast prosthesis garments shall be made 

21 regardless of whether such items are supplied to 

22 the beneficiary prior to or after the mastectomy 

23 procedure or other breast cancer surgical proce24 dure. The Secretary shall develop policies to en25 sure appropriate beneficiary access and utiliza-
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1 tion safeguards for such items supplied to a 

2 beneficiary prior to the mastectomy or other 

3 breast cancer surgical procedure.’’. 

4 (b) EFFECTIVE DATE.—This amendment shall apply 

5 not later than January 1, 2011. 

6 SEC. 1149A. PAYMENT FOR BIOSIMILAR BIOLOGICAL PROD7 UCTS. 

8 (a) IN GENERAL.—Section 1847A of the Social Secu9 rity Act (42 U.S.C. 1395w–3a) is amended— 

10 (1) in subsection (b)(1)— 

11 (A) in subparagraph (A), by striking ‘‘or’’ 

12 at the end; 

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

14 period at the end and inserting ‘‘; or’’; and 

15 (C) by adding at the end the following new 

16 subparagraph: 

17 ‘‘(C) in the case of one or more inter18 changeable biological products (as defined in 

19 subsection (c)(6)(I)) and their reference biologi20 cal product (as defined in subsection (c)(6)(J)), 

21 which shall be included in the same billing and 

22 payment code, the sum of— 

23 ‘‘(i) the average sales price as deter24 mined using the methodology described in 

25 paragraph (6) applied to such interchange-
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1 able and reference products for all Na2 tional Drug Codes assigned to such prod3 ucts in the same manner as such para4 graph (6) is applied to multiple source 

5 drugs; and 

6 ‘‘(ii) 6 percent of the amount deter7 mined under clause (i); 

8 ‘‘(D) in the case of a biosimilar biological 

9 product (as defined in subsection (c)(6)(H)), 

10 the sum of— 

11 ‘‘(i) the average sales price as deter12 mined using the methodology described in 

13 paragraph (4) applied to such biosimilar 

14 biological product for all National Drug 

15 Codes assigned to such product in the 

16 same manner as such paragraph (4) is ap17 plied to a single source drug; and 

18 ‘‘(ii) 6 percent of the amount deter19 mined under paragraph (4) or the amount 

20 determined under subparagraph (C)(ii), as 

21 the case may be, for the reference biologi22 cal product (as defined in subsection 

23 (c)(6)(J)); or 

24 ‘‘(E) in the case of a reference biological 

25 product for both an interchangeable biological 
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1 product and a biosimilar product, the amount 

2 determined in subparagraph (C).’’; and 

3 (2) in subsection (c)(6)— 

4 (A) by amending subparagraph (D)(i) to 

5 read as follows: 

6 ‘‘(i) a biological, including a reference 

7 biological product for a biosimilar product, 

8 but excluding— 

9 ‘‘(I) a biosimilar biological prod10 uct; 

11 ‘‘(II) an interchangeable biologi12 cal product; 

13 ‘‘(III) a reference biological prod14 uct for an interchangeable biological 

15 product; and 

16 ‘‘(IV) a reference biological prod17 uct for both an interchangeable bio18 logical product and a biosimilar prod19 uct; or’’; and 

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

21 subparagraphs: 

22 ‘‘(H) BIOSIMILAR BIOLOGICAL PRODUCT.— 

23 The term ‘biosimilar biological product’ means 

24 a biological product licensed as a biosimilar bio-
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1 logical product under section 351(k) of the 

2 Public Health Service Act. 

3 ‘‘(I) INTERCHANGEABLE BIOLOGICAL

4 PRODUCT.—The term ‘interchangeable biologi5 cal product’ means a biological product licensed 

6 as an interchangeable biological product under 

7 section 351(k) of the Public Health Service Act 

8 ‘‘(J) REFERENCE BIOLOGICAL PRODUCT.— 

9 The term ‘reference biological product’ means 

10 the biological product that is referred to in the 

11 application for a biosimilar or interchangeable 

12 biological product licensed under section 351(k) 

13 of the Public Health Service Act.’’. 

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

15 subsection (a) shall apply to payments for biosimilar bio16 logical products, interchangeable biological products, and 

17 reference biological products beginning with the first day 

18 of the second calendar quarter after the date of the enact19 ment of this Act. 

20 SEC. 1149B. STUDY AND REPORT ON DME COMPETITIVE 

21 BIDDING PROCESS. 

22 (a) STUDY.—The Comptroller General of the United 

23 States shall conduct a study to evaluate the potential es24 tablishment of a program under Medicare under title 

25 XVIII of the Social Security Act to acquire durable med-
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1 ical equipment and supplies through a competitive bidding 

2 process among manufacturers of such equipment and sup3 plies. Such study shall address the following: 

4 (1) Identification of types of durable medical 

5 equipment and supplies that would be appropriate 

6 for bidding under such a program. 

7 (2) Recommendations on how to structure such 

8 an acquisition program in order to promote fiscal re9 sponsibility while also ensuring beneficiary access to 

10 high quality equipment and supplies. 

11 (3) Recommendations on how such a program 

12 could be phased-in and on what geographic level 

13 would bidding be most appropriate. 

14 (4) In addition to price, recommendations on 

15 criteria that could be factored into the bidding proc16 ess. 

17 (5) Recommendations on how suppliers could be 

18 compensated for furnishing and servicing equipment 

19 and supplies acquired under such a program. 

20 (6) Comparison of such a program to the cur21 rent competitive bidding program under Medicare 

22 for durable medical equipment, as well as any other 

23 similar Federal acquisition programs, such as the 

24 General Services Administration’s vehicle purchasing 

25 program. 
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1 (7) Any other consideration relevant to the ac2 quisition, supply, and service of durable medical 

3 equipment and supplies that is deemed appropriate 

4 by the Comptroller General. 

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

6 date of the enactment of this Act, the Comptroller General 

7 of the United States shall submit to Congress a report 

8 on the findings of the study under subsection (a). 

9 Subtitle C—Provisions Related to 

10 Medicare Parts A and B 

11 SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOS12 PITAL READMISSIONS. 

13 (a) HOSPITALS.— 

14 (1) IN GENERAL.—Section 1886 of the Social 

15 Security Act (42 U.S.C. 1395ww), as amended by 

16 section 1103(a), is amended by adding at the end 

17 the following new subsection: 

18 ‘‘(p) ADJUSTMENT TO HOSPITAL PAYMENTS FOR

19 EXCESS READMISSIONS.— 

20 ‘‘(1) IN GENERAL.—With respect to payment 

21 for discharges from an applicable hospital (as de22 fined in paragraph (5)(C)) occurring during a fiscal 

23 year beginning on or after October 1, 2011, in order 

24 to account for excess readmissions in the hospital, 

25 the Secretary shall reduce the payments that would 
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1 otherwise be made to such hospital under subsection 

2 (d) (or section 1814(b)(3), as the case may be) for 

3 such a discharge by an amount equal to the product 

4 of— 

5 ‘‘(A) the base operating DRG payment 

6 amount (as defined in paragraph (2)) for the 

7 discharge; and 

8 ‘‘(B) the adjustment factor (described in 

9 paragraph (3)(A)) for the hospital for the fiscal 

10 year. 

11 ‘‘(2) BASE OPERATING DRG PAYMENT

12 AMOUNT.— 

13 ‘‘(A) IN GENERAL.—Except as provided in 

14 subparagraph (B), for purposes of this sub15 section, the term ‘base operating DRG payment 

16 amount’ means, with respect to a hospital for a 

17 fiscal year, the payment amount that would 

18 otherwise be made under subsection (d) for a 

19 discharge if this subsection did not apply, re20 duced by any portion of such amount that is at21 tributable to payments under subparagraphs 

22 (B) and (F) of paragraph (5). 

23 ‘‘(B) ADJUSTMENTS.—For purposes of 

24 subparagraph (A), in the case of a hospital that 

25 is paid under section 1814(b)(3), the term ‘base 
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1 operating DRG payment amount’ means the 

2 payment amount under such section. 

3 ‘‘(3) ADJUSTMENT FACTOR.— 

4 ‘‘(A) IN GENERAL.—For purposes of para5 graph (1), the adjustment factor under this 

6 paragraph for an applicable hospital for a fiscal 

7 year is equal to the greater of— 

8 ‘‘(i) the ratio described in subpara9 graph (B) for the hospital for the applica10 ble period (as defined in paragraph (5)(D)) 

11 for such fiscal year; or 

12 ‘‘(ii) the floor adjustment factor speci13 fied in subparagraph (C). 

14 ‘‘(B) RATIO.—The ratio described in this 

15 subparagraph for a hospital for an applicable 

16 period is equal to 1 minus the ratio of— 

17 ‘‘(i) the aggregate payments for ex18 cess readmissions (as defined in paragraph 

19 (4)(A)) with respect to an applicable hos20 pital for the applicable period; and 

21 ‘‘(ii) the aggregate payments for all 

22 discharges (as defined in paragraph 

23 (4)(B)) with respect to such applicable 

24 hospital for such applicable period. 
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1 ‘‘(C) FLOOR ADJUSTMENT FACTOR.—For 

2 purposes of subparagraph (A), the floor adjust3 ment factor specified in this subparagraph 

4 for— 

5 ‘‘(i) fiscal year 2012 is 0.99; 

6 ‘‘(ii) fiscal year 2013 is 0.98; 

7 ‘‘(iii) fiscal year 2014 is 0.97; or 

8 ‘‘(iv) a subsequent fiscal year is 0.95. 

9 ‘‘(4) AGGREGATE PAYMENTS, EXCESS READMIS10 SION RATIO DEFINED.—For purposes of this sub11 section: 

12 ‘‘(A) AGGREGATE PAYMENTS FOR EXCESS

13 READMISSIONS.—The term ‘aggregate payments 

14 for excess readmissions’ means, for a hospital 

15 for a fiscal year, the sum, for applicable condi16 tions (as defined in paragraph (5)(A)), of the 

17 product, for each applicable condition, of— 

18 ‘‘(i) the base operating DRG payment 

19 amount for such hospital for such fiscal 

20 year for such condition; 

21 ‘‘(ii) the number of admissions for 

22 such condition for such hospital for such 

23 fiscal year; and 

24 ‘‘(iii) the excess readmissions ratio (as 

25 defined in subparagraph (C)) for such hos-
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1 pital for the applicable period for such fis2 cal year minus 1. 

3 ‘‘(B) AGGREGATE PAYMENTS FOR ALL DIS4 CHARGES.—The term ‘aggregate payments for 

5 all discharges’ means, for a hospital for a fiscal 

6 year, the sum of the base operating DRG pay7 ment amounts for all discharges for all condi8 tions from such hospital for such fiscal year. 

9 ‘‘(C) EXCESS READMISSION RATIO.— 

10 ‘‘(i) IN GENERAL.—Subject to clauses 

11 (ii) and (iii), the term ‘excess readmissions 

12 ratio’ means, with respect to an applicable 

13 condition for a hospital for an applicable 

14 period, the ratio (but not less than 1.0) 

15 of— 

16 ‘‘(I) the risk adjusted readmis17 sions based on actual readmissions, as 

18 determined consistent with a readmis19 sion measure methodology that has 

20 been endorsed under paragraph 

21 (5)(A)(ii)(I), for an applicable hospital 

22 for such condition with respect to the 

23 applicable period; to 

24 ‘‘(II) the risk adjusted expected 

25 readmissions (as determined con-
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1 sistent with such a methodology) for 

2 such hospital for such condition with 

3 respect to such applicable period. 

4 ‘‘(ii) EXCLUSION OF CERTAIN RE5 ADMISSIONS.—For purposes of clause (i), 

6 with respect to a hospital, excess readmis7 sions shall not include readmissions for an 

8 applicable condition for which there are 

9 fewer than a minimum number (as deter10 mined by the Secretary) of discharges for 

11 such applicable condition for the applicable 

12 period and such hospital. 

13 ‘‘(iii) ADJUSTMENT.—In order to pro14 mote a reduction over time in the overall 

15 rate of readmissions for applicable condi16 tions, the Secretary may provide, beginning 

17 with discharges for fiscal year 2014, for 

18 the determination of the excess readmis19 sions ratio under subparagraph (C) to be 

20 based on a ranking of hospitals by read21 mission ratios (from lower to higher read22 mission ratios) normalized to a benchmark 

23 that is lower than the 50th percentile. 

24 ‘‘(5) DEFINITIONS.—For purposes of this sub25 section: 
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1 ‘‘(A) APPLICABLE CONDITION.—The term 

2 ‘applicable condition’ means, subject to sub3 paragraph (B), a condition or procedure se4 lected by the Secretary among conditions and 

5 procedures for which— 

6 ‘‘(i) readmissions (as defined in sub7 paragraph (E)) that represent conditions 

8 or procedures that are high volume or high 

9 expenditures under this title (or other cri10 teria specified by the Secretary); and 

11 ‘‘(ii) measures of such readmissions— 

12 ‘‘(I) have been endorsed by the 

13 entity with a contract under section 

14 1890(a); and 

15 ‘‘(II) such endorsed measures 

16 have appropriate exclusions for re17 admissions that are unrelated to the 

18 prior discharge (such as a planned re19 admission or transfer to another ap20 plicable hospital). 

21 ‘‘(B) EXPANSION OF APPLICABLE CONDI22 TIONS.—Beginning with fiscal year 2013, the 

23 Secretary shall expand the applicable conditions 

24 beyond the 3 conditions for which measures 

25 have been endorsed as described in subpara-
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1 graph (A)(ii)(I) as of the date of the enactment 

2 of this subsection to the additional 4 conditions 

3 that have been so identified by the Medicare 

4 Payment Advisory Commission in its report to 

5 Congress in June 2007 and to other conditions 

6 and procedures which may include an all-condi7 tion measure of readmissions, as determined 

8 appropriate by the Secretary. In expanding 

9 such applicable conditions, the Secretary shall 

10 seek the endorsement described in subpara11 graph (A)(ii)(I) but may apply such measures 

12 without such an endorsement. 

13 ‘‘(C) APPLICABLE HOSPITAL.—The term 

14 ‘applicable hospital’ means a subsection (d) hos15 pital or a hospital that is paid under section 

16 1814(b)(3). 

17 ‘‘(D) APPLICABLE PERIOD.—The term ‘ap18 plicable period’ means, with respect to a fiscal 

19 year, such period as the Secretary shall specify 

20 for purposes of determining excess readmis21 sions. 

22 ‘‘(E) READMISSION.—The term ‘readmis23 sion’ means, in the case of an individual who is 

24 discharged from an applicable hospital, the ad25 mission of the individual to the same or another 
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1 applicable hospital within a time period speci2 fied by the Secretary from the date of such dis3 charge. Insofar as the discharge relates to an 

4 applicable condition for which there is an en5 dorsed measure described in subparagraph 

6 (A)(ii)(I), such time period (such as 30 days) 

7 shall be consistent with the time period speci8 fied for such measure. 

9 ‘‘(6) LIMITATIONS ON REVIEW.—There shall be 

10 no administrative or judicial review under section 

11 1869, section 1878, or otherwise of— 

12 ‘‘(A) the determination of base operating 

13 DRG payment amounts; 

14 ‘‘(B) the methodology for determining the 

15 adjustment factor under paragraph (3), includ16 ing excess readmissions ratio under paragraph 

17 (4)(C), aggregate payments for excess readmis18 sions under paragraph (4)(A), and aggregate 

19 payments for all discharges under paragraph 

20 (4)(B), and applicable periods and applicable 

21 conditions under paragraph (5); 

22 ‘‘(C) the measures of readmissions as de23 scribed in paragraph (5)(A)(ii); and 

24 ‘‘(D) the determination of a targeted hos25 pital under paragraph (8)(B)(i), the increase in 
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1 payment under paragraph (8)(B)(ii), the aggre2 gate cap under paragraph (8)(C)(i), the hos3 pital-specific limit under paragraph (8)(C)(ii), 

4 and the form of payment made by the Secretary 

5 under paragraph (8)(D). 

6 ‘‘(7) MONITORING INAPPROPRIATE CHANGES IN

7 ADMISSIONS PRACTICES.—The Secretary shall mon8 itor the activities of applicable hospitals to determine 

9 if such hospitals have taken steps to avoid patients 

10 at risk in order to reduce the likelihood of increasing 

11 readmissions for applicable conditions or taken other 

12 inappropriate steps involving readmissions or trans13 fers. If the Secretary determines that such a hos14 pital has taken such a step, after notice to the hos15 pital and opportunity for the hospital to undertake 

16 action to alleviate such steps, the Secretary may im17 pose an appropriate sanction. 

18 ‘‘(8) ASSISTANCE TO CERTAIN HOSPITALS.— 

19 ‘‘(A) IN GENERAL.—For purposes of pro20 viding funds to applicable hospitals to take 

21 steps described in subparagraph (E) to address 

22 factors that may impact readmissions of indi23 viduals who are discharged from such a hos24 pital, for fiscal years beginning on or after Oc25 tober 1, 2011, the Secretary shall make a pay-
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1 ment adjustment for a hospital described in 

2 subparagraph (B), with respect to each such 

3 fiscal year, by a percent estimated by the Sec4 retary to be consistent with subparagraph (C). 

5 The Secretary shall provide priority to hospitals 

6 that serve Medicare beneficiaries at highest risk 

7 for readmission or for a poor transition from 

8 such a hospital to a post-hospital site of care. 

9 ‘‘(B) TARGETED HOSPITALS.—Subpara10 graph (A) shall apply to an applicable hospital 

11 that— 

12 ‘‘(i) had (or, in the case of an 

13 1814(b)(3) hospital, otherwise would have 

14 had) a disproportionate patient percentage 

15 (as defined in section 1886(d)(5)(F)) of at 

16 least 30 percent, using the latest available 

17 data as estimated by the Secretary; and 

18 ‘‘(ii) provides assurances satisfactory 

19 to the Secretary that the increase in pay20 ment under this paragraph shall be used 

21 for purposes described in subparagraph 

22 (E). 

23 ‘‘(C) CAPS.— 

24 ‘‘(i) AGGREGATE CAP.—The aggregate 

25 amount of the payment adjustment under 
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1 this paragraph for a fiscal year shall not 

2 exceed 5 percent of the estimated dif3 ference in the spending that would occur 

4 for such fiscal year with and without appli5 cation of the adjustment factor described 

6 in paragraph (3) and applied pursuant to 

7 paragraph (1). 

8 ‘‘(ii) HOSPITAL-SPECIFIC LIMIT.—The 

9 aggregate amount of the payment adjust10 ment for a hospital under this paragraph 

11 shall not exceed the estimated difference in 

12 spending that would occur for such fiscal 

13 year for such hospital with and without ap14 plication of the adjustment factor de15 scribed in paragraph (3) and applied pur16 suant to paragraph (1). 

17 ‘‘(D) FORM OF PAYMENT.—The Secretary 

18 may make the additional payments under this 

19 paragraph on a lump sum basis, a periodic 

20 basis, a claim by claim basis, or otherwise. 

21 ‘‘(E) USE OF ADDITIONAL PAYMENT.— 

22 ‘‘(i) IN GENERAL.—Funding under 

23 this paragraph shall be used by targeted 

24 hospitals for activities designed to address 

25 the patient noncompliance issues that re-
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1 sult in higher than normal readmission 

2 rates, including transitional care services 

3 described in clause (ii) and any or all of 

4 the other activities described in clause (iii). 

5 ‘‘(ii) TRANSITIONAL CARE SERV6 ICES.—The transitional care services de7 scribed in this clause are transitional care 

8 services furnished by a qualified transi9 tional care provider, such as a nurse or 

10 other health professional, who meets rel11 evant experience and training requirements 

12 as specified by the Secretary that support 

13 a beneficiary under this section beginning 

14 on the date of an individual’s admission to 

15 a hospital for inpatient hospital services 

16 and ending at the latest on the last day of 

17 the 90-day period beginning on the date of 

18 the individual’s discharge from the applica19 ble hospital. The Secretary shall determine 

20 and update services to be included in tran21 sitional care services under this clause as 

22 appropriate, based on evidence of their ef23 fectiveness in reducing hospital readmis24 sions and improving health outcomes. Such 

25 services shall include the following: 
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1 ‘‘(I) Conduct of an assessment 

2 prior to discharge, which assessment 

3 may include an assessment of the in4 dividual’s physical and mental condi5 tion, cognitive and functional capac6 ities, medication regimen and adher7 ence, social and environmental needs, 

8 and primary caregiver needs and re9 sources. 

10 ‘‘(II) Development of a evidence11 based plan of transitional care for the 

12 individual developed after consultation 

13 with the individual and the individ14 ual’s primary caregiver and other 

15 health team members, as appropriate. 

16 Such plan shall include a list of cur17 rent therapies prescribed, treatment 

18 goals and may include other items or 

19 elements as determined by the Sec20 retary, such as identifying list of po21 tential health risks and future services 

22 for both the individual and any pri23 mary caregiver. 
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1 ‘‘(iii) OTHER ACTIVITIES.—The other 

2 activities described in this clause are the 

3 following: 

4 ‘‘(I) Providing other care coordi5 nation services not described under 

6 clause (ii). 

7 ‘‘(II) Hiring translators and in8 terpreters. 

9 ‘‘(III) Increasing services offered 

10 by discharge planners. 

11 ‘‘(IV) Ensuring that individuals 

12 receive a summary of care and medi13 cation orders upon discharge. 

14 ‘‘(V) Developing a quality im15 provement plan to assess and remedy 

16 preventable readmission rates. 

17 ‘‘(VI) Assigning appropriate fol18 low-up care for discharged individuals. 

19 ‘‘(VII) Doing other activities as 

20 determined appropriate by the Sec21 retary. 

22 ‘‘(F) GAO REPORT ON USE OF FUNDS.— 

23 Not later than 3 years after the date on which 

24 funds are first made available under this para25 graph, the Comptroller General of the United 
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1 States shall submit to Congress a report on the 

2 use of such funds. Such report shall consider 

3 information on the effective uses of such funds, 

4 how the uses of such funds affected hospital re5 admission rates (including at 6 months post6 discharge), health outcomes and quality, reduc7 tions in expenditures under this title and the 

8 experiences of beneficiaries, primary caregivers, 

9 and providers, as well as any appropriate rec10 ommendations.’’. 

11 (b) APPLICATION TO CRITICAL ACCESS HOS12 PITALS.—Section 1814(l) of the Social Security Act (42 

13 U.S.C. 1395f(l)) is amended— 

14 (1) in paragraph (5)— 

15 (A) by striking ‘‘and’’ at the end of sub16 paragraph (C); 

17 (B) by striking the period at the end of 

18 subparagraph (D) and inserting ‘‘; and’’; 

19 (C) by inserting at the end the following 

20 new subparagraph: 

21 ‘‘(E) the methodology for determining the ad22 justment factor under paragraph (5), including the 

23 determination of aggregate payments for actual and 

24 expected readmissions, applicable periods, applicable 

25 conditions and measures of readmissions.’’; and 
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1 (D) by redesignating such paragraph as 

2 paragraph (6); and 

3 (2) by inserting after paragraph (4) the fol4 lowing new paragraph: 

5 ‘‘(5) The adjustment factor described in section 

6 1886(p)(3) shall apply to payments with respect to a crit7 ical access hospital with respect to a cost reporting period 

8 beginning in fiscal year 2012 and each subsequent fiscal 

9 year (after application of paragraph (4) of this subsection) 

10 in a manner similar to the manner in which such section 

11 applies with respect to a fiscal year to an applicable hos12 pital as described in section 1886(p)(2).’’. 

13 (c) POST ACUTE CARE PROVIDERS.— 

14 (1) INTERIM POLICY.— 

15 (A) IN GENERAL.—With respect to a read16 mission to an applicable hospital or a critical 

17 access hospital (as described in section 1814(l) 

18 of the Social Security Act) from a post acute 

19 care provider (as defined in paragraph (3)) and 

20 such a readmission is not governed by section 

21 412.531 of title 42, Code of Federal Regula22 tions, if the claim submitted by such a post23 acute care provider under title XVIII of the So24 cial Security Act indicates that the individual 

25 was readmitted to a hospital from such a post- 
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1 acute care provider or admitted from home and 

2 under the care of a home health agency within 

3 30 days of an initial discharge from an applica4 ble hospital or critical access hospital, the pay5 ment under such title on such claim shall be the 

6 applicable percent specified in subparagraph 

7 (B) of the payment that would otherwise be 

8 made under the respective payment system 

9 under such title for such post-acute care pro10 vider if this subsection did not apply. In apply11 ing the previous sentence, the Secretary shall 

12 exclude a period of 1 day from the date the in13 dividual is first admitted to or under the care 

14 of the post-acute care provider. 

15 (B) APPLICABLE PERCENT DEFINED.—For 

16 purposes of subparagraph (A), the applicable 

17 percent is— 

18 (i) for fiscal or rate year 2012 is 

19 0.996; 

20 (ii) for fiscal or rate year 2013 is 

21 0.993; and 

22 (iii) for fiscal or rate year 2014 is 

23 0.99. 

24 (C) EFFECTIVE DATE.—Subparagraph (1) 

25 shall apply to discharges or services furnished 
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1 (as the case may be with respect to the applica2 ble post acute care provider) on or after the 

3 first day of the fiscal year or rate year, begin4 ning on or after October 1, 2011, with respect 

5 to the applicable post acute care provider. 

6 (2) DEVELOPMENT AND APPLICATION OF PER7 FORMANCE MEASURES.— 

8 (A) IN GENERAL.—The Secretary of 

9 Health and Human Services shall develop ap10 propriate measures of readmission rates for 

11 post acute care providers. The Secretary shall 

12 seek endorsement of such measures by the enti13 ty with a contract under section 1890(a) of the 

14 Social Security Act but may adopt and apply 

15 such measures under this paragraph without 

16 such an endorsement. The Secretary shall ex17 pand such measures in a manner similar to the 

18 manner in which applicable conditions are ex19 panded under paragraph (5)(B) of section 

20 1886(p) of the Social Security Act, as added by 

21 subsection (a). 

22 (B) IMPLEMENTATION.—The Secretary 

23 shall apply, on or after October 1, 2014, with 

24 respect to post acute care providers, policies 

25 similar to the policies applied with respect to 
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1 applicable hospitals and critical access hospitals 

2 under the amendments made by subsection (a). 

3 The provisions of paragraph (1) shall apply 

4 with respect to any period on or after October 

5 1, 2014, and before such application date de6 scribed in the previous sentence in the same 

7 manner as such provisions apply with respect to 

8 fiscal or rate year 2014. 

9 (C) MONITORING AND PENALTIES.—The 

10 provisions of paragraph (7) of such section 

11 1886(p) shall apply to providers under this 

12 paragraph in the same manner as they apply to 

13 hospitals under such section. 

14 (3) DEFINITIONS.—For purposes of this sub15 section: 

16 (A) POST ACUTE CARE PROVIDER.—The 

17 term ‘‘post acute care provider’’ means— 

18 (i) a skilled nursing facility (as de19 fined in section 1819(a) of the Social Secu20 rity Act); 

21 (ii) an inpatient rehabilitation facility 

22 (described in section 1886(h)(1)(A) of such 

23 Act); 

24 (iii) a home health agency (as defined 

25 in section 1861(o) of such Act); and 
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1 (iv) a long term care hospital (as de2 fined in section 1861(ccc) of such Act). 

3 (B) OTHER TERMS .—The terms ‘‘applica4 ble condition’’, ‘‘applicable hospital’’, and ‘‘re5 admission’’ have the meanings given such terms 

6 in section 1886(p)(5) of the Social Security 

7 Act, as added by subsection (a)(1). 

8 (d) PHYSICIANS.— 

9 (1) STUDY.—The Secretary of Health and 

10 Human Services shall conduct a study to determine 

11 how the readmissions policy described in the pre12 vious subsections could be applied to physicians. 

13 (2) CONSIDERATIONS.—In conducting the 

14 study, the Secretary shall consider approaches such 

15 as— 

16 (A) creating a new code (or codes) and 

17 payment amount (or amounts) under the fee 

18 schedule in section 1848 of the Social Security 

19 Act (in a budget neutral manner) for services 

20 furnished by an appropriate physician who sees 

21 an individual within the first week after dis22 charge from a hospital or critical access hos23 pital; 

24 (B) developing measures of rates of read25 mission for individuals treated by physicians; 
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1 (C) applying a payment reduction for phy2 sicians who treat the patient during the initial 

3 admission that results in a readmission; and 

4 (D) methods for attributing payments or 

5 payment reductions to the appropriate physi6 cian or physicians. 

7 (3) REPORT.—The Secretary shall issue a pub8 lic report on such study not later than the date that 

9 is one year after the date of the enactment of this 

10 Act. 

11 (e) FUNDING.—For purposes of carrying out the pro12 visions of this section, in addition to funds otherwise avail13 able, out of any funds in the Treasury not otherwise ap14 propriated, there are appropriated to the Secretary of 

15 Health and Human Services for the Center for Medicare 

16 & Medicaid Services Program Management Account 

17 $25,000,000 for each fiscal year beginning with 2010. 

18 Amounts appropriated under this subsection for a fiscal 

19 year shall be available until expended. 

20 SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM 

21 PLAN AND BUNDLING PILOT PROGRAM. 

22 (a) PLAN.— 

23 (1) IN GENERAL.—The Secretary of Health and 

24 Human Services (in this section referred to as the 

25 ‘‘Secretary’’) shall develop a detailed plan to reform 
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1 payment for post acute care (PAC) services under 

2 the Medicare program under title XVIII of the So3 cial Security Act (in this section referred to as the 

4 ‘‘Medicare program)’’. The goals of such payment 

5 reform are to— 

6 (A) improve the coordination, quality, and 

7 efficiency of such services; and 

8 (B) improve outcomes for individuals such 

9 as reducing the need for readmission to hos10 pitals from providers of such services. 

11 (2) BUNDLING POST ACUTE SERVICES.—The 

12 plan described in paragraph (1) shall include de13 tailed specifications for a bundled payment for post 

14 acute services (in this section referred to as the 

15 ‘‘post acute care bundle’’), and may include other 

16 approaches determined appropriate by the Secretary. 

17 (3) POST ACUTE SERVICES.—For purposes of 

18 this section, the term ‘‘post acute services’’ means 

19 services for which payment may be made under the 

20 Medicare program that are furnished by skilled 

21 nursing facilities, inpatient rehabilitation facilities, 

22 long term care hospitals, hospital based outpatient 

23 rehabilitation facilities and home health agencies to 

24 an individual after discharge of such individual from 
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1 a hospital, and such other services determined ap2 propriate by the Secretary. 

3 (b) DETAILS.—The plan described in subsection 

4 (a)(1) shall include consideration of the following issues: 

5 (1) The nature of payments under a post acute 

6 care bundle, including the type of provider or entity 

7 to whom payment should be made, the scope of ac8 tivities and services included in the bundle, whether 

9 payment for physicians’ services should be included 

10 in the bundle, and the period covered by the bundle. 

11 (2) Whether the payment should be consoli12 dated with the payment under the inpatient prospec13 tive system under section 1886 of the Social Secu14 rity Act (in this section referred to as MS–DRGs) 

15 or a separate payment should be established for such 

16 bundle, and if a separate payment is established, 

17 whether it should be made only upon use of post 

18 acute care services or for every discharge. 

19 (3) Whether the bundle should be applied 

20 across all categories of providers of inpatient serv21 ices (including critical access hospitals) and post 

22 acute care services or whether it should be limited 

23 to certain categories of providers, services, or dis24 charges, such as high volume or high cost MS– 

25 DRGs. 
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1 (4) The extent to which payment rates could be 

2 established to achieve offsets for efficiencies that 

3 could be expected to be achieved with a bundle pay4 ment, whether such rates should be established on a 

5 national basis or for different geographic areas, 

6 should vary according to discharge, case mix, 

7 outliers, and geographic differences in wages or 

8 other appropriate adjustments, and how to update 

9 such rates. 

10 (5) The nature of protections needed for indi11 viduals under a system of bundled payments to en12 sure that individuals receive quality care, are fur13 nished the level and amount of services needed as 

14 determined by an appropriate assessment instru15 ment, are offered choice of provider, and the extent 

16 to which transitional care services would improve 

17 quality of care for individuals and the functioning of 

18 a bundled post-acute system. 

19 (6) The nature of relationships that may be re20 quired between hospitals and providers of post acute 

21 care services to facilitate bundled payments, includ22 ing the application of gainsharing, anti-referral, 

23 anti-kickback, and anti-trust laws. 

24 (7) Quality measures that would be appropriate 

25 for reporting by hospitals and post acute providers 
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1 (such as measures that assess changes in functional 

2 status and quality measures appropriate for each 

3 type of post acute services provider including how 

4 the reporting of such quality measures could be co5 ordinated with other reporting of such quality meas6 ures by such providers otherwise required). 

7 (8) How cost-sharing for a post acute care bun8 dle should be treated relative to current rules for 

9 cost-sharing for inpatient hospital, home health, 

10 skilled nursing facility, and other services. 

11 (9) How other programmatic issues should be 

12 treated in a post acute care bundle, including rules 

13 specific to various types of post-acute providers such 

14 as the post-acute transfer policy, 3-day hospital stay 

15 to qualify for services furnished by skilled nursing 

16 facilities, and the coordination of payments and care 

17 under the Medicare program and the Medicaid pro18 gram. 

19 (10) Such other issues as the Secretary deems 

20 appropriate. 

21 (c) CONSULTATIONS AND ANALYSIS.— 

22 (1) CONSULTATION WITH STAKEHOLDERS.—In 

23 developing the plan under subsection (a)(1), the Sec24 retary shall consult with relevant stakeholders and 

25 shall consider experience with such research studies 
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1 and demonstrations that the Secretary determines 

2 appropriate. 

3 (2) ANALYSIS AND DATA COLLECTION.—In de4 veloping such plan, the Secretary shall— 

5 (A) analyze the issues described in sub6 section (b) and other issues that the Secretary 

7 determines appropriate; 

8 (B) analyze the impacts (including geo9 graphic impacts) of post acute service reform 

10 approaches, including bundling of such services 

11 on individuals, hospitals, post acute care pro12 viders, and physicians; 

13 (C) use existing data (such as data sub14 mitted on claims) and collect such data as the 

15 Secretary determines are appropriate to develop 

16 such plan required in this section; and 

17 (D) if patient functional status measures 

18 are appropriate for the analysis, to the extent 

19 practical, build upon the CARE tool being de20 veloped pursuant to section 5008 of the Deficit 

21 Reduction Act of 2005. 

22 (d) ADMINISTRATION.— 

23 (1) FUNDING.—For purposes of carrying out 

24 the provisions of this section, in addition to funds 

25 otherwise available, out of any funds in the Treasury 
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1 not otherwise appropriated, there are appropriated 

2 to the Secretary for the Center for Medicare & Med3 icaid Services Program Management Account 

4 $15,000,000 for each of the fiscal years 2010 

5 through 2012. Amounts appropriated under this 

6 paragraph for a fiscal year shall be available until 

7 expended. 

8 (2) EXPEDITED DATA COLLECTION.—Chapter 

9 35 of title 44, United States Code, shall not apply 

10 to this section. 

11 (e) PUBLIC REPORTS.— 

12 (1) INTERIM REPORTS.—The Secretary shall 

13 issue interim public reports on a periodic basis on 

14 the plan described in subsection (a)(1), the issues 

15 described in subsection (b), and impact analyses as 

16 the Secretary determines appropriate. 

17 (2) FINAL REPORT.—Not later than the date 

18 that is 3 years after the date of the enactment of 

19 this Act, the Secretary shall issue a final public re20 port on such plan, including analysis of issues de21 scribed in subsection (b) and impact analyses. 

22 (f) CONVERSION OF ACUTE CARE EPISODE DEM23 ONSTRATION TO PILOT PROGRAM AND EXPANSION TO IN24 CLUDE POST ACUTE SERVICES.— 
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1 (1) IN GENERAL.—Part E of title XVIII of the 

2 Social Security Act is amended by inserting after 

3 section 1866C the following new section: 

4 ‘‘CONVERSION OF ACUTE CARE EPISODE DEMONSTRATION

5 TO PILOT PROGRAM AND EXPANSION TO INCLUDE

6 POST ACUTE SERVICES

7 ‘‘SEC. 1866D. (a) CONVERSION AND EXPANSION.— 

8 ‘‘(1) IN GENERAL.—By not later than January 

9 1, 2011, the Secretary shall, for the purpose of pro10 moting the use of bundled payments to promote effi11 cient, coordinated, and high quality delivery of 

12 care— 

13 ‘‘(A) convert the acute care episode dem14 onstration program conducted under section 

15 1866C to a pilot program; and 

16 ‘‘(B) subject to subsection (c), expand such 

17 program as so converted to include post acute 

18 services and such other services the Secretary 

19 determines to be appropriate, which may in20 clude transitional services. 

21 ‘‘(2) BUNDLED PAYMENT STRUCTURES.— 

22 ‘‘(A) IN GENERAL.—In carrying out para23 graph (1), the Secretary may apply bundled 

24 payments with respect to— 

25 ‘‘(i) hospitals and physicians; 
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1 ‘‘(ii) hospitals and post-acute care 

2 providers; 

3 ‘‘(iii) hospitals, physicians, and post4 acute care providers; or 

5 ‘‘(iv) combinations of post-acute pro6 viders. 

7 ‘‘(B) FURTHER APPLICATION.— 

8 ‘‘(i) IN GENERAL.—In carrying out 

9 paragraph (1), the Secretary shall apply 

10 bundled payments in a manner so as to in11 clude collaborative care networks and con12 tinuing care hospitals. 

13 ‘‘(ii) COLLABORATIVE CARE NETWORK

14 DEFINED.—For purposes of this subpara15 graph, the term ‘collaborative care net16 work’ means a consortium of health care 

17 providers that provides a comprehensive 

18 range of coordinated and integrated health 

19 care services to low-income patient popu20 lations (including the uninsured) which 

21 may include coordinated and comprehen22 sive care by safety net providers to reduce 

23 any unnecessary use of items and services 

24 furnished in emergency departments, man25 age chronic conditions, improve quality and 
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1 efficiency of care, increase preventive serv2 ices, and promote adherence to post-acute 

3 and follow-up care plans. 

4 ‘‘(iii) CONTINUING CARE HOSPITAL

5 DEFINED.—For purposes of this subpara6 graph, the term ‘continuing care hospital’ 

7 means an entity that has demonstrated the 

8 ability to meet patient care and patient 

9 safety standards and that provides under 

10 common management the medical and re11 habilitation services provided in inpatient 

12 rehabilitation hospitals and units (as de13 fined in section 1886(d)(1)(B)(ii)), long14 term care hospitals (as defined in section 

15 1886(d)(1)(B)(iv)(I)), and skilled nursing 

16 facilities (as defined in section 1819(a)) 

17 that are located in a hospital described in 

18 section 1886(d). 

19 ‘‘(b) SCOPE.—The Secretary shall set specific goals 

20 for the number of acute and post-acute bundling test sites 

21 under the pilot program to ensure that over time the pilot 

22 program is of sufficient size and scope to— 

23 ‘‘(1) test the approaches under the pilot pro24 gram in a variety of settings, including urban, rural, 

25 and underserved areas; 
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1 ‘‘(2) include geographic areas and additional 

2 conditions that account for significant program 

3 spending, as defined by the Secretary; and 

4 ‘‘(3) subject to subsection (d), disseminate the 

5 pilot program rapidly on a national basis. 

6 To the extent that the Secretary finds inpatient and post 

7 acute care bundling to be successful in improving quality 

8 and reducing costs, the Secretary shall implement such 

9 mechanisms and reforms under the pilot program on as 

10 large a geographic scale as practical and economical, con11 sistent with subsection (e). Nothing in this subsection 

12 shall be construed as limiting the number of hospital and 

13 physician groups or the number of hospital and post-acute 

14 provider groups that may participate in the pilot program. 

15 ‘‘(c) LIMITATION.—The Secretary shall only expand 

16 the pilot program under subsection (a) if the Secretary 

17 finds that— 

18 ‘‘(1) the demonstration program under section 

19 1866C and pilot program under this section main20 tain or increase the quality of care received by indi21 viduals enrolled under this title; and 

22 ‘‘(2) such demonstration program and pilot pro23 gram reduce program expenditures and, based on 

24 the certification under subsection (d), that the ex25 pansion of such pilot program would result in esti-
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1 mated spending that would be less than what spend2 ing would otherwise be in the absence of this section. 

3 ‘‘(d) CERTIFICATION.—For purposes of subsection 

4 (c), the Chief Actuary of the Centers for Medicare & Med5 icaid Services shall certify whether expansion of the pilot 

6 program under this section would result in estimated 

7 spending that would be less than what spending would 

8 otherwise be in the absence of this section. 

9 ‘‘(e) VOLUNTARY PARTICIPATION.—Nothing in this 

10 paragraph shall be construed as requiring the participa11 tion of an entity in the pilot program under this section. 

12 ‘‘(f) EVALUATION ON COST AND QUALITY OF

13 CARE.—The Secretary shall conduct an evaluation of the 

14 pilot program under subsection (a) to study the effect of 

15 such program on costs and quality of care. The findings 

16 of such evaluation shall be included in the final report re17 quired under section 1152(e)(2) of the Affordable Health 

18 Care for America Act. 

19 ‘‘(g) STUDY OF ADDITIONAL BUNDLING AND EPI20 SODE-BASED PAYMENT FOR PHYSICIANS’ SERVICES.— 

21 ‘‘(1) IN GENERAL.—The Secretary shall provide 

22 for a study of and development of a plan for testing 

23 additional ways to increase bundling of payments for 

24 physicians in connection with an episode of care, 

25 such as in connection with outpatient hospital serv-
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1 ices or services rendered in physicians’ offices, other 

2 than those provided under the pilot program. 

3 ‘‘(2) APPLICATION.—The Secretary may imple4 ment such a plan through a demonstration pro5 gram.’’. 

6 (2) CONFORMING AMENDMENT.—Section 

7 1866C(b) of the Social Security Act (42 U.S.C. 

8 1395cc–3(b)) is amended by striking ‘‘The Sec9 retary’’ and inserting ‘‘Subject to section 1866D, the 

10 Secretary’’. 

11 SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010. 

12 Section 1895(b)(3)(B)(ii) of the Social Security Act 

13 (42 U.S.C. 1395fff(b)(3)(B)(ii)) is amended— 

14 (1) in subclause (IV), by striking ‘‘and’’; 

15 (2) by redesignating subclause (V) as subclause 

16 (VII); and 

17 (3) by inserting after subclause (IV) the fol18 lowing new subclauses: 

19 ‘‘(V) 2007, 2008, and 2009, sub20 ject to clause (v), the home health 

21 market basket percentage increase; 

22 ‘‘(VI) 2010, subject to clause (v), 

23 0 percent; and’’. 
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1 SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH 

2 CARE. 

3 (a) ACCELERATION OF ADJUSTMENT FOR CASE MIX

4 CHANGES.—Section 1895(b)(3)(B) of the Social Security 

5 Act (42 U.S.C. 1395fff(b)(3)(B)) is amended— 

6 (1) in clause (iv), by striking ‘‘Insofar as’’ and 

7 inserting ‘‘Subject to clause (vi), insofar as’’; and 

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

9 clause: 

10 ‘‘(vi) SPECIAL RULE FOR CASE MIX

11 CHANGES FOR 2011.— 

12 ‘‘(I) IN GENERAL.—With respect 

13 to the case mix adjustments estab14 lished in section 484.220(a) of title 

15 42, Code of Federal Regulations, the 

16 Secretary shall apply, in 2010, the ad17 justment established in paragraph (3) 

18 of such section for 2011, in addition 

19 to applying the adjustment established 

20 in paragraph (2) for 2010. 

21 ‘‘(II) CONSTRUCTION.—Nothing 

22 in this clause shall be construed as 

23 limiting the amount of adjustment for 

24 case mix for 2010 or 2011 if more re25 cent data indicate an appropriate ad26 justment that is greater than the 
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1 amount established in the section de2 scribed in subclause (I).’’. 

3 (b) REBASING HOME HEALTH PROSPECTIVE PAY4 MENT AMOUNT.—Section 1895(b)(3)(A) of the Social Se5 curity Act (42 U.S.C. 1395fff(b)(3)(A)) is amended— 

6 (1) in clause (i)— 

7 (A) in subclause (III), by inserting ‘‘and 

8 before 2011’’ after ‘‘after the period described 

9 in subclause (II)’’; and 

10 (B) by inserting after subclause (III) the 

11 following new subclauses: 

12 ‘‘(IV) Subject to clause (iii)(I), 

13 for 2011, such amount (or amounts) 

14 shall be adjusted by a uniform per15 centage determined to be appropriate 

16 by the Secretary based on analysis of 

17 factors such as changes in the average 

18 number and types of visits in an epi19 sode, the change in intensity of visits 

20 in an episode, growth in cost per epi21 sode, and other factors that the Sec22 retary considers to be relevant. 

23 ‘‘(V) Subject to clause (iii)(II), 

24 for a year after 2011, such a amount 

25 (or amounts) shall be equal to the 
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1 amount (or amounts) determined 

2 under this clause for the previous 

3 year, updated under subparagraph 

4 (B).’’; and 

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

6 clause: 

7 ‘‘(iii) SPECIAL RULE IN CASE OF IN8 ABILITY TO EFFECT TIMELY REBASING.— 

9 ‘‘(I) APPLICATION OF PROXY

10 AMOUNT FOR 2011.—If the Secretary 

11 is not able to compute the amount (or 

12 amounts) under clause (i)(IV) so as to 

13 permit, on a timely basis, the applica14 tion of such clause for 2011, the Sec15 retary shall substitute for such 

16 amount (or amounts) 95 percent of 

17 the amount (or amounts) that would 

18 otherwise be specified under clause 

19 (i)(III) if it applied for 2011. 

20 ‘‘(II) ADJUSTMENT FOR SUBSE21 QUENT YEARS BASED ON DATA.—If 

22 the Secretary applies subclause (I), 

23 the Secretary before July 1, 2011, 

24 shall compare the amount (or 

25 amounts) applied under such sub-
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1 clause with the amount (or amounts) 

2 that should have been applied under 

3 clause (i)(IV). The Secretary shall de4 crease or increase the prospective pay5 ment amount (or amounts) under 

6 clause (i)(V) for 2012 (or, at the Sec7 retary’s discretion, over a period of 

8 several years beginning with 2012) by 

9 the amount (if any) by which the 

10 amount (or amounts) applied under 

11 subclause (I) is greater or less, re12 spectively, than the amount (or 

13 amounts) that should have been ap14 plied under clause (i)(IV).’’. 

15 SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVE16 MENTS INTO MARKET BASKET UPDATE FOR 

17 HOME HEALTH SERVICES. 

18 (a) IN GENERAL.—Section 1895(b)(3)(B) of the So19 cial Security Act (42 U.S.C. 1395fff(b)(3)(B)) is amend20 ed— 

21 (1) in clause (iii), by inserting ‘‘(including being 

22 subject to the productivity adjustment described in 

23 section 1886(b)(3)(B)(iii)(II))’’ after ‘‘in the same 

24 manner’’; and 
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1 (2) in clause (v)(I), by inserting ‘‘(but not 

2 below 0)’’ after ‘‘reduced’’. 

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

4 subsection (a) shall apply to home health market basket 

5 percentage increases for years beginning with 2011. 

6 SEC. 1155A. MEDPAC STUDY ON VARIATION IN HOME 

7 HEALTH MARGINS. 

8 (a) IN GENERAL.—The Medicare Payment Advisory 

9 Commission shall conduct a study regarding variation in 

10 performance of home health agencies in an effort to ex11 plain variation in Medicare margins for such agencies. 

12 Such study shall include an examination of at least the 

13 following issues: 

14 (1) The demographic characteristics of individ15 uals served and the geographic distribution associ16 ated with transportation costs. 

17 (2) The characteristics of such agencies, such 

18 as whether such agencies operate 24 hours each day, 

19 provide charity care, or are part of an integrated 

20 health system. 

21 (3) The socio-economic status of individuals 

22 served, such as the proportion of such individuals 

23 who are dually eligible for Medicare and Medicaid 

24 benefits. 
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1 (4) The presence of severe and or chronic dis2 ease or disability in individuals served, as evidenced 

3 by multiple discontinuous home health episodes with 

4 a high number of visits per episode. 

5 (5) The differences in services provided, such as 

6 therapy and non-therapy services. 

7 (b) REPORT.—Not later than June 1, 2011, the Com8 mission shall submit a report to the Congress on the re9 sults of the study conducted under subsection (a) and shall 

10 include in the report the Commission’s conclusions and 

11 recommendations, if appropriate, regarding each of the 

12 issues described in paragraphs (1), (2) and (3) of such 

13 subsection. 

14 SEC. 1155B. PERMITTING HOME HEALTH AGENCIES TO AS15 SIGN THE MOST APPROPRIATE SKILLED 

16 SERVICE TO MAKE THE INITIAL ASSESSMENT 

17 VISIT UNDER A MEDICARE HOME HEALTH 

18 PLAN OF CARE FOR REHABILITATION CASES. 

19 (a) IN GENERAL.—Notwithstanding section 

20 484.55(a)(2) of title 42 of the Code of Federal Regula21 tions or any other provision of law, a home health agency 

22 may determine the most appropriate skilled therapist to 

23 make the initial assessment visit for an individual who is 

24 referred (and may be eligible) for home health services 

25 under title XVIII of the Social Security Act but who does 
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1 not require skilled nursing care as long as the skilled serv2 ice (for which that therapist is qualified to provide the 

3 service) is included as part of the plan of care for home 

4 health services for such individual. 

5 (b) RULE OF CONSTRUCTION.—Nothing in sub6 section (a) shall be construed to provide for initial eligi7 bility for coverage of home health services under title 

8 XVIII of the Social Security Act on the basis of a need 

9 for occupational therapy. 

10 SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE 

11 PROHIBITION ON CERTAIN PHYSICIAN RE12 FERRALS MADE TO HOSPITALS. 

13 (a) IN GENERAL.—Section 1877 of the Social Secu14 rity Act (42 U.S.C. 1395nn) is amended— 

15 (1) in subsection (d)(2)— 

16 (A) in subparagraph (A), by striking 

17 ‘‘and’’ at the end; 

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

19 period at the end and inserting ‘‘; and’’; and 

20 (C) by adding at the end the following new 

21 subparagraph: 

22 ‘‘(C) in the case where the entity is a hos23 pital, the hospital meets the requirements of 

24 paragraph (3)(D).’’; 

25 (2) in subsection (d)(3)— 
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1 (A) in subparagraph (B), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (C), by striking the 

4 period at the end and inserting ‘‘; and’’; and 

5 (C) by adding at the end the following new 

6 subparagraph: 

7 ‘‘(D) the hospital meets the requirements 

8 described in subsection (i)(1).’’; 

9 (3) by amending subsection (f) to read as fol10 lows: 

11 ‘‘(f) REPORTING AND DISCLOSURE REQUIRE12 MENTS.— 

13 ‘‘(1) IN GENERAL.—Each entity providing cov14 ered items or services for which payment may be 

15 made under this title shall provide the Secretary 

16 with the information concerning the entity’s owner17 ship, investment, and compensation arrangements, 

18 including— 

19 ‘‘(A) the covered items and services pro20 vided by the entity, and 

21 ‘‘(B) the names and unique physician iden22 tification numbers of all physicians with an 

23 ownership or investment interest (as described 

24 in subsection (a)(2)(A)), or with a compensa25 tion arrangement (as described in subsection 
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1 (a)(2)(B)), in the entity, or whose immediate 

2 relatives have such an ownership or investment 

3 interest or who have such a compensation rela4 tionship with the entity. 

5 Such information shall be provided in such form, 

6 manner, and at such times as the Secretary shall 

7 specify. The requirement of this subsection shall not 

8 apply to designated health services provided outside 

9 the United States or to entities which the Secretary 

10 determines provide services for which payment may 

11 be made under this title very infrequently. 

12 ‘‘(2) REQUIREMENTS FOR HOSPITALS WITH

13 PHYSICIAN OWNERSHIP OR INVESTMENT.—In the 

14 case of a hospital that meets the requirements de15 scribed in subsection (i)(1), the hospital shall— 

16 ‘‘(A) submit to the Secretary an initial re17 port, and periodic updates at a frequency deter18 mined by the Secretary, containing a detailed 

19 description of the identity of each physician 

20 owner and physician investor and any other 

21 owners or investors of the hospital; 

22 ‘‘(B) require that any referring physician 

23 owner or investor discloses to the individual 

24 being referred, by a time that permits the indi25 vidual to make a meaningful decision regarding 
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1 the receipt of services, as determined by the 

2 Secretary, the ownership or investment interest, 

3 as applicable, of such referring physician in the 

4 hospital; and 

5 ‘‘(C) disclose the fact that the hospital is 

6 partially or wholly owned by one or more physi7 cians or has one or more physician investors— 

8 ‘‘(i) on any public website for the hos9 pital; and 

10 ‘‘(ii) in any public advertising for the 

11 hospital. 

12 The information to be reported or disclosed under 

13 this paragraph shall be provided in such form, man14 ner, and at such times as the Secretary shall specify. 

15 The requirements of this paragraph shall not apply 

16 to designated health services furnished outside the 

17 United States or to entities which the Secretary de18 termines provide services for which payment may be 

19 made under this title very infrequently. 

20 ‘‘(3) PUBLICATION OF INFORMATION.—The 

21 Secretary shall publish, and periodically update, the 

22 information submitted by hospitals under paragraph 

23 (2)(A) on the public Internet website of the Centers 

24 for Medicare & Medicaid Services.’’; 
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1 (4) by amending subsection (g)(5) to read as 

2 follows: 

3 ‘‘(5) FAILURE TO REPORT OR DISCLOSE INFOR4 MATION.— 

5 ‘‘(A) REPORTING.—Any person who is re6 quired, but fails, to meet a reporting require7 ment of paragraphs (1) and (2)(A) of sub8 section (f) is subject to a civil money penalty of 

9 not more than $10,000 for each day for which 

10 reporting is required to have been made. 

11 ‘‘(B) DISCLOSURE.—Any physician who is 

12 required, but fails, to meet a disclosure require13 ment of subsection (f)(2)(B) or a hospital that 

14 is required, but fails, to meet a disclosure re15 quirement of subsection (f)(2)(C) is subject to 

16 a civil money penalty of not more than $10,000 

17 for each case in which disclosure is required to 

18 have been made. 

19 ‘‘(C) APPLICATION.—The provisions of 

20 section 1128A (other than the first sentence of 

21 subsection (a) and other than subsection (b)) 

22 shall apply to a civil money penalty under sub23 paragraphs (A) and (B) in the same manner as 

24 such provisions apply to a penalty or proceeding 

25 under section 1128A(a).’’; and 
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1 (5) by adding at the end the following new sub2 section: 

3 ‘‘(i) REQUIREMENTS TO QUALIFY FOR RURAL PRO4 VIDER AND HOSPITAL OWNERSHIP EXCEPTIONS TO

5 SELF-REFERRAL PROHIBITION.— 

6 ‘‘(1) REQUIREMENTS DESCRIBED.—For pur7 poses of subsection (d)(3)(D), the requirements de8 scribed in this paragraph are as follows: 

9 ‘‘(A) PROVIDER AGREEMENT.—The hos10 pital had— 

11 ‘‘(i) physician ownership or invest12 ment on January 1, 2009; and 

13 ‘‘(ii) a provider agreement under sec14 tion 1866 in effect on such date. 

15 ‘‘(B) PROHIBITION ON PHYSICIAN OWNER16 SHIP OR INVESTMENT.—The percentage of the 

17 total value of the ownership or investment in18 terests held in the hospital, or in an entity 

19 whose assets include the hospital, by physician 

20 owners or investors in the aggregate does not 

21 exceed such percentage as of the date of enact22 ment of this subsection. 

23 ‘‘(C) PROHIBITION ON EXPANSION OF FA24 CILITY CAPACITY.—Except as provided in para25 graph (2), the number of operating rooms, pro-
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1 cedure rooms, or beds of the hospital at any 

2 time on or after the date of the enactment of 

3 this subsection are no greater than the number 

4 of operating rooms, procedure rooms, or beds, 

5 respectively, as of such date. 

6 ‘‘(D) ENSURING BONA FIDE OWNERSHIP

7 AND INVESTMENT.— 

8 ‘‘(i) Any ownership or investment in9 terests that the hospital offers to a physi10 cian are not offered on more favorable 

11 terms than the terms offered to a person 

12 who is not in a position to refer patients 

13 or otherwise generate business for the hos14 pital. 

15 ‘‘(ii) The hospital (or any investors in 

16 the hospital) does not directly or indirectly 

17 provide loans or financing for any physi18 cian owner or investor in the hospital. 

19 ‘‘(iii) The hospital (or any investors in 

20 the hospital) does not directly or indirectly 

21 guarantee a loan, make a payment toward 

22 a loan, or otherwise subsidize a loan, for 

23 any physician owner or investor or group 

24 of physician owners or investors that is re-
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1 lated to acquiring any ownership or invest2 ment interest in the hospital. 

3 ‘‘(iv) Ownership or investment returns 

4 are distributed to each owner or investor in 

5 the hospital in an amount that is directly 

6 proportional to the ownership or invest7 ment interest of such owner or investor in 

8 the hospital. 

9 ‘‘(v) The investment interest of the 

10 owner or investor is directly proportional 

11 to the owner’s or investor’s capital con12 tributions made at the time the ownership 

13 or investment interest is obtained. 

14 ‘‘(vi) Physician owners and investors 

15 do not receive, directly or indirectly, any 

16 guaranteed receipt of or right to purchase 

17 other business interests related to the hos18 pital, including the purchase or lease of 

19 any property under the control of other 

20 owners or investors in the hospital or lo21 cated near the premises of the hospital. 

22 ‘‘(vii) The hospital does not offer a 

23 physician owner or investor the oppor24 tunity to purchase or lease any property 

25 under the control of the hospital or any 
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1 other owner or investor in the hospital on 

2 more favorable terms than the terms of3 fered to a person that is not a physician 

4 owner or investor. 

5 ‘‘(viii) The hospital does not condition 

6 any physician ownership or investment in7 terests either directly or indirectly on the 

8 physician owner or investor making or in9 fluencing referrals to the hospital or other10 wise generating business for the hospital. 

11 ‘‘(E) PATIENT SAFETY.—In the case of a 

12 hospital that does not offer emergency services, 

13 the hospital has the capacity to— 

14 ‘‘(i) provide assessment and initial 

15 treatment for medical emergencies; and 

16 ‘‘(ii) if the hospital lacks additional 

17 capabilities required to treat the emergency 

18 involved, refer and transfer the patient 

19 with the medical emergency to a hospital 

20 with the required capability. 

21 ‘‘(F) LIMITATION ON APPLICATION TO

22 CERTAIN CONVERTED FACILITIES.—The hos23 pital was not converted from an ambulatory 

24 surgical center to a hospital on or after the date 

25 of enactment of this subsection. 
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1 ‘‘(2) EXCEPTION TO PROHIBITION ON EXPAN2 SION OF FACILITY CAPACITY.— 

3 ‘‘(A) PROCESS.— 

4 ‘‘(i) ESTABLISHMENT.—The Secretary 

5 shall establish and implement a process 

6 under which a hospital may apply for an 

7 exception from the requirement under 

8 paragraph (1)(C). 

9 ‘‘(ii) OPPORTUNITY FOR COMMUNITY

10 INPUT.—The process under clause (i) shall 

11 provide persons and entities in the commu12 nity in which the hospital applying for an 

13 exception is located with the opportunity to 

14 provide input with respect to the applica15 tion. 

16 ‘‘(iii) TIMING FOR IMPLEMENTA17 TION.—The Secretary shall implement the 

18 process under clause (i) on the date that is 

19 one month after the promulgation of regu20 lations described in clause (iv). 

21 ‘‘(iv) REGULATIONS.—Not later than 

22 the first day of the month beginning 18 

23 months after the date of the enactment of 

24 this subsection, the Secretary shall promul25 gate regulations to carry out the process 
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1 under clause (i). The Secretary may issue 

2 such regulations as interim final regula3 tions. 

4 ‘‘(B) FREQUENCY.—The process described 

5 in subparagraph (A) shall permit a hospital to 

6 apply for an exception up to once every 2 years. 

7 ‘‘(C) PERMITTED INCREASE.— 

8 ‘‘(i) IN GENERAL.—Subject to clause 

9 (ii) and subparagraph (D), a hospital 

10 granted an exception under the process de11 scribed in subparagraph (A) may increase 

12 the number of operating rooms, procedure 

13 rooms, or beds of the hospital above the 

14 baseline number of operating rooms, proce15 dure rooms, or beds, respectively, of the 

16 hospital (or, if the hospital has been grant17 ed a previous exception under this para18 graph, above the number of operating 

19 rooms, procedure rooms, or beds, respec20 tively, of the hospital after the application 

21 of the most recent increase under such an 

22 exception). 

23 ‘‘(ii) 100 PERCENT INCREASE LIMITA24 TION.—The Secretary shall not permit an 

25 increase in the number of operating rooms, 
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1 procedure rooms, or beds of a hospital 

2 under clause (i) to the extent such increase 

3 would result in the number of operating 

4 rooms, procedure rooms, or beds of the 

5 hospital exceeding 200 percent of the base6 line number of operating rooms, procedure 

7 rooms, or beds of the hospital. 

8 ‘‘(iii) BASELINE NUMBER OF OPER9 ATING ROOMS, PROCEDURE ROOMS, OR

10 BEDS.—In this paragraph, the term ‘base11 line number of operating rooms, procedure 

12 rooms, or beds’ means the number of oper13 ating rooms, procedure rooms, or beds of a 

14 hospital as of the date of enactment of this 

15 subsection. 

16 ‘‘(D) INCREASE LIMITED TO FACILITIES

17 ON THE MAIN CAMPUS OF THE HOSPITAL.— 

18 Any increase in the number of operating rooms, 

19 procedure rooms, or beds of a hospital pursuant 

20 to this paragraph may only occur in facilities on 

21 the main campus of the hospital. 

22 ‘‘(E) CONDITIONS FOR APPROVAL OF AN

23 INCREASE IN FACILITY CAPACITY.—The Sec24 retary may grant an exception under the proc25 ess described in subparagraph (A) only to a 
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1 hospital described in subparagraph (F) or a 

2 hospital— 

3 ‘‘(i) that is located in a county in 

4 which the percentage increase in the popu5 lation during the most recent 5-year period 

6 for which data are available is estimated to 

7 be at least 150 percent of the percentage 

8 increase in the population growth of the 

9 State in which the hospital is located dur10 ing that period, as estimated by Bureau of 

11 the Census and available to the Secretary; 

12 ‘‘(ii) whose annual percent of total in13 patient admissions that represent inpatient 

14 admissions under the program under title 

15 XIX is estimated to be equal to or greater 

16 than the average percent with respect to 

17 such admissions for all hospitals located in 

18 the county in which the hospital is located; 

19 ‘‘(iii) that does not discriminate 

20 against beneficiaries of Federal health care 

21 programs and does not permit physicians 

22 practicing at the hospital to discriminate 

23 against such beneficiaries; 

24 ‘‘(iv) that is located in a State in 

25 which the average bed capacity in the 
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1 State is estimated to be less than the na2 tional average bed capacity; 

3 ‘‘(v) that has an average bed occu4 pancy rate that is estimated to be greater 

5 than the average bed occupancy rate in the 

6 State in which the hospital is located; and 

7 ‘‘(vi) that meets other conditions as 

8 determined by the Secretary. 

9 ‘‘(F) SPECIAL RULE FOR A HIGH MED10 ICAID FACILITY.—A hospital described in this 

11 subparagraph is a hospital that— 

12 ‘‘(i) with respect to each of the 3 most 

13 recent cost reporting periods for which 

14 data are available, has an annual percent 

15 of total inpatient admissions that represent 

16 inpatient admissions under the program 

17 under title XIX that is determined by the 

18 Secretary to be greater than such percent 

19 with respect to such admissions for any 

20 other hospital located in the county in 

21 which the hospital is located; and 

22 ‘‘(ii) meets the conditions described in 

23 clauses (iii) and (vi) of subparagraph (E). 

24 ‘‘(G) PROCEDURE ROOMS.—In this sub25 section, the term ‘procedure rooms’ includes 
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1 rooms in which catheterizations, angiographies, 

2 angiograms, and endoscopies are furnished, but 

3 such term shall not include emergency rooms or 

4 departments (except for rooms in which cath5 eterizations, angiographies, angiograms, and 

6 endoscopies are furnished). 

7 ‘‘(H) PUBLICATION OF FINAL DECI8 SIONS.—Not later than 120 days after receiving 

9 a complete application under this paragraph, 

10 the Secretary shall publish on the public Inter11 net website of the Centers for Medicare & Med12 icaid Services the final decision with respect to 

13 such application. 

14 ‘‘(I) LIMITATION ON REVIEW.—There shall 

15 be no administrative or judicial review under 

16 section 1869, section 1878, or otherwise of the 

17 exception process under this paragraph, includ18 ing the establishment of such process, and any 

19 determination made under such process. 

20 ‘‘(3) PHYSICIAN OWNER OR INVESTOR DE21 FINED.—For purposes of this subsection and sub22 section (f)(2), the term ‘physician owner or investor’ 

23 means a physician (or an immediate family member 

24 of such physician) with a direct or an indirect own25 ership or investment interest in the hospital. 
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1 ‘‘(4) PATIENT SAFETY REQUIREMENT.—In the 

2 case of a hospital to which the requirements of para3 graph (1) apply, insofar as the hospital admits a pa4 tient and does not have any physician available on 

5 the premises 24 hours per day, 7 days per week, be6 fore admitting the patient— 

7 ‘‘(A) the hospital shall disclose such fact to 

8 the patient; and 

9 ‘‘(B) following such disclosure, the hospital 

10 shall receive from the patient a signed acknowl11 edgment that the patient understands such fact. 

12 ‘‘(5) CLARIFICATION.—Nothing in this sub13 section shall be construed as preventing the Sec14 retary from terminating a hospital’s provider agree15 ment if the hospital is not in compliance with regu16 lations pursuant to section 1866.’’. 

17 (b) VERIFYING COMPLIANCE.—The Secretary of 

18 Health and Human Services shall establish policies and 

19 procedures to verify compliance with the requirements de20 scribed in subsections (i)(1) and (i)(4) of section 1877 of 

21 the Social Security Act, as added by subsection (a)(5). 

22 The Secretary may use unannounced site reviews of hos23 pitals and audits to verify compliance with such require24 ments. 

25 (c) IMPLEMENTATION.— 
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1 (1) FUNDING.—For purposes of carrying out 

2 the amendments made by subsection (a) and the 

3 provisions of subsection (b), in addition to funds 

4 otherwise available, out of any funds in the Treasury 

5 not otherwise appropriated there are appropriated to 

6 the Secretary of Health and Human Services for the 

7 Centers for Medicare & Medicaid Services Program 

8 Management Account $5,000,000 for each fiscal 

9 year beginning with fiscal year 2010. Amounts ap10 propriated under this paragraph for a fiscal year 

11 shall be available until expended. 

12 (2) ADMINISTRATION.—Chapter 35 of title 44, 

13 United States Code, shall not apply to the amend14 ments made by subsection (a) and the provisions of 

15 subsection (b). 

16 SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEO17 GRAPHIC ADJUSTMENT FACTORS UNDER 

18 MEDICARE. 

19 (a) IN GENERAL.—The Secretary of Health and 

20 Human Services shall enter into a contract with the Insti21 tute of Medicine of the National Academy of Science to 

22 conduct a comprehensive empirical study, and provide rec23 ommendations as appropriate, on the accuracy of the geo24 graphic adjustment factors established under sections 
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1 1848(e) and 1886(d)(3)(E) of the Social Security Act (42 

2 U.S.C. 1395w–4(e), 1395ww(d)(3)(E)). 

3 (b) MATTERS INCLUDED.—Such study shall include 

4 an evaluation and assessment of the following with respect 

5 to such adjustment factors: 

6 (1) Empirical validity of the adjustment factors. 

7 (2) Methodology used to determine the adjust8 ment factors. 

9 (3) Measures used for the adjustment factors, 

10 taking into account— 

11 (A) timeliness of data and frequency of re12 visions to such data; 

13 (B) sources of data and the degree to 

14 which such data are representative of costs; and 

15 (C) operational costs of providers who par16 ticipate in Medicare. 

17 (c) EVALUATION.—Such study shall, within the con18 text of the United States health care marketplace, evalu19 ate and consider the following: 

20 (1) The effect of the adjustment factors on the 

21 level and distribution of the health care workforce 

22 and resources, including— 

23 (A) recruitment and retention that takes 

24 into account workforce mobility between urban 

25 and rural areas; 
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1 (B) ability of hospitals and other facilities 

2 to maintain an adequate and skilled workforce; 

3 and 

4 (C) patient access to providers and needed 

5 medical technologies. 

6 (2) The effect of the adjustment factors on pop7 ulation health and quality of care. 

8 (3) The effect of the adjustment factors on the 

9 ability of providers to furnish efficient, high value 

10 care. 

11 (d) REPORT.—The contract under subsection (a) 

12 shall provide for the Institute of Medicine to submit, not 

13 later than 1 year after the date of the enactment of this 

14 Act, to the Secretary and the Congress a report containing 

15 results and recommendations of the study conducted 

16 under this section. 

17 (e) FUNDING.—There are authorized to be appro18 priated to carry out this section such sums as may be nec19 essary. 

20 SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO 

21 ADDRESS GEOGRAPHIC INEQUITIES. 

22 (a) REVISION OF MEDICARE PAYMENT SYSTEMS.— 

23 Taking into account the recommendations described in the 

24 report under section 1157, and notwithstanding the geo25 graphic adjustments that would otherwise apply under sec-
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1 tion 1848(e) and section 1886(d)(3)(E) of the Social Se2 curity Act (42 U.S.C. 1395w–4(e), 1395ww(d)(3)(E)), the 

3 Secretary of Health and Human Services shall include in 

4 proposed rules applicable to the rulemaking cycle for pay5 ment systems for physicians’ services and inpatient hos6 pital services under sections 1848 and section 1886(d) of 

7 such Act, respectively, proposals (as the Secretary deter8 mines to be appropriate) to revise the geographic adjust9 ment factors used in such systems. Such proposals’ rules 

10 shall be contained in the next rulemaking cycle following 

11 the submission to the Secretary of the report described 

12 in section 1157. 

13 (b) PAYMENT ADJUSTMENTS.— 

14 (1) FUNDING FOR IMPROVEMENTS.—For years 

15 before 2014, the Secretary shall ensure that the ad16 ditional expenditures resulting from the implementa17 tion of the provisions of this section, as estimated by 

18 the Secretary, do not exceed $8,000,000,000, and do 

19 not exceed half of such amount in any payment year. 

20 (2) HOLD HARMLESS.—In carrying out this 

21 subsection— 

22 (A) for payment years before 2014, the 

23 Secretary shall not reduce the geographic ad24 justment below the factor that applied for such 
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1 payment system in the payment year before 

2 such changes; and 

3 (B) for payment years beginning with 

4 2014, the Secretary shall implement the geo5 graphic adjustment in a manner that does not 

6 result in any net change in aggregate expendi7 tures under title XVIII of the Social Security 

8 Act from the amount of such expenditures that 

9 the Secretary estimates would have occurred if 

10 no geographic adjustment had occurred under 

11 this section. 

12 (c) MEDICARE IMPROVEMENT FUND.— 

13 (1) Amounts in the Medicare Improvement 

14 Fund under section 1898 of the Social Security Act, 

15 as amended by paragraph (2), shall be available to 

16 the Secretary to make changes to the geographic ad17 justments factors as described in subsections (a) and 

18 (b) with respect to services furnished before January 

19 1, 2014. No more than one-half of such amounts 

20 shall be available with respect to services furnished 

21 in any one payment year. 

22 (2) Section 1898(b) of the Social Security Act 

23 (42 U.S.C. 1395iii(b)) is amended— 

24 (A) by amending paragraph (1)(A) to read 

25 as follows: 
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1 ‘‘(A) the period beginning with fiscal year 

2 2011 and ending with fiscal year 2019, 

3 $8,000,000,000; and’’; and 

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

5 paragraph: 

6 ‘‘(5) ADJUSTMENT FOR UNDERFUNDING.—For 

7 fiscal year 2014 or a subsequent fiscal year specified 

8 by the Secretary, the amount available to the fund 

9 under subsection (a) shall be increased by the Sec10 retary’s estimate of the amount (based on data on 

11 actual expenditures) by which— 

12 ‘‘(A) the additional expenditures resulting 

13 from the implementation of subsection (a) of 

14 section 1158 of the Affordable Health Care for 

15 America Act for the period before fiscal year 

16 2014, is less than 

17 ‘‘(B) the maximum amount of funds avail18 able under subsection (a) of such section for 

19 funding for such expenditures.’’. 

20 SEC. 1159. INSTITUTE OF MEDICINE STUDY OF GEO21 GRAPHIC VARIATION IN HEALTH CARE 

22 SPENDING AND PROMOTING HIGH-VALUE 

23 HEALTH CARE. 

24 (a) IN GENERAL.—The Secretary of Health and 

25 Human Services (in this section and the succeeding sec-
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1 tion referred to as the ‘‘Secretary’’) shall enter into an 

2 agreement with the Institute of Medicine of the National 

3 Academies (referred to in this section as the ‘‘Institute’’) 

4 to conduct a study on geographic variation and growth 

5 in volume and intensity of services in per capita health 

6 care spending among the Medicare, Medicaid, privately in7 sured and uninsured populations. Such study may draw 

8 on recent relevant reports of the Institute and shall in9 clude each of the following: 

10 (1) An evaluation of the extent and range of 

11 such variation using various units of geographic 

12 measurement, including micro areas within larger 

13 areas. 

14 (2) An evaluation of the extent to which geo15 graphic variation can be attributed to differences in 

16 input prices; health status; practice patterns; access 

17 to medical services; supply of medical services; socio18 economic factors, including race, ethnicity, gender, 

19 age, income and educational status; and provider 

20 and payer organizational models. 

21 (3) An evaluation of the extent to which vari22 ations in spending are correlated with patient access 

23 to care, insurance status, distribution of health care 

24 resources, health care outcomes, and consensus25 based measures of health care quality. 
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1 (4) An evaluation of the extent to which vari2 ation can be attributed to physician and practitioner 

3 discretion in making treatment decisions, and the 

4 degree to which discretionary treatment decisions 

5 are made that could be characterized as different 

6 from the best available medical evidence. 

7 (5) An evaluation of the extent to which vari8 ation can be attributed to patient preferences and 

9 patient compliance with treatment protocols. 

10 (6) An assessment of the degree to which vari11 ation cannot be explained by empirical evidence. 

12 (7) For Medicare beneficiaries, An evaluation of 

13 the extent to which variations in spending are cor14 related with insurance status prior to enrollment in 

15 the Medicare program under title XVIII of the So16 cial Security Act, and institutionalization status; 

17 whether beneficiaries are dually eligible for the 

18 Medicare program and Medicaid under title XIX of 

19 such Act; and whether beneficiaries are enrolled in 

20 fee-for-service Medicare or Medicare Advantage. 

21 (8) An evaluation of such other factors as the 

22 Institute deems appropriate. 

23 The Institute shall conduct public hearings and provide 

24 an opportunity for comments prior to completion of the 

25 reports under subsection (e). 
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1 (b) RECOMMENDATIONS.—Taking into account the 

2 findings under subsection (a) and the changes to the pay3 ment systems made by this Act, the Institute shall rec4 ommend changes to payment for items and services under 

5 parts A and B of title XVIII of the Social Security Act, 

6 for addressing variation in Medicare per capita spending 

7 for items and services (not including add-ons for graduate 

8 medical education, disproportionate share payments, and 

9 health information technology, as specified in sections 

10 1886(d)(5)(F), 1886(d)(5)(B), 1886(h), 1848(o), and 

11 1886(n), respectively, of such Act) by promoting high12 value care (as defined in subsection (f)), with particular 

13 attention to high-volume, high-cost conditions. In making 

14 such recommendations, the Institute shall consider each 

15 of the following: 

16 (1) Measurement and reporting on quality and 

17 population health. 

18 (2) Reducing fragmented and duplicative care. 

19 (3) Promoting the practice of evidence-based 

20 medicine. 

21 (4) Empowering patients to make value-based 

22 care decisions. 

23 (5) Leveraging the use of health information 

24 technology. 
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1 (6) The role of financial and other incentives 

2 affecting provision of care. 

3 (7) Variation in input costs. 

4 (8) The characteristics of the patient popu5 lation, including socio-economic factors (including 

6 race, ethnicity, gender, age, income and educational 

7 status), and whether the beneficiaries are dually eli8 gible for the Medicare program under title XVIII of 

9 the Social Security Act and Medicaid under title 

10 XIX of such Act. 

11 (9) Other topics the Institute deems appro12 priate. 

13 In making such recommendations, the Institute shall con14 sider an appropriate phase-in that takes into account the 

15 impact of payment changes on providers and facilities and 

16 preserves access to care for Medicare beneficiaries. 

17 (c) SPECIFIC CONSIDERATIONS.—In making the rec18 ommendations under subsection (b), the Institute shall 

19 specifically address whether payment systems under title 

20 XVIII of the Social Security Act for physicians and hos21 pitals should be further modified to incentivize high-value 

22 care. In so doing, the Institute shall consider the adoption 

23 of a value index based on a composite of appropriate meas24 ures of quality and cost that would adjust provider pay25 ments on a regional or provider-level basis. If the Institute 
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1 finds that application of such a value index would signifi2 cantly incentivize providers to furnish high-value care, it 

3 shall make specific recommendations on how such an 

4 index would be designed and implemented. In so doing, 

5 it should identify specific measures of quality and cost ap6 propriate for use in such an index, and include a thorough 

7 analysis (including on a geographic basis) of how pay8 ments and spending under such title would be affected by 

9 such an index. 

10 (d) ADDITIONAL CONSIDERATIONS.—The Institute 

11 shall consider the experience of governmental and commu12 nity-based programs that promote high-value care. 

13 (e) REPORTS.— 

14 (1) Not later than April 15, 2011, the Institute 

15 shall submit to the Secretary and each House of 

16 Congress a report containing findings and rec17 ommendations of the study conducted under this 

18 section. 

19 (2) Following submission of the report under 

20 paragraph (1), the Institute shall use the data col21 lected and analyzed in this section to issue a subse22 quent report, or series of reports, on how best to ad23 dress geographic variation or efforts to promote 

24 high-value care for items and services reimbursed by 

25 private insurance or other programs. Such reports 
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1 shall include a comparison to the Institute’s findings 

2 and recommendations regarding the Medicare pro3 gram. Such reports, and any recommendations, 

4 would not be subject to the procedures outlined in 

5 section 1160. 

6 (f) HIGH-VALUE CARE DEFINED.—For purposes of 

7 this section, the term ‘‘high-value care’’ means the effi8 cient delivery of high quality, evidence-based, patient-cen9 tered care. 

10 (g) APPROPRIATIONS.—There is appropriated from 

11 amounts in the general fund of the Treasury not otherwise 

12 appropriated $10,000,000 to carry out this section. Such 

13 sums are authorized to remain available until expended. 

14 SEC. 1160. IMPLEMENTATION, AND CONGRESSIONAL RE15 VIEW, OF PROPOSAL TO REVISE MEDICARE 

16 PAYMENTS TO PROMOTE HIGH VALUE 

17 HEALTH CARE. 

18 (a) PREPARATION AND SUBMISSION OF IMPLEMEN19 TATION PLANS.— 

20 (1) FINAL IMPLEMENTATION PLAN.—Not later 

21 than 240 days after the date of receipt by the Sec22 retary and each House of Congress of the report 

23 under section 1159(e)(1), the Secretary shall submit 

24 to each House of Congress a final implementation 

25 plan describing proposed changes to payment for 
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1 items and services under parts A and B of title 

2 XVIII of the Social Security Act (which may include 

3 payment for inpatient and outpatient hospital serv4 ices for services furnished in PPS and PPS-exempt 

5 hospitals, physicians’ services, dialysis facility serv6 ices, skilled nursing facility services, home health 

7 services, hospice care, clinical laboratory services, 

8 durable medical equipment, and other items and 

9 services, but which shall exclude add-on payments 

10 for graduate medical education, disproportionate 

11 share payments, and health information technology, 

12 as specified in sections 1886(d)(5)(F), 

13 1886(d)(5)(B), 1886(h), 1848(o), and 1886(n), re14 spectively, of the Social Security Act) taking into 

15 consideration, as appropriate, the recommendations 

16 of the report submitted under section 1159(e)(1) 

17 and the changes to the payment systems made by 

18 this Act. To the extent such implementation plan re19 quires a substantial change to the payment system, 

20 it shall include a transition phase-in that takes into 

21 consideration possible disruption to provider partici22 pation in the Medicare program under title XVIII of 

23 the Social Security Act and preserves access to care 

24 for Medicare beneficiaries. 
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1 (2) PRELIMINARY IMPLEMENTATION PLAN.— 

2 Not later than 90 days after the date the Institute 

3 of Medicine submits to each House of Congress the 

4 report under section 1159(e)(1), the Secretary shall 

5 submit to each House of Congress a preliminary 

6 version of the implementation plan provided for 

7 under paragraph (1)(A). 

8 (3) NO INCREASE IN BUDGET EXPENDI9 TURES.—The Secretary shall include with the sub10 mission of the final implementation plan under para11 graph (1) a certification by the Chief Actuary of the 

12 Centers for Medicare & Medicaid Services that over 

13 the initial 10-year period in which the plan is imple14 mented, the aggregate level of net expenditures 

15 under the Medicare program under title XVIII of 

16 the Social Security Act will not exceed the aggregate 

17 level of such expenditures that would have occurred 

18 if the plan were not implemented. 

19 (4) WAIVERS REQUIRED.—To the extent the 

20 final implementation plan under paragraph (1) pro21 poses changes that are not otherwise permitted 

22 under title XVIII of the Social Security Act, the 

23 Secretary shall specify in the plan the specific waiv24 ers required under such title to implement such 

25 changes. Except as provided in subsection (c), the 
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1 Secretary is authorized to waive the requirements so 

2 specified in order to implement such changes. 

3 (5) ASSESSMENT OF IMPACT.—In addition, 

4 both the preliminary and final implementation plans 

5 under this subsection shall include a detailed assess6 ment of the effects of the proposed payment changes 

7 by provider or supplier type and State relative to the 

8 payments that would otherwise apply. 

9 (b) REVIEW BY MEDPAC AND GAO.—Not later than 

10 45 days after the date the preliminary implementation 

11 plan is received by each House of Congress under sub12 section (a)(2), the Medicare Payment Advisory Committee 

13 and the Comptroller General of the United States shall 

14 each evaluate such plan and submit to each House of Con15 gress a report containing its analysis and recommenda16 tions regarding implementation of the plan, including an 

17 analysis of the effects of the proposed changes in the plan 

18 on payments and projected spending. 

19 (c) IMPLEMENTATION.— 

20 (1) IN GENERAL.—The Secretary shall include, 

21 in applicable proposed rules for the next rulemaking 

22 cycle beginning after the Congressional action dead23 line, appropriate proposals to revise payments under 

24 title XVIII of the Social Security Act in accordance 

25 with the final implementation plan submitted under 
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1 subsection (a)(1), and the waivers specified in sub2 section (a)(4) to the extent required to carry out 

3 such plan are effective, unless a joint resolution (de4 scribed in subsection (d)(5)(A)) with respect to such 

5 plan is enacted by not later than such deadline. If 

6 such a joint resolution is enacted, the Secretary is 

7 not authorized to implement such plan and the waiv8 er authority provided under subsection (a)(4) shall 

9 no longer be effective. 

10 (2) CONGRESSIONAL ACTION DEADLINE.—For 

11 purposes of this section, the term ‘‘Congressional ac12 tion deadline’’ means, with respect to a final imple13 mentation plan under subsection (a)(1), May 31, 

14 2012, or, if later, the date that is 145 days after the 

15 date of receipt of such plan by each House of Con16 gress under subsection (a). 

17 (d) CONGRESSIONAL PROCEDURES.— 

18 (1) INTRODUCTION.—On the day on which the 

19 final implementation plan is received by the House 

20 of Representatives and the Senate under subsection 

21 (a), a joint resolution specified in paragraph (5)(A) 

22 shall be introduced in the House of Representatives 

23 by the majority leader and minority leader of the 

24 House of Representatives and in the Senate by the 

25 majority leader and minority leader of the Senate. If 
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1 either House is not in session on the day on which 

2 such a plan is received, the joint resolution with re3 spect to such plan shall be introduced in that House, 

4 as provided in the preceding sentence, on the first 

5 day thereafter on which that House is in session. 

6 (2) CONSIDERATION IN THE HOUSE OF REP7 RESENTATIVES.— 

8 (A) REPORTING AND DISCHARGE.—Any 

9 committee of the House of Representatives to 

10 which a joint resolution introduced under para11 graph (1) is referred shall report such joint res12 olution to the House not later than 50 legisla13 tive days after the applicable date of introduc14 tion of the joint resolution. If a committee fails 

15 to report such joint resolution within that pe16 riod, a motion to discharge the committee from 

17 further consideration of the joint resolution 

18 shall be in order. Such a motion shall be in 

19 order only at a time designated by the Speaker 

20 in the legislative schedule within two legislative 

21 days after the day on which the proponent an22 nounces an intention to offer the motion. Notice 

23 may not be given on an anticipatory basis. Such 

24 a motion shall not be in order after the last 

25 committee authorized to consider the joint reso-
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1 lution reports it to the House or after the 

2 House has disposed of a motion to discharge 

3 the joint resolution. The previous question shall 

4 be considered as ordered on the motion to its 

5 adoption without intervening motion except 20 

6 minutes of debate equally divided and controlled 

7 by the proponent and an opponent. A motion to 

8 reconsider the vote by which the motion is dis9 posed of shall not be in order. 

10 (B) PROCEEDING TO CONSIDERATION.— 

11 After each committee authorized to consider a 

12 joint resolution reports such joint resolution to 

13 the House of Representatives or has been dis14 charged from its consideration, a motion to pro15 ceed to consider such joint resolution shall be in 

16 order. Such a motion shall be in order only at 

17 a time designated by the Speaker in the legisla18 tive schedule within two legislative days after 

19 the day on which the proponent announces an 

20 intention to offer the motion. Notice may not be 

21 given on an anticipatory basis. Such a motion 

22 shall not be in order after the House of Rep23 resentatives has disposed of a motion to proceed 

24 on the joint resolution. The previous question 

25 shall be considered as ordered on the motion to 
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1 its adoption without intervening motion. A mo2 tion to reconsider the vote by which the motion 

3 is disposed of shall not be in order. 

4 (C) CONSIDERATION.—The joint resolution 

5 shall be considered in the House and shall be 

6 considered as read. All points of order against 

7 a joint resolution and against its consideration 

8 are waived. The previous question shall be con9 sidered as ordered on the joint resolution to its 

10 passage without intervening motion except two 

11 hours of debate equally divided and controlled 

12 by the proponent and an opponent. A motion to 

13 reconsider the vote on passage of a joint resolu14 tion shall not be in order. 

15 (3) CONSIDERATION IN THE SENATE.— 

16 (A) REPORTING AND DISCHARGE.—Any 

17 committee of the Senate to which a joint resolu18 tion introduced under paragraph (1) is referred 

19 shall report such joint resolution to the Senate 

20 within 50 legislative days. If a committee fails 

21 to report such joint resolution at the close of 

22 the 15th legislative day after its receipt by the 

23 Senate, such committee shall be automatically 

24 discharged from further consideration of such 

25 joint resolution and such joint resolution or 
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1 joint resolutions shall be placed on the calendar. 

2 A vote on final passage of such joint resolution 

3 shall be taken in the Senate on or before the 

4 close of the second legislative day after such 

5 joint resolution is reported by the committee or 

6 committees of the Senate to which it was re7 ferred, or after such committee or committees 

8 have been discharged from further consider9 ation of such joint resolution. 

10 (B) PROCEEDING TO CONSIDERATION.—A 

11 motion in the Senate to proceed to the consider12 ation of a joint resolution shall be privileged 

13 and not debatable. An amendment to such a 

14 motion shall not be in order, nor shall it be in 

15 order to move to reconsider the vote by which 

16 such a motion is agreed to or disagreed to. 

17 (C) CONSIDERATION.— 

18 (i) Debate in the Senate on a joint 

19 resolution, and all debatable motions and 

20 appeals in connection therewith, shall be 

21 limited to not more than 20 hours. The 

22 time shall be equally divided between, and 

23 controlled by, the majority leader and the 

24 minority leader or their designees. 
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1 (ii) Debate in the Senate on any de2 batable motion or appeal in connection 

3 with a joint resolution shall be limited to 

4 not more than 1 hour, to be equally di5 vided between, and controlled by, the 

6 mover and the manager of the resolution, 

7 except that in the event the manager of the 

8 joint resolution is in favor of any such mo9 tion or appeal, the time in opposition 

10 thereto shall be controlled by the minority 

11 leader or a designee. Such leaders, or ei12 ther of them, may, from time under their 

13 control on the passage of a joint resolu14 tion, allot additional time to any Senator 

15 during the consideration of any debatable 

16 motion or appeal. 

17 (iii) A motion in the Senate to further 

18 limit debate is not debatable. A motion to 

19 recommit a joint resolution is not in order. 

20 (4) RULES RELATING TO SENATE AND HOUSE

21 OF REPRESENTATIVES.— 

22 (A) COORDINATION WITH ACTION BY

23 OTHER HOUSE.—If, before the passage by one 

24 House of a joint resolution of that House, that 

25 House receives from the other House a joint 
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1 resolution, then the following procedures shall 

2 apply: 

3 (i) The joint resolution of the other 

4 House shall not be referred to a com5 mittee. 

6 (ii) With respect to the joint resolu7 tion of the House receiving the resolution, 

8 the procedure in that House shall be the 

9 same as if no such joint resolution had 

10 been received from the other House; but 

11 the vote on passage shall be on the joint 

12 resolution of the other House. 

13 (B) TREATMENT OF COMPANION MEAS14 URES.—If, following passage of a joint resolu15 tion in the Senate, the Senate then receives the 

16 companion measure from the House of Rep17 resentatives, the companion measure shall not 

18 be debatable. 

19 (C) RULES OF HOUSE OF REPRESENTA20 TIVES AND SENATE.—This paragraph and the 

21 preceding paragraphs are enacted by Con22 gress— 

23 (i) as an exercise of the rulemaking 

24 power of the Senate and House of Rep25 resentatives, respectively, and as such it is 
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1 deemed a part of the rules of each House, 

2 respectively, but applicable only with re3 spect to the procedure to be followed in 

4 that House in the case of a joint resolu5 tion, and it supersedes other rules only to 

6 the extent that it is inconsistent with such 

7 rules; and 

8 (ii) with full recognition of the con9 stitutional right of either House to change 

10 the rules (so far as relating to the proce11 dure of that House) at any time, in the 

12 same manner, and to the same extent as in 

13 the case of any other rule of that House. 

14 (5) DEFINITIONS.—In this section: 

15 (A) JOINT RESOLUTION.—The term ‘‘joint 

16 resolution’’ means only a joint resolution— 

17 (i) which does not have a preamble; 

18 (ii) the title of which is as follows: 

19 ‘‘Joint resolution disapproving a Medicare 

20 final implementation plan of the Secretary 

21 of Health and Human Services submitted 

22 under section 1160(a) of the Affordable 

23 Health Care for America Act’’; and 

24 (iii) the sole matter after the resolving 

25 clause of which is as follows: ‘‘That the 
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1 Congress disapproves the final implementa2 tion plan of the Secretary of Health and 

3 Human Services transmitted to the Con4 gress on—————.’’, the blank space 

5 being filled with the appropriate date. 

6 (B) LEGISLATIVE DAY.—The term ‘‘legis7 lative day’’ means any calendar day excluding 

8 any day on which that House was not in ses9 sion. 

10 (6) BUDGETARY TREATMENT.—For the pur11 poses of consideration of a joint resolution, the 

12 Chairmen of the House of Representatives and Sen13 ate Committees on the Budget shall exclude from 

14 the evaluation of the budgetary effects of the meas15 ure, any such effects that are directly attributable to 

16 disapproving a Medicare final implementation plan 

17 of the Secretary submitted under subsection (a). 

18 Subtitle D—Medicare Advantage 

19 Reforms 

20 PART 1—PAYMENT AND ADMINISTRATION 

21 SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR22 SERVICE COSTS; QUALITY BONUS PAYMENTS. 

23 (a) PHASE-IN OF PAYMENT BASED ON FEE-FOR24 SERVICE COSTS.—Section 1853 of the Social Security Act 

25 (42 U.S.C. 1395w–23) is amended— 
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1 (1) in subsection (j)(1)(A)— 

2 (A) by striking ‘‘beginning with 2007’’ and 

3 inserting ‘‘for 2007, 2008, 2009, and 2010’’; 

4 and 

5 (B) by inserting after ‘‘(k)(1)’’ the following: ‘‘, or, beginning with 2011, 1 6 ⁄12 of the 

7 blended benchmark amount determined under 

8 subsection (n)(1)’’; and 

9 (2) by adding at the end the following new sub10 section: 

11 ‘‘(n) DETERMINATION OF BLENDED BENCHMARK

12 AMOUNT.— 

13 ‘‘(1) IN GENERAL.—For purposes of subsection 

14 (j), subject to paragraphs (3) and (4), the term 

15 ‘blended benchmark amount’ means for an area— 

16 ‘‘(A) for 2011 the sum of— 

‘‘(i) 2 17 ⁄3 of the applicable amount (as 

18 defined in subsection (k)) for the area and 

19 year; and 

‘‘(ii) 1 20 ⁄3 of the amount specified in 

21 paragraph (2) for the area and year; 

22 ‘‘(B) for 2012 the sum of— 

‘‘(i) 1 23 ⁄3 of the applicable amount for 

24 the area and year; and 
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‘‘(ii) 2 1 ⁄3 of the amount specified in 

2 paragraph (2) for the area and year; and 

3 ‘‘(C) for a subsequent year the amount 

4 specified in paragraph (2) for the area and 

5 year. 

6 ‘‘(2) SPECIFIED AMOUNT.—The amount speci7 fied in this paragraph for an area and year is the 

8 amount specified in subsection (c)(1)(D)(i) for the 

9 area and year adjusted (in a manner specified by the 

10 Secretary) to take into account the phase-out in the 

11 indirect costs of medical education from capitation 

12 rates described in subsection (k)(4). 

13 ‘‘(3) FEE-FOR-SERVICE PAYMENT FLOOR.—In 

14 no case shall the blended benchmark amount for an 

15 area and year be less than the amount specified in 

16 paragraph (2). 

17 ‘‘(4) EXCEPTION FOR PACE PLANS.—This sub18 section shall not apply to payments to a PACE pro19 gram under section 1894.’’. 

20 (b) QUALITY BONUS PAYMENTS.—Section 1853 of 

21 the Social Security Act (42 U.S.C. 1395w–23), as amend22 ed by subsection (a), is amended— 

23 (1) in subsection (j), by inserting ‘‘subject to 

24 subsection (o),’’ after ‘‘For purposes of this part,’’; 

25 and 
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1 (2) by adding at the end the following new sub2 section: 

3 ‘‘(o) QUALITY BASED PAYMENT ADJUSTMENT.— 

4 ‘‘(1) IN GENERAL.—In the case of a qualifying 

5 plan in a qualifying county with respect to a year 

6 beginning with 2011, the blended benchmark 

7 amount under subsection (n)(1) shall be increased— 

8 ‘‘(A) for 2011, by 1.5 percent; 

9 ‘‘(B) for 2012, by 3.0 percent; and 

10 ‘‘(C) for a subsequent year, by 5.0 percent. 

11 ‘‘(2) QUALIFYING PLAN AND QUALIFYING

12 COUNTY DEFINED.—For purposes of this subsection: 

13 ‘‘(A) QUALIFYING PLAN.—The term ‘quali14 fying plan’ means, for a year and subject to 

15 paragraph (4), a plan that, in a preceding year 

16 specified by the Secretary, had a quality rank17 ing (based on the quality ranking system estab18 lished by the Centers for Medicare & Medicaid 

19 Services for Medicare Advantage plans) of 4 

20 stars or higher. 

21 ‘‘(B) QUALIFYING COUNTY.—The term 

22 ‘qualifying county’ means, for a year, a coun23 ty— 

24 ‘‘(i) that ranked within the lowest 

25 third of counties in the amount specified in 
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1 subsection (n)(2) for a year specified by 

2 the Secretary; and 

3 ‘‘(ii) for which, as of June of a year 

4 specified by the Secretary, of the Medicare 

5 Advantage eligible individuals residing in 

6 the county at least 20 percent of such indi7 viduals were enrolled in Medicare Advan8 tage plans. 

9 ‘‘(3) DETERMINATIONS OF QUALITY.— 

10 ‘‘(A) QUALITY PERFORMANCE.—The Sec11 retary shall provide for the computation of a 

12 quality performance score for each Medicare 

13 Advantage plan to be applied for each year. 

14 ‘‘(B) COMPUTATION OF SCORE.— 

15 ‘‘(i) QUALITY PERFORMANCE SORE.— 

16 For years before a year specified by the 

17 Secretary, the quality performance score 

18 for a Medicare Advantage plan shall be 

19 computed based on a blend (as designated 

20 by the Secretary) of the plan’s perform21 ance on— 

22 ‘‘(I) HEDIS effectiveness of care 

23 quality measures; 

24 ‘‘(II) CAHPS quality measures; 

25 and 
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1 ‘‘(III) such other measures of 

2 clinical quality as the Secretary may 

3 specify. 

4 Such measures shall be risk-adjusted as 

5 the Secretary deems appropriate. 

6 ‘‘(ii) ESTABLISHMENT OF OUTCOME7 BASED MEASURES.—By not later than for 

8 a year specified by the Secretary, the Sec9 retary shall implement reporting require10 ments for quality under this section on 

11 measures selected under clause (iii) that 

12 reflect the outcomes of care experienced by 

13 individuals enrolled in Medicare Advantage 

14 plans (in addition to measures described in 

15 clause (i)). Such measures may include— 

16 ‘‘(I) measures of rates of admis17 sion and readmission to a hospital; 

18 ‘‘(II) measures of prevention 

19 quality, such as those established by 

20 the Agency for Healthcare Research 

21 and Quality (that include hospital ad22 mission rates for specified conditions); 

23 ‘‘(III) measures of patient mor24 tality and morbidity following surgery; 
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1 ‘‘(IV) measures of health func2 tioning (such as limitations on activi3 ties of daily living) and survival for 

4 patients with chronic diseases; 

5 ‘‘(V) measures of patient safety; 

6 and 

7 ‘‘(VI) other measure of outcomes 

8 and patient quality of life as deter9 mined by the Secretary. 

10 Such measures shall be risk-adjusted as 

11 the Secretary deems appropriate. In deter12 mining the quality measures to be used 

13 under this clause, the Secretary shall take 

14 into consideration the recommendations of 

15 the Medicare Payment Advisory Commis16 sion in its report to Congress under section 

17 168 of the Medicare Improvements for Pa18 tients and Providers Act of 2008 (Public 

19 Law 110–275) and shall provide pref20 erence to measures collected on and com21 parable to measures used in measuring 

22 quality under parts A and B. 

23 ‘‘(iii) RULES FOR SELECTION OF

24 MEASURES.—The Secretary shall select 
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1 measures for purposes of clause (ii) con2 sistent with the following: 

3 ‘‘(I) The Secretary shall provide 

4 preference to clinical quality measures 

5 that have been endorsed by the entity 

6 with a contract with the Secretary 

7 under section 1890(a). 

8 ‘‘(II) Prior to any measure being 

9 selected under this clause, the Sec10 retary shall publish in the Federal 

11 Register such measure and provide for 

12 a period of public comment on such 

13 measure. 

14 ‘‘(iv) TRANSITIONAL USE OF

15 BLEND.—For payments for years specified 

16 by the Secretary, the Secretary may com17 pute the quality performance score for a 

18 Medicare Advantage plan based on a blend 

19 of the measures specified in clause (i) and 

20 the measures described in clause (ii) and 

21 selected under clause (iii). 

22 ‘‘(v) USE OF QUALITY OUTCOMES

23 MEASURES.—For payments beginning with 

24 a year specified by the Secretary (begin25 ning after the years specified for section 
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1 (iv)), the preponderance of measures used 

2 under this paragraph shall be quality out3 comes measures described in clause (ii) 

4 and selected under clause (iii). 

5 ‘‘(C) REPORTING OF DATA.—Each Medi6 care Advantage organization shall provide for 

7 the reporting to the Secretary of quality per8 formance data described in this paragraph (in 

9 order to determine a quality performance score 

10 under this paragraph) in such time and manner 

11 as the Secretary shall specify. 

12 ‘‘(4) NOTIFICATION.—The Secretary, in the an13 nual announcement required under subsection 

14 (b)(1)(B) in 2010 and each succeeding year, shall 

15 notify the Medicare Advantage organization that is 

16 offering a qualifying plan in a qualifying county of 

17 such identification for the year. The Secretary shall 

18 provide for publication on the website for the Medi19 care program of the information described in the 

20 previous sentence. 

21 ‘‘(5) AUTHORITY TO DISQUALIFY DEFICIENT

22 PLANS.—The Secretary may determine that a Medi23 care Advantage plan is not a qualifying plan if the 

24 Secretary has identified deficiencies in the plan’s 
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1 compliance with rules for Medicare Advantage plans 

2 under this part.’’. 

3 SEC. 1162. AUTHORITY FOR SECRETARIAL CODING INTEN4 SITY ADJUSTMENT AUTHORITY. 

5 Section 1853(a)(1)(C)(ii) of the Social Security Act 

6 (42 U.S.C. 1395w–23(a)(1)(C)(ii) is amended— 

7 (1) in the matter before subclause (I), by strik8 ing ‘‘through 2010’’ and inserting ‘‘and each subse9 quent year’’; and 

10 (2) in subclause (II)— 

11 (A) by inserting ‘‘periodically’’ before ‘‘con12 duct an analysis’’; 

13 (B) by inserting ‘‘on a timely basis’’ after 

14 ‘‘are incorporated’’; and 

15 (C) by striking ‘‘only for 2008, 2009, and 

16 2010’’ and inserting ‘‘for 2008 and subsequent 

17 years’’. 

18 SEC. 1163. SIMPLIFICATION OF ANNUAL BENEFICIARY 

19 ELECTION PERIODS. 

20 (a) 2 WEEK PROCESSING PERIOD FOR ANNUAL EN21 ROLLMENT PERIOD (AEP).—Paragraph (3)(B) of section 

22 1851(e) of the Social Security Act (42 U.S.C. 1395w– 

23 21(e)) is amended— 

24 (1) by striking ‘‘and’’ at the end of clause (iii); 

25 (2) in clause (iv)— 
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1 (A) by striking ‘‘and succeeding years’’ 

2 and inserting ‘‘, 2008, 2009, and 2010’’; and 

3 (B) by striking the period at the end and 

4 inserting ‘‘; and’’; and 

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

6 clause: 

7 ‘‘(v) with respect to 2011 and suc8 ceeding years, the period beginning on No9 vember 1 and ending on December 15 of 

10 the year before such year.’’. 

11 (b) ELIMINATION OF 3-MONTH ADDITIONAL OPEN

12 ENROLLMENT PERIOD (OEP).—Effective for plan years 

13 beginning with 2011, paragraph (2) of such section is 

14 amended by striking subparagraph (C). 

15 SEC. 1164. EXTENSION OF REASONABLE COST CONTRACTS. 

16 Section 1876(h)(5)(C) of the Social Security Act (42 

17 U.S.C. 1395mm(h)(5)(C)) is amended— 

18 (1) in clause (ii), by striking ‘‘January 1, 

19 2010’’ and inserting ‘‘January 1, 2012’’; and 

20 (2) in clause (iii), by striking ‘‘the service area 

21 for the year’’ and inserting ‘‘the portion of the 

22 plan’s service area for the year that is within the 

23 service area of a reasonable cost reimbursement con24 tract’’. 
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1 SEC. 1165. LIMITATION OF WAIVER AUTHORITY FOR EM2 PLOYER GROUP PLANS. 

3 (a) IN GENERAL.—The first sentence of each of para4 graphs (1) and (2) of section 1857(i) of the Social Secu5 rity Act (42 U.S.C. 1395w–27(i)) is amended by inserting 

6 before the period at the end the following: ‘‘, but only if 

7 90 percent of the Medicare Advantage eligible individuals 

8 enrolled under such plan reside in a county in which the 

9 MA organization offers an MA local plan’’. 

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

11 subsection (a) shall apply for plan years beginning on or 

12 after January 1, 2011, and shall not apply to plans which 

13 were in effect as of December 31, 2010. 

14 SEC. 1166. IMPROVING RISK ADJUSTMENT FOR PAYMENTS. 

15 (a) REPORT TO CONGRESS.—Not later than 1 year 

16 after the date of the enactment of this Act, the Secretary 

17 of Health and Human Services shall submit to Congress 

18 a report that evaluates the adequacy of the risk adjust19 ment system under section 1853(a)(1)(C) of the Social Se20 curity Act (42 U.S.C. 1395–23(a)(1)(C)) in predicting 

21 costs for beneficiaries with chronic or co-morbid condi22 tions, beneficiaries dually-eligible for Medicare and Med23 icaid, and non-Medicaid eligible low-income beneficiaries; 

24 and the need and feasibility of including further grada25 tions of diseases or conditions and multiple years of bene26 ficiary data. 
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1 (b) IMPROVEMENTS TO RISK ADJUSTMENT.—Not 

2 later than January 1, 2012, the Secretary shall implement 

3 necessary improvements to the risk adjustment system 

4 under section 1853(a)(1)(C) of the Social Security Act (42 

5 U.S.C. 1395–23(a)(1)(C)), taking into account the evalua6 tion under subsection (a). 

7 SEC. 1167. ELIMINATION OF MA REGIONAL PLAN STA8 BILIZATION FUND. 

9 (a) IN GENERAL.—Section 1858 of the Social Secu10 rity Act (42 U.S.C. 1395w–27a) is amended by striking 

11 subsection (e). 

12 (b) TRANSITION.—Any amount contained in the MA 

13 Regional Plan Stabilization Fund as of the date of the 

14 enactment of this Act shall be transferred to the Federal 

15 Supplementary Medical Insurance Trust Fund. 

16 SEC. 1168. STUDY REGARDING THE EFFECTS OF CALCU17 LATING MEDICARE ADVANTAGE PAYMENT 

18 RATES ON A REGIONAL AVERAGE OF MEDI19 CARE FEE FOR SERVICE RATES. 

20 (a) IN GENERAL.—The Administrator of the Centers 

21 for Medicare and Medicaid Services shall conduct a study 

22 to determine the potential effects of calculating Medicare 

23 Advantage payment rates on a more aggregated geo24 graphic basis (such as metropolitan statistical areas or 

25 other regional delineations) rather than using county 
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1 boundaries. In conducting such study, the Administrator 

2 shall consider the effect of such alternative geographic 

3 basis on the following: 

4 (1) The quality of care received by Medicare 

5 Advantage enrollees. 

6 (2) The networks of Medicare Advantage plans, 

7 including any implications for providers contracting 

8 with Medicare Advantage plans. 

9 (3) The predictability of benchmark amounts 

10 for Medicare advantage plans. 

11 (b) CONSULTATIONS.—In conducting the study, the 

12 Administrator shall consult with the following: 

13 (1) Experts in health care financing. 

14 (2) Representatives of foundations and other 

15 nonprofit entities that have conducted or supported 

16 research on Medicare financing issues. 

17 (3) Representatives from Medicare Advantage 

18 plans. 

19 (4) Such other entities or people as determined 

20 by the Secretary. 

21 (c) REPORT.—Not later than 1 year after the date 

22 of the enactment of this Act, the Administrator shall 

23 transmit a report to the Congress on the study conducted 

24 under this section. The report shall contain a detailed 

25 statement of findings and conclusions of the study, to-
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1 gether with its recommendations for such legislation and 

2 administrative actions as the Administrator considers ap3 propriate. 

4 PART 2—BENEFICIARY PROTECTIONS AND ANTI5 FRAUD 

6 SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL 

7 HEALTH SERVICES. 

8 (a) IN GENERAL.—Section 1852(a)(1) of the Social 

9 Security Act (42 U.S.C. 1395w–22(a)(1)) is amended— 

10 (1) in subparagraph (A), by inserting before the 

11 period at the end the following: ‘‘with cost-sharing 

12 that is no greater (and may be less) than the cost13 sharing that would otherwise be imposed under such 

14 program option’’; 

15 (2) in subparagraph (B)(i), by striking ‘‘or an 

16 actuarially equivalent level of cost-sharing as deter17 mined in this part’’; and 

18 (3) by amending clause (ii) of subparagraph 

19 (B) to read as follows: 

20 ‘‘(ii) PERMITTING USE OF FLAT CO21 PAYMENT OR PER DIEM RATE.—Nothing in 

22 clause (i) shall be construed as prohibiting 

23 a Medicare Advantage plan from using a 

24 flat copayment or per diem rate, in lieu of 

25 the cost-sharing that would be imposed 
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1 under part A or B, so long as the amount 

2 of the cost-sharing imposed does not ex3 ceed the amount of the cost-sharing that 

4 would be imposed under the respective part 

5 if the individual were not enrolled in a plan 

6 under this part.’’. 

7 (b) LIMITATION FOR DUAL ELIGIBLES AND QUALI8 FIED MEDICARE BENEFICIARIES.—Section 1852(a)(7) of 

9 such Act is amended to read as follows: 

10 ‘‘(7) LIMITATION ON COST-SHARING FOR DUAL

11 ELIGIBLES AND QUALIFIED MEDICARE BENE12 FICIARIES.—In the case of a individual who is a full13 benefit dual eligible individual (as defined in section 

14 1935(c)(6)) or a qualified medicare beneficiary (as 

15 defined in section 1905(p)(1)) who is enrolled in a 

16 Medicare Advantage plan, the plan may not impose 

17 cost-sharing that exceeds the amount of cost-sharing 

18 that would be permitted with respect to the indi19 vidual under this title and title XIX if the individual 

20 were not enrolled with such plan.’’. 

21 (c) EFFECTIVE DATES.— 

22 (1) The amendments made by subsection (a) 

23 shall apply to plan years beginning on or after Janu24 ary 1, 2011. 
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1 (2) The amendments made by subsection (b) 

2 shall apply to plan years beginning on or after Janu3 ary 1, 2011. 

4 SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLL5 EES IN PLANS WITH ENROLLMENT SUSPEN6 SION. 

7 Section 1851(e)(4) of the Social Security Act (42 

8 U.S.C. 1395w(e)(4)) is amended— 

9 (1) in subparagraph (C), by striking at the end 

10 ‘‘or’’; 

11 (2) in subparagraph (D)— 

12 (A) by inserting ‘‘, taking into account the 

13 health or well-being of the individual’’ before 

14 the period; and 

15 (B) by redesignating such subparagraph as 

16 subparagraph (E); and 

17 (3) by inserting after subparagraph (C) the fol18 lowing new subparagraph: 

19 ‘‘(D) the individual is enrolled in an MA 

20 plan and enrollment in the plan is suspended 

21 under paragraph (2)(B) or (3)(C) of section 

22 1857(g) because of a failure of the plan to meet 

23 applicable requirements; or’’. 
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1 SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN 

2 ADMINISTRATIVE COSTS. 

3 (a) DISCLOSURE OF MEDICAL LOSS RATIOS AND

4 OTHER EXPENSE DATA.—Section 1851 of the Social Se5 curity Act (42 U.S.C. 1395w–21), as previously amended 

6 by this subtitle, is amended by adding at the end the fol7 lowing new subsection: 

8 ‘‘(p) PUBLICATION OF MEDICAL LOSS RATIOS AND

9 OTHER COST-RELATED INFORMATION.— 

10 ‘‘(1) IN GENERAL.—The Secretary shall pub11 lish, not later than November 1 of each year (begin12 ning with 2011), for each MA plan contract, the 

13 medical loss ratio of the plan in the previous year. 

14 ‘‘(2) SUBMISSION OF DATA.— 

15 ‘‘(A) IN GENERAL.—Each MA organization 

16 shall submit to the Secretary, in a form and 

17 manner specified by the Secretary, data nec18 essary for the Secretary to publish the medical 

19 loss ratio on a timely basis. 

20 ‘‘(B) DATA FOR 2010 AND 2011.—The data 

21 submitted under subparagraph (A) for 2010 

22 and for 2011 shall be consistent in content with 

23 the data reported as part of the MA plan bid 

24 in June 2009 for 2010. 

25 ‘‘(C) USE OF STANDARDIZED ELEMENTS

26 AND DEFINITIONS.—The data to be submitted 
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1 under subparagraph (A) relating to medical loss 

2 ratio for a year, beginning with 2012, shall be 

3 submitted based on the standardized elements 

4 and definitions developed under paragraph (3). 

5 ‘‘(3) DEVELOPMENT OF DATA REPORTING

6 STANDARDS.— 

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

8 develop and implement standardized data ele9 ments and definitions for reporting under this 

10 subsection, for contract years beginning with 

11 2012, of data necessary for the calculation of 

12 the medical loss ratio for MA plans. Not later 

13 than December 31, 2010, the Secretary shall 

14 publish a report describing the elements and 

15 definitions so developed. 

16 ‘‘(B) CONSULTATION.—The Secretary 

17 shall consult with the Health Choices Commis18 sioner, representatives of MA organizations, ex19 perts on health plan accounting systems, and 

20 representatives of the National Association of 

21 Insurance Commissioners, in the development 

22 of such data elements and definitions. 

23 ‘‘(4) MEDICAL LOSS RATIO TO BE DEFINED.— 

24 For purposes of this part, the term ‘medical loss 

25 ratio’ has the meaning given such term by the Sec-
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1 retary, taking into account the meaning given such 

2 term by the Health Choices Commissioner under 

3 section 116 of the Affordable Health Care for Amer4 ica Act.’’. 

5 (b) MINIMUM MEDICAL LOSS RATIO.—Section 

6 1857(e) of the Social Security Act (42 U.S.C. 1395w– 

7 27(e)) is amended by adding at the end the following new 

8 paragraph: 

9 ‘‘(4) REQUIREMENT FOR MINIMUM MEDICAL

10 LOSS RATIO.—If the Secretary determines for a con11 tract year (beginning with 2014) that an MA plan 

12 has failed to have a medical loss ratio (as defined in 

13 section 1851(p)(4)) of at least .85— 

14 ‘‘(A) the Secretary shall require the Medi15 care Advantage organization offering the plan 

16 to give enrollees a rebate (in the second suc17 ceeding contract year) of premiums under this 

18 part (or part B or part D, if applicable) by 

19 such amount as would provide for a benefits 

20 ratio of at least .85; 

21 ‘‘(B) for 3 consecutive contract years, the 

22 Secretary shall not permit the enrollment of 

23 new enrollees under the plan for coverage dur24 ing the second succeeding contract year; and 
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1 ‘‘(C) the Secretary shall terminate the plan 

2 contract if the plan fails to have such a medical 

3 loss ratio for 5 consecutive contract years.’’. 

4 SEC. 1174. STRENGTHENING AUDIT AUTHORITY. 

5 (a) FOR PART C PAYMENTS RISK ADJUSTMENT.— 

6 Section 1857(d)(1) of the Social Security Act (42 U.S.C. 

7 1395w–27(d)(1)) is amended by inserting after ‘‘section 

8 1858(c))’’ the following: ‘‘, and data submitted with re9 spect to risk adjustment under section 1853(a)(3)’’. 

10 (b) ENFORCEMENT OF AUDITS AND DEFI11 CIENCIES.— 

12 (1) IN GENERAL.—Section 1857(e) of such Act, 

13 as amended by section 1173, is amended by adding 

14 at the end the following new paragraph: 

15 ‘‘(5) ENFORCEMENT OF AUDITS AND DEFI16 CIENCIES.— 

17 ‘‘(A) INFORMATION IN CONTRACT.—The 

18 Secretary shall require that each contract with 

19 an MA organization under this section shall in20 clude terms that inform the organization of the 

21 provisions in subsection (d). 

22 ‘‘(B) ENFORCEMENT AUTHORITY.—The 

23 Secretary is authorized, in connection with con24 ducting audits and other activities under sub25 section (d), to take such actions, including pur-
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1 suit of financial recoveries, necessary to address 

2 deficiencies identified in such audits or other 

3 activities.’’. 

4 (2) APPLICATION UNDER PART D.—For provi5 sion applying the amendment made by paragraph 

6 (1) to prescription drug plans under part D, see sec7 tion 1860D–12(b)(3)(D) of the Social Security Act. 

8 (c) EFFECTIVE DATE.—The amendments made by 

9 this section shall take effect on the date of the enactment 

10 of this Act and shall apply to audits and activities con11 ducted for contract years beginning on or after January 

12 1, 2011. 

13 SEC. 1175. AUTHORITY TO DENY PLAN BIDS. 

14 (a) IN GENERAL.—Section 1854(a)(5) of the Social 

15 Security Act (42 U.S.C. 1395w–24(a)(5)) is amended by 

16 adding at the end the following new subparagraph: 

17 ‘‘(C) REJECTION OF BIDS.—Nothing in 

18 this section shall be construed as requiring the 

19 Secretary to accept any or every bid by an MA 

20 organization under this subsection.’’. 

21 (b) APPLICATION UNDER PART D.—Section 1860D– 

22 11(d) of such Act (42 U.S.C. 1395w–111(d)) is amended 

23 by adding at the end the following new paragraph: 

24 ‘‘(3) REJECTION OF BIDS.—Paragraph (5)(C) 

25 of section 1854(a) shall apply with respect to bids 
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1 under this section in the same manner as it applies 

2 to bids by an MA organization under such section.’’. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 this section shall apply to bids for contract years begin5 ning on or after January 1, 2011. 

6 SEC. 1175A. STATE AUTHORITY TO ENFORCE STANDARD7 IZED MARKETING REQUIREMENTS. 

8 Section 1856(b)(3) of the Social Security Act (42 

9 U.S.C. 1395w–26(b)(3)) is amended— 

10 (1) by striking ‘‘The standards’’ and inserting 

11 ‘‘(A) IN GENERAL.—The standards’’ with appro12 priate indentation that is the same as for the sub13 paragraph (B) added by paragraph (2); and 

14 (2) by adding at the end the following new sub15 paragraph: 

16 ‘‘(B) ENFORCEMENT OF FEDERAL STAND17 ARDS PERMITTED.— 

18 ‘‘(i) IN GENERAL.—Subject to the 

19 subsequent provision of this subparagraph, 

20 nothing in this title shall be construed to 

21 prohibit a State from conducting a market 

22 conduct examination or from imposing civil 

23 monetary penalties, in accordance with 

24 laws and procedures of the State, against 

25 Medicare Advantage organizations, PDP 
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1 sponsors, or agents or brokers of such or2 ganizations or sponsors for violations of 

3 the marketing requirements under sub4 sections (h)(4), (h)(6), and (j) of section 

5 1851 and section 1857(g)(1)(E). 

6 ‘‘(ii) ADDITIONAL REMEDIES RESULT7 ING FROM FEDERAL-STATE COOPERA8 TION.— 

9 ‘‘(I) STATE RECOMMENDA10 TION.—A State may recommend to 

11 the Secretary the imposition of an in12 termediate sanction not described in 

13 clause (i) (such as those available 

14 under section 1857(g)) against a 

15 Medicare Advantage organization, 

16 PDP sponsor, or agent or broker of 

17 such an organization or sponsor for a 

18 violation described in such clause. 

19 ‘‘(II) RESPONSE TO REC20 OMMENDATION.—Not later than 30 

21 days after receipt of a recommenda22 tion under subclause (I) from a State, 

23 with respect to a violation described in 

24 clause (i), the Secretary shall respond 

25 in writing to the State indicating the 
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1 progress of any investigation involving 

2 such violation, whether the Secretary 

3 intends to pursue the recommendation 

4 from the State, and in the case the 

5 Secretary does not intend to pursue 

6 such recommendation, the reason for 

7 such decision. 

8 ‘‘(iii) NON-DUPLICATION OF PEN9 ALTIES.—In the case that an action has 

10 been initiated against a Medicare Advan11 tage organization, PDP sponsor, or agent 

12 or broker of such an organization or spon13 sor for a violation of a marketing require14 ment under subsection (h)(4), (h)(6), or (j) 

15 of section 1851 or section 1857(g)(1)(E)— 

16 ‘‘(I) in the case such action has 

17 been initiated by the Secretary, no 

18 State may bring an action under such 

19 applicable subsection or section 

20 against such organization, sponsor, 

21 agent, or broker with respect to such 

22 violation during the pendency period 

23 of the action initiated by the Sec24 retary and, if a penalty is imposed 
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1 pursuant to such action, after such 

2 period; and 

3 ‘‘(II) in the case such action has 

4 been initiated by a State, the Sec5 retary may not bring an action under 

6 such applicable subsection or section 

7 against such organization, sponsor, 

8 agent, or broker with respect to such 

9 violation during the pendency period 

10 of the action initiated by the Sec11 retary and, if a penalty is imposed 

12 pursuant to such action, after such 

13 period. 

14 Nothing in this clause shall be construed 

15 as limiting the ability of the Secretary to 

16 impose any sanction other than a civil 

17 monetary penalty under section 1857 

18 against a Medicare Advantage organiza19 tion, PDP sponsor, or agent or broker of 

20 such an organization or sponsor for a vio21 lation described in clause (i). 

22 ‘‘(iv) CONSTRUCTION.—Nothing in 

23 this subparagraph shall be construed as af24 fecting any State authority to regulate bro25 kers described in this paragraph or any 
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1 other conduct of a Medicare Advantage or2 ganization or PDP sponsor.’’. 

3 PART 3—TREATMENT OF SPECIAL NEEDS PLANS 

4 SEC. 1176. LIMITATION ON ENROLLMENT OUTSIDE OPEN 

5 ENROLLMENT PERIOD OF INDIVIDUALS INTO 

6 CHRONIC CARE SPECIALIZED MA PLANS FOR 

7 SPECIAL NEEDS INDIVIDUALS. 

8 Section 1859(f)(4) of the Social Security Act (42 

9 U.S.C. 1395w–28(f)(4)) is amended by adding at the end 

10 the following new subparagraph: 

11 ‘‘(C) The plan does not enroll an individual 

12 on or after January 1, 2011, other than— 

13 ‘‘(i) during an annual, coordinated 

14 open enrollment period; or 

15 ‘‘(ii) during a special election period 

16 consisting of the period for which the indi17 vidual has a chronic condition that quali18 fies the individual as an individual de19 scribed in subsection (b)(6)(B)(iii) for such 

20 plan and ending on the date on which the 

21 individual enrolls in such a plan on the 

22 basis of such condition. 

23 If an individual is enrolled in such a plan on 

24 the basis of a chronic condition and becomes el25 igible for another such plan on the basis of an-
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1 other chronic condition, the other plan may en2 roll the individual on the basis of such other 

3 chronic condition during a special enrollment 

4 period described in clause (ii). An individual is 

5 eligible to apply such clause only once on the 

6 basis of any specific chronic condition.’’. 

7 SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS 

8 PLANS TO RESTRICT ENROLLMENT; SERVICE 

9 AREA MORATORIUM FOR CERTAIN SNPS. 

10 (a) IN GENERAL.—Section 1859(f)(1) of the Social 

11 Security Act (42 U.S.C. 1395w–28(f)(1)) is amended by 

12 striking ‘‘January 1, 2011’’ and inserting ‘‘January 1, 

13 2013 (or January 1, 2016, in the case of a plan described 

14 in section 1177(b)(1) of the Affordable Health Care for 

15 America Act)’’. 

16 (b) EXTENSION OF CERTAIN PLANS.— 

17 (1) PLANS DESCRIBED.—For purposes of Sec18 tion 1859(f)(1) of the Social Security Act (42 

19 U.S.C. 1395w–28(f)(1)), a plan described in this 

20 paragraph is a Medicare Advantage dual eligible spe21 cial needs plan that— 

22 (A) whose sponsoring Medicare Advantage 

23 organization, as of the date enactment of the 

24 Affordable Health Care for America Act, has a 

25 contract with a State Medicaid Agency that 
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1 participated in the ‘‘Demonstrations Serving 

2 Those Dually-Eligible for Medicare and Med3 icaid’’ under the Medicare program; and 

4 (B) that has been approved by the Centers 

5 for Medicare & Medicaid Services as a dual eli6 gible special needs plan and that offers inte7 grated Medicare and Medicaid services under a 

8 contract with the State Medicaid agency. 

9 (2) ANALYSIS; REPORT.— 

10 (A) ANALYSIS.—The Secretary of Health 

11 and Human Services shall provide, through a 

12 contract with an independent health services 

13 evaluation organization, for an analysis of the 

14 plans described in paragraph (1) with regard to 

15 the impact of such plans on cost, quality of 

16 care, patient satisfaction, and other subjects 

17 specified by the Secretary. Such report also will 

18 identify statutory changes needed to simplify 

19 access to needed services, improve coordination 

20 of benefits and services and ensure protection 

21 for dual eligibles as appropriate. 

22 (B) REPORT.—Not later than December 

23 31, 2011, the Secretary shall submit to the 

24 Congress a report on the analysis under sub25 paragraph (A) and shall include in such report 
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1 such recommendations with regard to the treat2 ment of such plans as the Secretary deems ap3 propriate. 

4 (c) EXTENSION OF SERVICE AREA MORATORIUM FOR

5 CERTAIN SNPS.—Section 164(c)(2) of the Medicare Im6 provements for Patients and Providers Act of 2008 is 

7 amended by striking ‘‘December 31, 2010’’ and inserting 

8 ‘‘December 31, 2012’’. 

9 SEC. 1178. EXTENSION OF MEDICARE SENIOR HOUSING 

10 PLANS. 

11 Section 1859 of the Social Security Act (42 U.S.C. 

12 1395w–28) is amended by adding at the end the following 

13 new subsection: 

14 ‘‘(g) SPECIAL RULES FOR SENIOR HOUSING FACIL15 ITY PLANS.— 

16 ‘‘(1) IN GENERAL.—Notwithstanding any other 

17 provision of this part, in the case of a Medicare Ad18 vantage senior housing facility plan described in 

19 paragraph (2) and for periods before January 1, 

20 2013— 

21 ‘‘(A) the service area of such plan may be 

22 limited to a senior housing facility in a geo23 graphic area; 

24 ‘‘(B) the service area of such plan may not 

25 be expanded; and 
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1 ‘‘(C) additional senior housing facilities 

2 may not be serviced by such plan. 

3 ‘‘(2) MEDICARE ADVANTAGE SENIOR HOUSING

4 FACILITY PLAN DESCRIBED.—For purposes of this 

5 subsection, a Medicare Advantage senior housing fa6 cility plan is a Medicare Advantage plan that— 

7 ‘‘(A)(i) restricts enrollment of individuals 

8 under this part to individuals who reside in a 

9 continuing care retirement community (as de10 fined in section 1852(l)(4)(B)); 

11 ‘‘(ii) provides primary care services onsite 

12 and has a ratio of accessible providers to bene13 ficiaries that the Secretary determines is ade14 quate, taking into consideration the number of 

15 residents onsite, the health needs of those resi16 dents, and the accessibility of providers offsite; 

17 and 

18 ‘‘(iii) provides transportation services for 

19 beneficiaries to providers outside of the facility; 

20 and 

21 ‘‘(B) is offered by a Medicare Advantage 

22 organization that has offered at least 1 plan de23 scribed in subparagraph (A) for at least 1 year 

24 prior to January 1, 2010, under a demonstra25 tion project established by the Secretary.’’. 
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1 Subtitle E—Improvements to 

2 Medicare Part D 

3 SEC. 1181. ELIMINATION OF COVERAGE GAP. 

4 (a) IMMEDIATE REDUCTION IN COVERAGE GAP IN

5 2010.—Section 1860D–2(b) of the Social Security Act 

6 (42 U.S.C. 1395w–102(b)) is amended— 

7 (1) in paragraph (3)(A), by striking ‘‘paragraph 

8 (4)’’ and inserting ‘‘paragraphs (4) and (7)’’; and 

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

10 paragraph: 

11 ‘‘(7) INCREASE IN INITIAL COVERAGE LIMIT IN

12 2010.— 

13 ‘‘(A) IN GENERAL.—For plan years begin14 ning during 2010, the initial coverage limit de15 scribed in paragraph (3)(B) otherwise applica16 ble shall be increased by $500. 

17 ‘‘(B) APPLICATION.—In applying subpara18 graph (A)— 

19 ‘‘(i) except as otherwise provided in 

20 this subparagraph, there shall be no 

21 change in the premiums, bids, or any other 

22 parameters under this part or part C; 

23 ‘‘(ii) costs that would be treated as in24 curred costs for purposes of applying para25 graph (4) but for the application of sub-
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1 paragraph (A) shall continue to be treated 

2 as incurred costs; 

3 ‘‘(iii) the Secretary shall establish pro4 cedures, which may include a reconciliation 

5 process, to fully reimburse PDP sponsors 

6 with respect to prescription drug plans and 

7 MA organizations with respect to MA–PD 

8 plans for the reduction in beneficiary cost 

9 sharing associated with the application of 

10 subparagraph (A); 

11 ‘‘(iv) the Secretary shall develop an 

12 estimate of the additional increased costs 

13 attributable to the application of this para14 graph for increased drug utilization and fi15 nancing and administrative costs and shall 

16 use such estimate to adjust payments to 

17 PDP sponsors with respect to prescription 

18 drug plans under this part and MA organi19 zations with respect to MA–PD plans 

20 under part C; and 

21 ‘‘(v) the Secretary shall establish pro22 cedures for retroactive reimbursement of 

23 part D eligible individuals who are covered 

24 under such a plan for costs which are in25 curred before the date of initial implemen-
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1 tation of subparagraph (A) and which 

2 would be reimbursed under such a plan if 

3 such implementation occurred as of Janu4 ary 1, 2010.’’. 

5 (b) ADDITIONAL CLOSURE IN GAP BEGINNING IN

6 2011.—Section 1860D–2(b) of such Act (42 U.S.C. 

7 1395w–102(b)) as amended by subsection (a), is further 

8 amended— 

9 (1) in paragraph (3)(A), by striking ‘‘and (7)’’ 

10 and inserting ‘‘, (7), and (8)’’; 

11 (2) in paragraph (4)(B)(i), by inserting ‘‘sub12 ject to paragraph (8)’’ after ‘‘purposes of this part’’; 

13 and 

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

15 paragraph: 

16 ‘‘(8) PHASED-IN ELIMINATION OF COVERAGE

17 GAP.— 

18 ‘‘(A) IN GENERAL.—For each year begin19 ning with 2011, the Secretary shall consistent 

20 with this paragraph progressively increase the 

21 initial coverage limit (described in subsection 

22 (b)(3)) and decrease the annual out-of-pocket 

23 threshold from the amounts otherwise computed 

24 until, beginning in 2019, there is a continuation 

25 of coverage from the initial coverage limit for 
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1 expenditures incurred through the total amount 

2 of expenditures at which benefits are available 

3 under paragraph (4). 

4 ‘‘(B) INCREASE IN INITIAL COVERAGE

5 LIMIT.— 

6 ‘‘(i) IN GENERAL.—For a year begin7 ning with 2011, subject to clause (ii), the 

8 initial coverage limit otherwise computed 

9 without regard to this paragraph shall be 

10 increased by the cumulative ICL phase-in 

11 percentage (as defined in clause (iii) for 

12 the year) times the out-of-pocket gap 

13 amount (as defined in subparagraph (D)) 

14 for the year. 

15 ‘‘(ii) MAINTENANCE OF 2010 INITIAL

16 COVERAGE LIMIT LEVEL.—If for a year the 

17 initial coverage limit otherwise computed 

18 under this paragraph would be less than 

19 the initial coverage limit applied during 

20 2010, taking into account paragraph (7), 

21 the initial coverage limit for that year shall 

22 be such initial coverage limit as so applied 

23 during 2010. 

24 ‘‘(iii) CUMULATIVE PHASE-IN PER25 CENTAGE.— 
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1 ‘‘(I) IN GENERAL.—For purposes 

2 of this paragraph, subject to sub3 clause (II), the term ‘cumulative ICL 

4 phase-in percentage’ means for a year 

5 the sum of the annual ICL phase-in 

6 percentage (as defined in clause (iv)) 

7 for the year and the annual ICL 

8 phase-in percentages for each previous 

9 year beginning with 2011. 

10 ‘‘(II) LIMITATION.—If the sum 

11 of the cumulative ICL phase-in per12 centage and the cumulative OPT 

13 phase-in percentage (as defined in 

14 subparagraph (C)(iii)) for a year 

15 would otherwise exceed 100 percent, 

16 each such percentage shall be reduced 

17 in a proportional amount so the sum 

18 does not exceed 100 percent. 

19 ‘‘(iv) ANNUAL ICL PHASE-IN PER20 CENTAGE.—For purposes of this para21 graph, the term ‘annual ICL phase-in per22 centage’ means— 

23 ‘‘(I) for 2011, 8.25 percent; 

24 ‘‘(II) for 2012, 2013, and 2014, 

25 4.5 percent; 
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1 ‘‘(III) for 2015 and 2016, 6 per2 cent; 

3 ‘‘(IV) for 2017, 7.5 percent; 

4 ‘‘(V) for 2018, 8 percent; and 

5 ‘‘(VI) for 2019, 8 percent, or 

6 such other percent as may be nec7 essary to provide for a full continu8 ation of coverage as described in sub9 paragraph (A) in that year. 

10 ‘‘(C) DECREASE IN ANNUAL OUT-OF-POCK11 ET THRESHOLD.— 

12 ‘‘(i) IN GENERAL.—For a year begin13 ning with 2011, subject to clause (ii), the 

14 annual out-of-pocket threshold otherwise 

15 computed without regard to this paragraph 

16 shall be decreased by the cumulative OPT 

17 phase-in percentage (as defined in clause 

18 (iii) for the year) of the out-of-pocket gap 

19 amount for the year multiplied by 1.75. 

20 ‘‘(ii) MAINTENANCE.—The Secretary 

21 shall adjust the annual out-of-pocket 

22 threshold for a year to the extent nec23 essary to ensure that the sum of the initial 

24 coverage limit described in subparagraph 

25 (A) and the out-of-pocket gap amount (de-
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1 fined in subparagraph (D)), as determined 

2 for the year pursuant to the provisions of 

3 this paragraph for such year, does not ex4 ceed such sum that would have applied if 

5 this paragraph did not apply. 

6 ‘‘(iii) CUMULATIVE OPT PHASE-IN

7 PERCENTAGE.—For purposes of this para8 graph, subject to subparagraph (B)(iii)(II), 

9 the term ‘cumulative OPT phase-in per10 centage’ means for a year the sum of the 

11 annual OPT phase-in percentage (as de12 fined in clause (iv)) for the year and the 

13 annual OPT phase-in percentages for each 

14 previous year beginning with 2011. 

15 ‘‘(iv) ANNUAL OPT PHASE-IN PER16 CENTAGE.—For purposes of this para17 graph, the term ‘annual OPT phase-in per18 centage’ means— 

19 ‘‘(I) for 2011, 0 percent; 

20 ‘‘(II) for 2012, 2013, and 2014, 

21 4.5 percent; 

22 ‘‘(III) for 2015 and 2016, 6 per23 cent; 

24 ‘‘(IV) for 2017, 7.5 percent; and 
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1 ‘‘(V) for 2018 and 2019, 8 per2 cent. 

3 ‘‘(D) OUT-OF-POCKET GAP AMOUNT.—For 

4 purposes of this paragraph, the term ‘out-of5 pocket gap amount’ means for a year the 

6 amount by which— 

7 ‘‘(i) the annual out-of-pocket thresh8 old specified in paragraph (4)(B) for the 

9 year (as determined as if this paragraph 

10 did not apply), exceeds 

11 ‘‘(ii) the sum of— 

12 ‘‘(I) the annual deductible under 

13 paragraph (1) for the year; and 

‘‘(II) 1 14 ⁄4 of the amount by which 

15 the initial coverage limit under para16 graph (3) for the year (as determined 

17 as if this paragraph did not apply) ex18 ceeds such annual deductible. 

19 ‘‘(E) RELATION TO AAHCA TRANSITIONAL

20 INCREASE.—Except as otherwise specifically 

21 provided, this paragraph shall be applied as if 

22 no increase had been made in the initial cov23 erage limit under paragraph (7).’’. 

24 (c) REQUIRING DRUG MANUFACTURERS TO PROVIDE

25 DRUG REBATES FOR REBATE ELIGIBLE INDIVIDUALS.— 
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1 (1) IN GENERAL.—Section 1860D–2 of the So2 cial Security Act (42 U.S.C. 1395w–102) is amend3 ed— 

4 (A) in subsection (e)(1), in the matter be5 fore subparagraph (A), by inserting ‘‘and sub6 section (f)’’ after ‘‘this subsection’’; and 

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

8 subsection: 

9 ‘‘(f) PRESCRIPTION DRUG REBATE AGREEMENT FOR

10 REBATE ELIGIBLE INDIVIDUALS.— 

11 ‘‘(1) REQUIREMENT.— 

12 ‘‘(A) IN GENERAL.—For plan years begin13 ning on or after January 1, 2011, in this part, 

14 the term ‘covered part D drug’ does not include 

15 any drug or biological product that is manufac16 tured by a manufacturer that has not entered 

17 into and have in effect a rebate agreement de18 scribed in paragraph (2). 

19 ‘‘(B) 2010 PLAN YEAR REQUIREMENT.— 

20 Any drug or biological product manufactured by 

21 a manufacturer that declines to enter into a re22 bate agreement described in paragraph (2) for 

23 the period beginning on January 1, 2010, and 

24 ending on December 31, 2010, shall not be in-
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1 cluded as a ‘covered part D drug ‘ for the sub2 sequent plan year. 

3 ‘‘(2) REBATE AGREEMENT.—A rebate agree4 ment under this subsection shall require the manu5 facturer to provide to the Secretary a rebate for 

6 each rebate period (as defined in paragraph (6)(B)) 

7 ending after December 31, 2009, in the amount 

8 specified in paragraph (3) for any covered part D 

9 drug of the manufacturer dispensed after December 

10 31, 2009, to any rebate eligible individual (as de11 fined in paragraph (6)(A)) for which payment was 

12 made by a PDP sponsor under part D or a MA or13 ganization under part C for such period, including 

14 payments passed through the low-income and rein15 surance subsidies under sections 1860D–14 and 

16 1860D–15(b), respectively. Such rebate shall be paid 

17 by the manufacturer to the Secretary not later than 

18 30 days after the date of receipt of the information 

19 described in section 1860D–12(b)(7), including as 

20 such section is applied under section 1857(f)(3), or 

21 30 days after the receipt of information under sub22 paragraph (D) of paragraph (3), as determined by 

23 the Secretary. Insofar as not inconsistent with this 

24 subsection, the Secretary shall establish terms and 

25 conditions of such agreement relating to compliance, 
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1 penalties, and program evaluations, investigations, 

2 and audits that are similar to the terms and condi3 tions for rebate agreements under paragraphs (3) 

4 and (4) of section 1927(b). 

5 ‘‘(3) REBATE FOR REBATE ELIGIBLE MEDICARE

6 DRUG PLAN ENROLLEES.— 

7 ‘‘(A) IN GENERAL.—The amount of the re8 bate specified under this paragraph for a manu9 facturer for a rebate period, with respect to 

10 each dosage form and strength of any covered 

11 part D drug provided by such manufacturer 

12 and dispensed to a rebate eligible individual, 

13 shall be equal to the product of— 

14 ‘‘(i) the total number of units of such 

15 dosage form and strength of the drug so 

16 provided and dispensed for which payment 

17 was made by a PDP sponsor under part D 

18 or a MA organization under part C for the 

19 rebate period, including payments passed 

20 through the low-income and reinsurance 

21 subsidies under sections 1860D–14 and 

22 1860D–15(b), respectively; and 

23 ‘‘(ii) the amount (if any) by which— 

24 ‘‘(I) the Medicaid rebate amount 

25 (as defined in subparagraph (B)) for 
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1 such form, strength, and period, ex2 ceeds 

3 ‘‘(II) the average Medicare drug 

4 program rebate eligible rebate amount 

5 (as defined in subparagraph (C)) for 

6 such form, strength, and period. 

7 ‘‘(B) MEDICAID REBATE AMOUNT.—For 

8 purposes of this paragraph, the term ‘Medicaid 

9 rebate amount’ means, with respect to each 

10 dosage form and strength of a covered part D 

11 drug provided by the manufacturer for a rebate 

12 period— 

13 ‘‘(i) in the case of a single source 

14 drug or an innovator multiple source drug, 

15 the amount specified in paragraph 

16 (1)(A)(ii) of section 1927(c) plus the 

17 amount, if any, specified in paragraph 

18 (2)(A)(ii) of such section, for such form, 

19 strength, and period; or 

20 ‘‘(ii) in the case of any other covered 

21 outpatient drug, the amount specified in 

22 paragraph (3)(A)(i) of such section for 

23 such form, strength, and period. 

24 ‘‘(C) AVERAGE MEDICARE DRUG PROGRAM

25 REBATE ELIGIBLE REBATE AMOUNT.—For pur-
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1 poses of this subsection, the term ‘average 

2 Medicare drug program rebate eligible rebate 

3 amount’ means, with respect to each dosage 

4 form and strength of a covered part D drug 

5 provided by a manufacturer for a rebate period, 

6 the sum, for all PDP sponsors under part D 

7 and MA organizations administering a MA–PD 

8 plan under part C, of— 

9 ‘‘(i) the product, for each such spon10 sor or organization, of— 

11 ‘‘(I) the sum of all rebates, dis12 counts, or other price concessions (not 

13 taking into account any rebate pro14 vided under paragraph (2) for such 

15 dosage form and strength of the drug 

16 dispensed, calculated on a per-unit 

17 basis, but only to the extent that any 

18 such rebate, discount, or other price 

19 concession applies equally to drugs 

20 dispensed to rebate eligible Medicare 

21 drug plan enrollees and drugs dis22 pensed to PDP and MA–PD enrollees 

23 who are not rebate eligible individuals; 

24 and 
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1 ‘‘(II) the number of the units of 

2 such dosage and strength of the drug 

3 dispensed during the rebate period to 

4 rebate eligible individuals enrolled in 

5 the prescription drug plans adminis6 tered by the PDP sponsor or the MA– 

7 PD plans administered by the MA or8 ganization; divided by 

9 ‘‘(ii) the total number of units of such 

10 dosage and strength of the drug dispensed 

11 during the rebate period to rebate eligible 

12 individuals enrolled in all prescription drug 

13 plans administered by PDP sponsors and 

14 all MA–PD plans administered by MA or15 ganizations. 

16 ‘‘(D) USE OF ESTIMATES.—The Secretary 

17 may establish a methodology for estimating the 

18 average Medicare drug program rebate eligible 

19 rebate amounts for each rebate period based on 

20 bid and utilization information under this part 

21 and may use these estimates as the basis for 

22 determining the rebates under this section. If 

23 the Secretary elects to estimate the average 

24 Medicare drug program rebate eligible rebate 

25 amounts, the Secretary shall establish a rec-
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1 onciliation process for adjusting manufacturer 

2 rebate payments not later than 3 months after 

3 the date that manufacturers receive the infor4 mation collected under section 1860D– 

5 12(b)(7)(B). 

6 ‘‘(4) LENGTH OF AGREEMENT.—The provisions 

7 of paragraph (4) of section 1927(b) (other than 

8 clauses (iv) and (v) of subparagraph (B)) shall apply 

9 to rebate agreements under this subsection in the 

10 same manner as such paragraph applies to a rebate 

11 agreement under such section. 

12 ‘‘(5) OTHER TERMS AND CONDITIONS.—The 

13 Secretary shall establish other terms and conditions 

14 of the rebate agreement under this subsection, in15 cluding terms and conditions related to compliance, 

16 that are consistent with this subsection. 

17 ‘‘(6) DEFINITIONS.—In this subsection and sec18 tion 1860D–12(b)(7): 

19 ‘‘(A) REBATE ELIGIBLE INDIVIDUAL.—The 

20 term ‘rebate eligible individual’— 

21 ‘‘(i) means a full-benefit dual eligible 

22 individual (as defined in section 

23 1935(c)(6)); and 

24 ‘‘(ii) includes, for drugs dispensed 

25 after December 31, 2014, a subsidy eligi-
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1 ble individual (as defined in section 

2 1860D–14(a)(3)(A)). 

3 ‘‘(B) REBATE PERIOD.—The term ‘rebate 

4 period’ has the meaning given such term in sec5 tion 1927(k)(8). 

6 ‘‘(7) WAIVER.—Chapter 35 of title 44, United 

7 States Code, shall not apply to the requirements 

8 under this subsection for the period beginning on 

9 January 1, 2010, and ending on December 31, 

10 2010.’’. 

11 (2) REPORTING REQUIREMENT FOR THE DE12 TERMINATION AND PAYMENT OF REBATES BY MANU13 FACTURES RELATED TO REBATE FOR REBATE ELIGI14 BLE MEDICARE DRUG PLAN ENROLLEES.— 

15 (A) REQUIREMENTS FOR PDP SPON16 SORS.—Section 1860D–12(b) of the Social Se17 curity Act (42 U.S.C. 1395w–112(b)) is amend18 ed by adding at the end the following new para19 graph: 

20 ‘‘(7) REPORTING REQUIREMENT FOR THE DE21 TERMINATION AND PAYMENT OF REBATES BY MANU22 FACTURERS RELATED TO REBATE FOR REBATE ELI23 GIBLE MEDICARE DRUG PLAN ENROLLEES.— 

24 ‘‘(A) IN GENERAL.—For purposes of the 

25 rebate under section 1860D–2(f) for contract 
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1 years beginning on or after January 1, 2011, 

2 each contract entered into with a PDP sponsor 

3 under this part with respect to a prescription 

4 drug plan shall require that the sponsor comply 

5 with subparagraphs (B) and (C). 

6 ‘‘(B) REPORT FORM AND CONTENTS.—Not 

7 later than a date specified by the Secretary, a 

8 PDP sponsor of a prescription drug plan under 

9 this part shall report to each manufacturer— 

10 ‘‘(i) information (by National Drug 

11 Code number) on the total number of units 

12 of each dosage, form, and strength of each 

13 drug of such manufacturer dispensed to re14 bate eligible Medicare drug plan enrollees 

15 under any prescription drug plan operated 

16 by the PDP sponsor during the rebate pe17 riod; 

18 ‘‘(ii) information on the price dis19 counts, price concessions, and rebates for 

20 such drugs for such form, strength, and 

21 period; 

22 ‘‘(iii) information on the extent to 

23 which such price discounts, price conces24 sions, and rebates apply equally to rebate 

25 eligible Medicare drug plan enrollees and 
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1 PDP enrollees who are not rebate eligible 

2 Medicare drug plan enrollees; and 

3 ‘‘(iv) any additional information that 

4 the Secretary determines is necessary to 

5 enable the Secretary to calculate the aver6 age Medicare drug program rebate eligible 

7 rebate amount (as defined in paragraph 

8 (3)(C) of such section), and to determine 

9 the amount of the rebate required under 

10 this section, for such form, strength, and 

11 period. 

12 Such report shall be in a form consistent with 

13 a standard reporting format established by the 

14 Secretary. 

15 ‘‘(C) SUBMISSION TO SECRETARY.—Each 

16 PDP sponsor shall promptly transmit a copy of 

17 the information reported under subparagraph 

18 (B) to the Secretary for the purpose of audit 

19 oversight and evaluation. 

20 ‘‘(D) CONFIDENTIALITY OF INFORMA21 TION.—The provisions of subparagraph (D) of 

22 section 1927(b)(3), relating to confidentiality of 

23 information, shall apply to information reported 

24 by PDP sponsors under this paragraph in the 

25 same manner that such provisions apply to in-
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1 formation disclosed by manufacturers or whole2 salers under such section, except— 

3 ‘‘(i) that any reference to ‘this sec4 tion’ in clause (i) of such subparagraph 

5 shall be treated as being a reference to this 

6 section; 

7 ‘‘(ii) the reference to the Director of 

8 the Congressional Budget Office in clause 

9 (iii) of such subparagraph shall be treated 

10 as including a reference to the Medicare 

11 Payment Advisory Commission; and 

12 ‘‘(iii) clause (iv) of such subparagraph 

13 shall not apply. 

14 ‘‘(E) OVERSIGHT.—Information reported 

15 under this paragraph may be used by the In16 spector General of the Department of Health 

17 and Human Services for the statutorily author18 ized purposes of audit, investigation, and eval19 uations. 

20 ‘‘(F) PENALTIES FOR FAILURE TO PRO21 VIDE TIMELY INFORMATION AND PROVISION OF

22 FALSE INFORMATION.—In the case of a PDP 

23 sponsor— 

24 ‘‘(i) that fails to provide information 

25 required under subparagraph (B) on a 
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1 timely basis, the sponsor is subject to a 

2 civil money penalty in the amount of 

3 $10,000 for each day in which such infor4 mation has not been provided; or 

5 ‘‘(ii) that knowingly (as defined in 

6 section 1128A(i)) provides false informa7 tion under such subparagraph, the sponsor 

8 is subject to a civil money penalty in an 

9 amount not to exceed $100,000 for each 

10 item of false information. 

11 Such civil money penalties are in addition to 

12 other penalties as may be prescribed by law. 

13 The provisions of section 1128A (other than 

14 subsections (a) and (b)) shall apply to a civil 

15 money penalty under this subparagraph in the 

16 same manner as such provisions apply to a pen17 alty or proceeding under section 1128A(a).’’. 

18 (B) APPLICATION TO MA ORGANIZA19 TIONS.—Section 1857(f)(3) of the Social Secu20 rity Act (42 U.S.C. 1395w–27(f)(3)) is amend21 ed by adding at the end the following: 

22 ‘‘(D) REPORTING REQUIREMENT RELATED

23 TO REBATE FOR REBATE ELIGIBLE MEDICARE

24 DRUG PLAN ENROLLEES.—Section 1860D– 

25 12(b)(7).’’. 
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1 (3) DEPOSIT OF REBATES INTO MEDICARE PRE2 SCRIPTION DRUG ACCOUNT.—Section 1860D–16(c) 

3 of such Act (42 U.S.C. 1395w–116(c)) is amended 

4 by adding at the end the following new paragraph: 

5 ‘‘(6) REBATE FOR REBATE ELIGIBLE MEDICARE

6 DRUG PLAN ENROLLEES.—Amounts paid under a re7 bate agreement under section 1860D–2(f) shall be 

8 deposited into the Account and shall be used to pay 

9 for all or part of the gradual elimination of the cov10 erage gap under section 1860D–2(b)(7).’’. 

11 SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN 

12 ORIGINAL COVERAGE GAP. 

13 Section 1860D–2 of the Social Security Act (42 

14 U.S.C. 1395w–102), as amended by section 1181, is 

15 amended— 

16 (1) in subsection (b)(4)(C)(ii), by inserting 

17 ‘‘subject to subsection (g)(2)(C),’’ after ‘‘(ii)’’; 

18 (2) in subsection (e)(1), in the matter before 

19 subparagraph (A), by striking ‘‘subsection (f)’’ and 

20 inserting ‘‘subsections (f) and (g)’’ after ‘‘this sub21 section’’; and 

22 (3) by adding at the end the following new sub23 section: 

24 ‘‘(g) REQUIREMENT FOR MANUFACTURER DISCOUNT

25 AGREEMENT FOR CERTAIN QUALIFYING DRUGS.— 
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1 ‘‘(1) IN GENERAL.—In this part, the term ‘cov2 ered part D drug’ does not include any drug or bio3 logical product that is manufactured by a manufac4 turer that has not entered into and have in effect for 

5 all qualifying drugs (as defined in paragraph (5)(A)) 

6 a discount agreement described in paragraph (2). 

7 ‘‘(2) DISCOUNT AGREEMENT.— 

8 ‘‘(A) PERIODIC DISCOUNTS.—A discount 

9 agreement under this paragraph shall require 

10 the manufacturer involved to provide, to each 

11 PDP sponsor with respect to a prescription 

12 drug plan or each MA organization with respect 

13 to each MA–PD plan, a discount in an amount 

14 specified in paragraph (3) for qualifying drugs 

15 (as defined in paragraph (5)(A)) of the manu16 facturer dispensed to a qualifying enrollee after 

17 January 1, 2010, insofar as the individual is in 

18 the original gap in coverage (as defined in para19 graph (5)(E)). 

20 ‘‘(B) DISCOUNT AGREEMENT.—Insofar as 

21 not inconsistent with this subsection, the Sec22 retary shall establish terms and conditions of 

23 such agreement, including terms and conditions 

24 relating to compliance, similar to the terms and 

25 conditions for rebate agreements under para-
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1 graphs (2), (3), and (4) of section 1927(b), ex2 cept that— 

3 ‘‘(i) discounts shall be applied under 

4 this subsection to prescription drug plans 

5 and MA–PD plans instead of State plans 

6 under title XIX; 

7 ‘‘(ii) PDP sponsors and MA organiza8 tions shall be responsible, instead of 

9 States, for provision of necessary utiliza10 tion information to drug manufacturers; 

11 and 

12 ‘‘(iii) sponsors and MA organizations 

13 shall be responsible for reporting informa14 tion on drug-component negotiated price. 

15 ‘‘(C) COUNTING DISCOUNT TOWARD TRUE

16 OUT-OF-POCKET COSTS.—Under the discount 

17 agreement, in applying subsection (b)(4), with 

18 regard to subparagraph (C)(i) of such sub19 section, if a qualified enrollee purchases the 

20 qualified drug insofar as the enrollee is in an 

21 actual gap of coverage (as defined in paragraph 

22 (5)(D)), the amount of the discount under the 

23 agreement shall be treated and counted as costs 

24 incurred by the plan enrollee. 
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1 ‘‘(3) DISCOUNT AMOUNT.—The amount of the 

2 discount specified in this paragraph for a discount 

3 period for a plan is equal to 50 percent of the 

4 amount of the drug-component negotiated price (as 

5 defined in paragraph (5)(C)) for qualifying drugs for 

6 the period involved. 

7 ‘‘(4) ADDITIONAL TERMS.—In the case of a dis8 count provided under this subsection with respect to 

9 a prescription drug plan offered by a PDP sponsor 

10 or an MA–PD plan offered by an MA organization, 

11 if a qualified enrollee purchases the qualified drug— 

12 ‘‘(A) insofar as the enrollee is in an actual 

13 gap of coverage (as defined in paragraph 

14 (5)(D)), the sponsor or plan shall provide the 

15 discount to the enrollee at the time the enrollee 

16 pays for the drug; and 

17 ‘‘(B) insofar as the enrollee is in the por18 tion of the original gap in coverage (as defined 

19 in paragraph (5)(E)) that is not in the actual 

20 gap in coverage, the discount shall not be ap21 plied against the negotiated price (as defined in 

22 subsection (d)(1)(B)) for the purpose of calcu23 lating the beneficiary payment. 

24 ‘‘(5) DEFINITIONS.—In this subsection: 
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1 ‘‘(A) QUALIFYING DRUG.—The term 

2 ‘qualifying drug’ means, with respect to a pre3 scription drug plan or MA–PD plan, a drug or 

4 biological product that— 

5 ‘‘(i)(I) is a drug produced or distrib6 uted under an original new drug applica7 tion approved by the Food and Drug Ad8 ministration, including a drug product 

9 marketed by any cross-licensed producers 

10 or distributors operating under the new 

11 drug application; 

12 ‘‘(II) is a drug that was originally 

13 marketed under an original new drug ap14 plication approved by the Food and Drug 

15 Administration; or 

16 ‘‘(III) is a biological product as ap17 proved under section 351(a) of the Public 

18 Health Services Act; 

19 ‘‘(ii) is covered under the formulary of 

20 the plan or is treated as covered under the 

21 formulary of the plan as a result of a cov22 erage determination or appeal under sub23 section (g) or (h) of section 1860D–4; and 

24 ‘‘(iii) is dispensed to an individual 

25 who is in the original gap in coverage. 
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1 ‘‘(B) QUALIFYING ENROLLEE.—The term 

2 ‘qualifying enrollee’ means an individual en3 rolled in a prescription drug plan or MA–PD 

4 plan other than such an individual who is a 

5 subsidy-eligible individual (as defined in section 

6 1860D–14(a)(3)). 

7 ‘‘(C) DRUG-COMPONENT NEGOTIATED

8 PRICE.—The term ‘drug-component negotiated 

9 price’ means, with respect to a qualifying drug, 

10 the negotiated price (as defined in section 

11 423.100 of title 42, Code of Federal Regula12 tions, as in effect on the date of enactment of 

13 this subsection), as determined without regard 

14 to any dispensing fee, of the drug under the 

15 prescription drug plan or MA–PD plan in16 volved. 

17 ‘‘(D) ACTUAL GAP IN COVERAGE.—The 

18 term ‘actual gap in coverage’ means the gap in 

19 prescription drug coverage that occurs between 

20 the initial coverage limit (as modified under 

21 paragraph (7) and subparagraph (B) of para22 graph (8) of subsection (b)) and the annual 

23 out-of-pocket threshold (as modified under sub24 paragraph (C) of such subsection). 
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1 ‘‘(E) ORIGINAL GAP IN COVERAGE.—The 

2 term ‘original in gap coverage’ means the gap 

3 in prescription drug coverage that would occur 

4 between the initial coverage limit (described in 

5 subsection (b)(3)) and the out-of-pocket thresh6 old (as defined in subsection (b)(4)(B)) if sub7 sections (b)(7) and (b)(8) did not apply. 

8 ‘‘(6) SPECIAL RULE FOR 2010.—For the period 

9 beginning January 1, 2010, and ending December 

10 31, 2010, the Secretary may— 

11 ‘‘(A) enter into agreements with manufac12 turers to directly receive the discount amount 

13 described in paragraph (3); 

14 ‘‘(B) collect the necessary information 

15 from prescription drug plans and MA-PD plans 

16 to calculate the discount amount described in 

17 such paragraph; and 

18 ‘‘(C) provide the discount described in such 

19 paragraph to beneficiaries as close as prac20 ticable after the point of sale. 

21 ‘‘(7) WAIVER.—Chapter 35 of title 44, United 

22 States Code, shall not apply to the requirements 

23 under this subsection for the period beginning on 

24 January 1, 2010, and ending on December 31, 

25 2010.’’. 
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1 SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMIS2 SION OF CLAIMS BY PHARMACIES LOCATED 

3 IN OR CONTRACTING WITH LONG-TERM CARE 

4 FACILITIES. 

5 (a) PART D SUBMISSION.—Section 1860D–12(b) of 

6 the Social Security Act (42 U.S.C. 1395w–112(b)), as 

7 amended by section 172(a)(1) of Public Law 110–275, is 

8 amended by striking paragraph (5) and redesignating 

9 paragraph (6) and paragraph (7), as added by section 

10 1181(c)(2)(A), as paragraph (5) and paragraph (6), re11 spectively. 

12 (b) SUBMISSION TO MA–PD PLANS.—Section 

13 1857(f)(3) of the Social Security Act (42 U.S.C. 1395w– 

14 27(f)(3)), as added by section 171(b) of Public Law 110– 

15 275 and amended by section 172(a)(2) of such Public Law 

16 and section 1181 of this Act, is amended by striking sub17 paragraph (B) and redesignating subparagraphs (C) and 

18 (D) as subparagraphs (B) and (C) respectively. 

19 (c) EFFECTIVE DATE.—The amendments made by 

20 this section shall apply for contract years beginning with 

21 2010. 
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1 SEC. 1184. INCLUDING COSTS INCURRED BY AIDS DRUG AS2 SISTANCE PROGRAMS AND INDIAN HEALTH 

3 SERVICE IN PROVIDING PRESCRIPTION 

4 DRUGS TOWARD THE ANNUAL OUT-OF-POCK5 ET THRESHOLD UNDER PART D. 

6 (a) IN GENERAL.—Section 1860D–2(b)(4)(C) of the 

7 Social Security Act (42 U.S.C. 1395w–102(b)(4)(C)) is 

8 amended— 

9 (1) in clause (i), by striking ‘‘and’’ at the end; 

10 (2) in clause (ii)— 

11 (A) by striking ‘‘such costs shall be treated 

12 as incurred only if’’ and inserting ‘‘and subject 

13 to clause (iii), such costs shall be treated as in14 curred only if’’; 

15 (B) by striking ‘‘, under section 1860D– 

16 14, or under a State Pharmaceutical Assistance 

17 Program’’; and 

18 (C) by striking the period at the end and 

19 inserting ‘‘; and’’; and 

20 (3) by inserting after clause (ii) the following 

21 new clause: 

22 ‘‘(iii) such costs shall be treated as in23 curred and shall not be considered to be 

24 reimbursed under clause (ii) if such costs 

25 are borne or paid— 

26 ‘‘(I) under section 1860D–14; 
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1 ‘‘(II) under a State Pharma2 ceutical Assistance Program; 

3 ‘‘(III) by the Indian Health Serv4 ice, an Indian tribe or tribal organiza5 tion, or an urban Indian organization 

6 (as defined in section 4 of the Indian 

7 Health Care Improvement Act); or 

8 ‘‘(IV) under an AIDS Drug As9 sistance Program under part B of 

10 title XXVI of the Public Health Serv11 ice Act.’’. 

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

13 subsection (a) shall apply to costs incurred on or after 

14 January 1, 2011. 

15 SEC. 1185. NO MID-YEAR FORMULARY CHANGES PER16 MITTED. 

17 (a) IN GENERAL.—Section 1860D–4(b)(3)(E) of the 

18 Social Security Act (42 U.S.C. 1395w–104(b)(3)(E)) is 

19 amended— 

20 (1) in the heading, by inserting ‘‘; CERTAIN

21 FORMULARY CHANGES ONLY BEFORE INITIATING

22 MARKETING FOR A PLAN YEAR’’ after ‘‘STATUS OF

23 DRUG’’; 
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1 (2) by striking ‘‘Any removal’’ and inserting 

2 ‘‘(i) NOTICE.—Any removal’’ with the same indenta3 tion as the clause added by paragraph (2); 

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

5 clause: 

6 ‘‘(ii) CERTAIN CHANGES IN FOR7 MULARY ONLY BEFORE INITIATING MAR8 KETING FOR A PLAN YEAR.—Any removal 

9 of a covered part D drug from a formulary 

10 used by a PDP sponsor of a prescription 

11 drug plan (or MA organization of a MA– 

12 PD plan) or any other material change to 

13 the formulary so as to reduce the coverage 

14 (or increase the cost-sharing) of the drug 

15 under the plan for a plan year shall take 

16 effect by a date specified by the Secretary 

17 but no later than the start of plan mar18 keting activities for the plan year. In addi19 tion to any exceptions to the previous sen20 tence specified by the Secretary, the pre21 vious sentence shall not apply in the case 

22 that a drug is removed from the formulary 

23 of a plan because of a recall or withdrawal 

24 of the drug issued by the Food and Drug 

25 Administration, because the drug is re-
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1 placed with a generic drug that is a thera2 peutic equivalent, or because of utilization 

3 management applied to— 

4 ‘‘(I) a drug whose labeling in5 cludes a boxed warning required by 

6 the Food and Drug Administration 

7 under section 201.57(c)(1) of title 21, 

8 Code of Federal Regulations (or a 

9 successor regulation); or 

10 ‘‘(II) a drug required under sub11 section (c)(2) of section 505–1 of the 

12 Federal Food, Drug, and Cosmetic 

13 Act to have a Risk Evaluation and 

14 Management Strategy that includes 

15 elements under subsection (f) of such 

16 section.’’. 

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

18 subsection (a) shall apply to contract years beginning on 

19 or after January 1, 2011. 

20 SEC. 1186. NEGOTIATION OF LOWER COVERED PART D 

21 DRUG PRICES ON BEHALF OF MEDICARE 

22 BENEFICIARIES. 

23 (a) NEGOTIATION BY SECRETARY.—Section 1860D– 

24 11 of the Social Security Act (42 U.S.C. 1395w–111) is 
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1 amended by striking subsection (i) (relating to noninter2 ference) and inserting the following: 

3 ‘‘(i) NEGOTIATION OF LOWER DRUG PRICES.— 

4 ‘‘(1) IN GENERAL.—Notwithstanding any other 

5 provision of law, the Secretary shall negotiate with 

6 pharmaceutical manufacturers the prices (including 

7 discounts, rebates, and other price concessions) that 

8 may be charged to PDP sponsors and MA organiza9 tions for covered part D drugs for part D eligible in10 dividuals who are enrolled under a prescription drug 

11 plan or under an MA-PD plan. 

12 ‘‘(2) NO CHANGE IN RULES FOR

13 FORMULARIES.— 

14 ‘‘(A) IN GENERAL.—Nothing in paragraph 

15 (1) shall be construed to authorize the Sec16 retary to establish or require a particular for17 mulary. 

18 ‘‘(B) CONSTRUCTION.—Subparagraph (A) 

19 shall not be construed as affecting the Sec20 retary’s authority to ensure appropriate and 

21 adequate access to covered part D drugs under 

22 prescription drug plans and under MA-PD 

23 plans, including compliance of such plans with 

24 formulary requirements under section 1860D– 

25 4(b)(3). 
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1 ‘‘(3) CONSTRUCTION.—Nothing in this sub2 section shall be construed as preventing the sponsor 

3 of a prescription drug plan, or an organization offer4 ing an MA-PD plan, from obtaining a discount or 

5 reduction of the price for a covered part D drug 

6 below the price negotiated under paragraph (1). 

7 ‘‘(4) ANNUAL REPORTS TO CONGRESS.—Not 

8 later than June 1, 2011, and annually thereafter, 

9 the Secretary shall submit to the Committees on 

10 Ways and Means, Energy and Commerce, and Over11 sight and Government Reform of the House of Rep12 resentatives and the Committee on Finance of the 

13 Senate a report on negotiations conducted by the 

14 Secretary to achieve lower prices for Medicare bene15 ficiaries, and the prices and price discounts achieved 

16 by the Secretary as a result of such negotiations.’’. 

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

18 subsection (a) shall take effect on the date of the enact19 ment of this Act and shall first apply to negotiations and 

20 prices for plan years beginning on January 1, 2011. 

21 SEC. 1187. ACCURATE DISPENSING IN LONG-TERM CARE 

22 FACILITIES. 

23 Section 1860D–4(c) of the Social Security Act (42 

24 U.S.C. 1395w–104(c)) is amended by adding at the end 

25 the following new paragraph: 
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1 ‘‘(3) REDUCTION OF WASTEFUL DISPENSING.— 

2 ‘‘(A) IN GENERAL.—For plan years begin3 ning on or after January 1, 2012, a PDP spon4 sor offering a prescription drug plan and MA 

5 organization offering a MA–PD plan under part 

6 C shall have in place the utilization manage7 ment techniques established under subpara8 graph (B). 

9 ‘‘(B) REQUIREMENTS.—The Secretary 

10 shall establish utilization management tech11 niques, such as daily, weekly, or automated 

12 dose dispensing, to apply to PDP sponsors and 

13 MA organizations to reduce the quantities of 

14 covered part D drugs dispensed to enrollees 

15 who are residing in long-term care facilities in 

16 order to reduce waste associated with unused 

17 medications. 

18 ‘‘(C) CONSULTATION.—In establishing the 

19 requirements under subparagraph (A), the Sec20 retary shall consult with the Administrator of 

21 the Environmental Protection Agency, Adminis22 trator of the Food and Drug Administration, 

23 Administrator of the Drug Enforcement Admin24 istration, State Boards of Pharmacy, pharmacy 

25 and physician organizations, and other appro-
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1 priate stakeholders to study and determine ad2 ditional methods for prescription drug plans to 

3 reduce waste associated with unused prescrip4 tion drugs.’’. 

5 SEC. 1188. FREE GENERIC FILL. 

6 (a) IN GENERAL.—Section 1128A(i)(6) of the Social 

7 Security Act (42 U.S.C. 1320a–7a(i)(6)) is amended— 

8 (1) in subparagraph (C), by striking ‘‘of 1996’’ 

9 and all that follows and inserting ‘‘of 1996;’’; 

10 (2) in the first subparagraph (D), by striking 

11 ‘‘promulgated’’ and all that follows and inserting 

12 ‘‘promulgated;’’; 

13 (3) by redesignating the second subparagraph 

14 (D) as a subparagraph (E) and by striking the pe15 riod at the end of such subparagraph and inserting 

16 ‘‘; and’’; and 

17 (4) by adding at the end the following new sub18 paragraph: 

19 ‘‘(F) with regard to a prescription drug 

20 plan offered by a PDP sponsor or an MA–PD 

21 plan offered by an MA organization, a reduc22 tion in or waiver of the copayment amount 

23 under the plan given to an individual to induce 

24 the individual to switch to a generic, bioequiva25 lent drug, or biosimilar.’’. 
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1 (b) EFFECTIVE DATE.—The amendments made by 

2 this subsection shall take effect on the date of the enact3 ment of this Act and shall first apply with respect to remu4 neration offered, paid, solicited, or received on or after 

5 January 1, 2011. 

6 SEC. 1189. STATE CERTIFICATION PRIOR TO WAIVER OF LI7 CENSURE REQUIREMENTS UNDER MEDICARE 

8 PRESCRIPTION DRUG PROGRAM. 

9 (a) IN GENERAL.—Section 1860D–12(c) of the So10 cial Security Act (42 U.S.C. 1395w–112(c)) is amended— 

11 (1) in paragraph (1)(A), by striking ‘‘In the 

12 case’’ and inserting ‘‘Subject to paragraph (5), in 

13 the case’’; and 

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

15 paragraph: 

16 ‘‘(5) STATE CERTIFICATION REQUIRED.— 

17 ‘‘(A) IN GENERAL.—Except as provided in 

18 section 1860D–21(f)(4), the Secretary may only 

19 grant a waiver under paragraph (1)(A) if the 

20 Secretary has received a certification from the 

21 State insurance commissioner that the prescrip22 tion drug plan has a substantially complete ap23 plication pending in the State. 

24 ‘‘(B) REVOCATION OF WAIVER UPON FIND25 ING OF FRAUD AND ABUSE.—The Secretary 
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1 shall revoke a waiver granted under paragraph 

2 (1)(A) if the State insurance commissioner sub3 mits a certification to the Secretary that the re4 cipient of such a waiver— 

5 ‘‘(i) has committed fraud or abuse 

6 with respect to such waiver; 

7 ‘‘(ii) has failed to make a good faith 

8 effort to satisfy State licensing require9 ments; or 

10 ‘‘(iii) was determined ineligible for li11 censure by the State.’’. 

12 (b) EXCEPTION FOR PACE PROGRAMS.—Section 

13 1860D–21(f) of such Act (42 U.S.C. 1395w–131(f)) is 

14 amended— 

15 (1) in paragraph (1), by striking ‘‘paragraphs 

16 (2) and (3)’’ and inserting ‘‘the succeeding para17 graphs’’; and 

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

19 paragraph: 

20 ‘‘(4) INAPPLICABILITY OF CERTAIN LICENSURE

21 WAIVER REQUIREMENTS.—The provisions of para22 graph (1) of section 1860D–12(c) (relating to waiver 

23 of licensure under certain circumstances) shall apply 

24 without regard to paragraph (5) of such section in 

25 the case of a PACE program that elects to provide 
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1 qualified prescription drug coverage to a part D eli2 gible individual who is enrolled under such pro3 gram.’’. 

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

5 this section shall apply with respect to plan years begin6 ning on or after January 1, 2010. 

7 Subtitle F—Medicare Rural Access 

8 Protections 

9 SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS. 

10 (a) ADDITIONAL TELEHEALTH SITE.— 

11 (1) IN GENERAL.—Paragraph (4)(C)(ii) of sec12 tion 1834(m) of the Social Security Act (42 U.S.C. 

13 1395m(m)) is amended by adding at the end the fol14 lowing new subclause: 

15 ‘‘(IX) A renal dialysis facility.’’. 

16 (2) EFFECTIVE DATE.—The amendment made 

17 by paragraph (1) shall apply to services furnished on 

18 or after January 1, 2011. 

19 (b) TELEHEALTH ADVISORY COMMITTEE.— 

20 (1) ESTABLISHMENT.—Section 1868 of the So21 cial Security Act (42 U.S.C. 1395ee) is amended— 

22 (A) in the heading, by adding at the end 

23 the following: ‘‘TELEHEALTH ADVISORY COM24 MITTEE’’; and 
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1 (B) by adding at the end the following new 

2 subsection: 

3 ‘‘(c) TELEHEALTH ADVISORY COMMITTEE.— 

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

5 a Telehealth Advisory Committee (in this subsection 

6 referred to as the ‘Advisory Committee’) to make 

7 recommendations to the Secretary on policies of the 

8 Centers for Medicare & Medicaid Services regarding 

9 telehealth services as established under section 

10 1834(m), including the appropriate addition or dele11 tion of services (and HCPCS codes) to those speci12 fied in paragraphs (4)(F)(i) and (4)(F)(ii) of such 

13 section and for authorized payment under paragraph 

14 (1) of such section. 

15 ‘‘(2) MEMBERSHIP; TERMS.— 

16 ‘‘(A) MEMBERSHIP.— 

17 ‘‘(i) IN GENERAL.—The Advisory 

18 Committee shall be composed of 9 mem19 bers, to be appointed by the Secretary, of 

20 whom— 

21 ‘‘(I) 5 shall be practicing physi22 cians; 

23 ‘‘(II) 2 shall be practicing non24 physician health care practitioners; 

25 and 
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1 ‘‘(III) 2 shall be administrators 

2 of telehealth programs. 

3 ‘‘(ii) REQUIREMENTS FOR APPOINT4 ING MEMBERS.—In appointing members of 

5 the Advisory Committee, the Secretary 

6 shall— 

7 ‘‘(I) ensure that each member 

8 has prior experience with the practice 

9 of telemedicine or telehealth; 

10 ‘‘(II) give preference to individ11 uals who are currently providing tele12 medicine or telehealth services or who 

13 are involved in telemedicine or tele14 health programs; 

15 ‘‘(III) ensure that the member16 ship of the Advisory Committee rep17 resents a balance of specialties and 

18 geographic regions; and 

19 ‘‘(IV) take into account the rec20 ommendations of stakeholders. 

21 ‘‘(B) TERMS.—The members of the Advi22 sory Committee shall serve for such term as the 

23 Secretary may specify. 

24 ‘‘(C) CONFLICTS OF INTEREST.—An advi25 sory committee member may not participate 
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1 with respect to a particular matter considered 

2 in an advisory committee meeting if such mem3 ber (or an immediate family member of such 

4 member) has a financial interest that could be 

5 affected by the advice given to the Secretary 

6 with respect to such matter. 

7 ‘‘(3) MEETINGS.—The Advisory Committee 

8 shall meet twice each calendar year and at such 

9 other times as the Secretary may provide. 

10 ‘‘(4) PERMANENT COMMITTEE.—Section 14 of 

11 the Federal Advisory Committee Act (5 U.S.C. 

12 App.) shall not apply to the Advisory Committee.’’. 

13 (2) FOLLOWING RECOMMENDATIONS.—Section 

14 1834(m)(4)(F) of such Act (42 U.S.C. 

15 1395m(m)(4)(F)) is amended by adding at the end 

16 the following new clause: 

17 ‘‘(iii) RECOMMENDATIONS OF THE

18 TELEHEALTH ADVISORY COMMITTEE.—In 

19 making determinations under clauses (i) 

20 and (ii), the Secretary shall take into ac21 count the recommendations of the Tele22 health Advisory Committee (established 

23 under section 1868(c)) when adding or de24 leting services (and HCPCS codes) and in 

25 establishing policies of the Centers for 
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1 Medicare & Medicaid Services regarding 

2 the delivery of telehealth services. If the 

3 Secretary does not implement such a rec4 ommendation, the Secretary shall publish 

5 in the Federal Register a statement re6 garding the reason such recommendation 

7 was not implemented.’’. 

8 (3) WAIVER OF ADMINISTRATIVE LIMITA9 TION.—The Secretary of Health and Human Serv10 ices shall establish the Telehealth Advisory Com11 mittee under the amendment made by paragraph (1) 

12 notwithstanding any limitation that may apply to 

13 the number of advisory committees that may be es14 tablished (within the Department of Health and 

15 Human Services or otherwise). 

16 (c) HOSPITAL CREDENTIALING OF TELEMEDICINE

17 PHYSICIANS AND PRACTITIONERS.— 

18 (1) IN GENERAL.—Not later than 60 days after 

19 the date of the enactment of this Act, the Secretary 

20 of Health and Human Services shall issue guidance 

21 for hospitals (as defined in paragraph (4)) to sim22 plify requirements regarding compiling practitioner 

23 credentials for the purpose of rendering a medical 

24 staff privileging decision (under bylaws of the type 

25 described in section 1861(e)(3) of the Social Secu-
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1 rity Act) for physicians and practitioners (as defined 

2 in paragraph (4)) delivering telehealth services that 

3 are furnished via a telecommunications system. 

4 (2) FLEXIBILITY IN ACCEPTING

5 CREDENTIALING BY ANOTHER MEDICARE PARTICI6 PATING HOSPITAL.— 

7 (A) IN GENERAL.—Such guidance shall 

8 permit a hospital to accept credentialing pack9 ages compiled by another hospital participating 

10 under Medicare with regard to physicians and 

11 practitioners who seek medical staff privileges 

12 in the hospital to provide telehealth services via 

13 a telecommunications system from a site other 

14 than the hospital where the patient is located. 

15 (B) CONSTRUCTION.—Nothing in this sub16 section shall be construed to require a hospital 

17 to accept the credentialing package compiled by 

18 another facility. 

19 (C) NO OVERSIGHT REQUIRED.—If a hos20 pital does accept the credentialing materials 

21 prepared by another hospital, the hospital shall 

22 not be required to exercise oversight over the 

23 other hospital’s process for compiling and 

24 verifying credentials.
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1 (D) PRIVILEGING.—This paragraph shall 

2 only apply to credentialing and does not relieve 

3 a hospital from any applicable privileging re4 quirements. 

5 (3) CONSTRUCTION.—This subsection shall not 

6 be construed as limiting the ability of the Secretary 

7 to issue additional guidance regarding the require8 ments for the compilation of credentials for physi9 cians and practitioners not described in paragraph 

10 (1). 

11 (4) DEFINITIONS.—In this subsection: 

12 (A) The term ‘‘hospital’’ has the meaning 

13 given such term in subsection (e) of section 

14 1861 of the Social Security Act (42 U.S.C. 

15 1395x) and includes a critical access hospital 

16 (as defined in subsection (mm)(1) of such sec17 tion). 

18 (B) The term ‘‘physician’’ has the meaning 

19 given such term in subsection (r) of such sec20 tion. 

21 (C) The term ‘‘practitioner’’ means a prac22 titioner described in section 1842(b)(18)(C) of 

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

24 1395u(b)(18)(C)). 
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1 SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS 

2 PROVISION. 

3 Section 1833(t)(7)(D)(i) of the Social Security Act 

4 (42 U.S.C. 1395l(t)(7)(D)(i)) is amended— 

5 (1) in subclause (II)— 

6 (A) in the first sentence, by striking 

7 ‘‘‘2010’’ and inserting ‘‘2012’’; and 

8 (B) in the second sentence, by striking ‘‘or 

9 2009’’ and inserting ‘‘, 2009, 2010, or 2011’’; 

10 and 

11 (2) in subclause (III), by striking ‘‘January 1, 

12 2010’’ and inserting ‘‘January 1, 2012’’. 

13 SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL RECLAS14 SIFICATIONS. 

15 (a) IN GENERAL.—Subsection (a) of section 106 of 

16 division B of the Tax Relief and Health Care Act of 2006 

17 (42 U.S.C. 1395 note), as amended by section 117 of the 

18 Medicare, Medicaid, and SCHIP Extension Act of 2007 

19 (Public Law 110–173) and section 124 of the Medicare 

20 Improvements for Patients and Providers Act of 2008 

21 (Public Law 110–275), is amended by striking ‘‘Sep22 tember 30, 2009’’ and inserting ‘‘September 30, 2011’’. 

23 (b) USE OF PARTICULAR WAGE INDEX FOR FISCAL

24 YEAR 2010.—For purposes of implementation of the 

25 amendment made by subsection (a) for fiscal year 2010, 

26 the Secretary shall use the hospital wage index that was 
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1 promulgated by the Secretary in the Federal Register on 

2 August 27, 2009 (74 Fed. Reg. 43754), and any subse3 quent corrections. 

4 SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK. 

5 Section 1848(e)(1)(E) of the Social Security Act (42 

6 U.S.C. 1395w–4(e)(1)(E)) is amended by striking ‘‘before 

7 January 1, 2010’’ and inserting ‘‘before January 1, 

8 2012’’. 

9 SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COM10 PONENT OF CERTAIN PHYSICIAN PATHOL11 OGY SERVICES. 

12 Section 542(c) of the Medicare, Medicaid, and 

13 SCHIP Benefits Improvement and Protection Act of 2000 

14 (as enacted into law by section 1(a)(6) of Public Law 106– 

15 554), as amended by section 732 of the Medicare Prescrip16 tion Drug, Improvement, and Modernization Act of 2003 

17 (42 U.S.C. 1395w–4 note), section 104 of division B of 

18 the Tax Relief and Health Care Act of 2006 (42 U.S.C. 

19 1395w–4 note), section 104 of the Medicare, Medicaid, 

20 and SCHIP Extension Act of 2007 (Public Law 110– 

21 173), and section 136 of the Medicare Improvements for 

22 Patients and Providers Act of 1008 (Public Law 110– 

23 275), is amended by striking ‘‘and 2009’’ and inserting 

24 ‘‘2009, 2010, and 2011’’. 
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1 SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS. 

2 (a) IN GENERAL.—Section 1834(l)(13) of the Social 

3 Security Act (42 U.S.C. 1395m(l)(13)) is amended— 

4 (1) in subparagraph (A)— 

5 (A) in the matter preceding clause (i), by 

6 striking ‘‘before January 1, 2010’’ and insert7 ing ‘‘before January 1, 2012’’; and 

8 (B) in each of clauses (i) and (ii), by strik9 ing ‘‘before January 1, 2010’’ and inserting 

10 ‘‘before January 1, 2012’’. 

11 (b) AIR AMBULANCE IMPROVEMENTS.—Section 

12 146(b)(1) of the Medicare Improvements for Patients and 

13 Providers Act of 2008 (Public Law 110–275) is amended 

14 by striking ‘‘ending on December 31, 2009’’ and inserting 

15 ‘‘ending on December 31, 2011’’. 

16 TITLE II—MEDICARE 

17 BENEFICIARY IMPROVEMENTS 

18 Subtitle A—Improving and Simpli19 fying Financial Assistance for 

20 Low Income Medicare Bene21 ficiaries 

22 SEC. 1201. IMPROVING ASSETS TESTS FOR MEDICARE SAV23 INGS PROGRAM AND LOW-INCOME SUBSIDY 

24 PROGRAM. 

25 (a) APPLICATION OF HIGHEST LEVEL PERMITTED

26 UNDER LIS TO ALL SUBSIDY ELIGIBLE INDIVIDUALS.— 
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1 (1) IN GENERAL.—Section 1860D–14(a)(1) of 

2 the Social Security Act (42 U.S.C. 1395w– 

3 114(a)(1)) is amended in the matter before subpara4 graph (A), by inserting ‘‘(or, beginning with 2012, 

5 paragraph (3)(E))’’ after ‘‘paragraph (3)(D)’’. 

6 (2) ANNUAL INCREASE IN LIS RESOURCE

7 TEST.—Section 1860D–14(a)(3)(E)(i) of such Act 

8 (42 U.S.C. 1395w–114(a)(3)(E)(i)) is amended— 

9 (A) by striking ‘‘and’’ at the end of sub10 clause (I); 

11 (B) in subclause (II), by inserting ‘‘(before 

12 2012)’’ after ‘‘subsequent year’’; 

13 (C) by striking the period at the end of 

14 subclause (II) and inserting a semicolon; 

15 (D) by inserting after subclause (II) the 

16 following new subclauses: 

17 ‘‘(III) for 2012, $17,000 (or 

18 $34,000 in the case of the combined 

19 value of the individual’s assets or re20 sources and the assets or resources of 

21 the individual’s spouse); and 

22 ‘‘(IV) for a subsequent year, the 

23 dollar amounts specified in this sub24 clause (or subclause (III)) for the pre25 vious year increased by the annual 
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1 percentage increase in the consumer 

2 price index (all items; United States 

3 city average) as of September of such 

4 previous year.’’; and 

5 (E) in the last sentence, by inserting ‘‘or 

6 (IV)’’ after ‘‘subclause (II)’’. 

7 (3) APPLICATION OF LIS TEST UNDER MEDI8 CARE SAVINGS PROGRAM.—Section 1905(p)(1)(C) of 

9 such Act (42 U.S.C. 1396d(p)(1)(C)) is amended— 

10 (A) by striking ‘‘effective beginning with 

11 January 1, 2010’’ and inserting ‘‘effective for 

12 the period beginning with January 1, 2010, and 

13 ending with December 31, 2011’’; and 

14 (B) by inserting before the period at the 

15 end the following: ‘‘or, effective beginning with 

16 January 1, 2012, whose resources (as so deter17 mined) do not exceed the maximum resource 

18 level applied for the year under subparagraph 

19 (E) of section 1860D–14(a)(3) (determined 

20 without regard to the life insurance policy ex21 clusion provided under subparagraph (G) of 

22 such section) applicable to an individual or to 

23 the individual and the individual’s spouse (as 

24 the case may be)’’. 
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1 (b) EFFECTIVE DATE.—The amendments made by 

2 subsection (a) shall apply to eligibility determinations for 

3 income-related subsidies and medicare cost-sharing fur4 nished for periods beginning on or after January 1, 2012. 

5 SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR 

6 CERTAIN NON-INSTITUTIONALIZED FULL7 BENEFIT DUAL ELIGIBLE INDIVIDUALS. 

8 (a) IN GENERAL.—Section 1860D–14(a)(1)(D)(i) of 

9 the Social Security Act (42 U.S.C. 1395w– 

10 114(a)(1)(D)(i)) is amended— 

11 (1) by striking ‘‘INSTITUTIONALIZED INDIVID12 UALS.—In’’ and inserting ‘‘ELIMINATION OF COST13 SHARING FOR CERTAIN FULL-BENEFIT DUAL ELIGI14 BLE INDIVIDUALS.— 

15 ‘‘(I) INSTITUTIONALIZED INDI16 VIDUALS.—In’’; and 

17 (2) by adding at the end the following new sub18 clause: 

19 ‘‘(II) CERTAIN OTHER INDIVID20 UALS.—In the case of an individual 

21 who is a full-benefit dual eligible indi22 vidual and with respect to whom there 

23 has been a determination that but for 

24 the provision of home and community 

25 based care (whether under section 
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1 1915, 1932, or under a waiver under 

2 section 1115) the individual would re3 quire the level of care provided in a 

4 hospital or a nursing facility or inter5 mediate care facility for the mentally 

6 retarded the cost of which could be re7 imbursed under the State plan under 

8 title XIX, the elimination of any bene9 ficiary coinsurance described in sec10 tion 1860D–2(b)(2) (for all amounts 

11 through the total amount of expendi12 tures at which benefits are available 

13 under section 1860D–2(b)(4)).’’. 

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

15 subsection (a) shall apply to drugs dispensed on or after 

16 January 1, 2011. 

17 SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT. 

18 (a) ADMINISTRATIVE VERIFICATION OF INCOME AND

19 RESOURCES UNDER THE LOW-INCOME SUBSIDY PRO20 GRAM.— 

21 (1) IN GENERAL.—Clause (iii) of section 

22 1860D–14(a)(3)(E) of the Social Security Act (42 

23 U.S.C. 1395w–114(a)(3)(E)) is amended to read as 

24 follows: 
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1 ‘‘(iii) CERTIFICATION OF INCOME AND

2 RESOURCES.—For purposes of applying 

3 this section— 

4 ‘‘(I) an individual shall be per5 mitted to apply on the basis of self6 certification of income and resources; 

7 and 

8 ‘‘(II) matters attested to in the 

9 application shall be subject to appro10 priate methods of verification without 

11 the need of the individual to provide 

12 additional documentation, except in 

13 extraordinary situations as determined 

14 by the Commissioner.’’. 

15 (2) EFFECTIVE DATE.—The amendment made 

16 by paragraph (1) shall apply beginning January 1, 

17 2010. 

18 (b) DISCLOSURES TO FACILITATE IDENTIFICATION

19 OF INDIVIDUALS LIKELY TO BE INELIGIBLE FOR THE

20 LOW-INCOME ASSISTANCE UNDER THE MEDICARE PRE21 SCRIPTION DRUG PROGRAM TO ASSIST SOCIAL SECURITY

22 ADMINISTRATION’S OUTREACH TO ELIGIBLE INDIVID23 UALS.—For provision authorizing disclosure of return in24 formation to facilitate identification of individuals likely 
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1 to be ineligible for low-income subsidies under Medicare 

2 prescription drug program, see section 1801. 

3 SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIM4 BURSEMENTS FOR RETROACTIVE LOW IN5 COME SUBSIDY ENROLLMENT. 

6 (a) IN GENERAL.—In the case of a retroactive LIS 

7 enrollment beneficiary who is enrolled under a prescription 

8 drug plan under part D of title XVIII of the Social Secu9 rity Act (or an MA–PD plan under part C of such title), 

10 the beneficiary (or any eligible third party) is entitled to 

11 reimbursement by the plan for covered drug costs incurred 

12 by the beneficiary during the retroactive coverage period 

13 of the beneficiary in accordance with subsection (b) and 

14 in the case of such a beneficiary described in subsection 

15 (c)(4)(A)(i), such reimbursement shall be made automati16 cally by the plan upon receipt of appropriate notice the 

17 beneficiary is eligible for assistance described in such sub18 section (c)(4)(A)(i) without further information required 

19 to be filed with the plan by the beneficiary. 

20 (b) ADMINISTRATIVE REQUIREMENTS RELATING TO

21 REIMBURSEMENTS.— 

22 (1) LINE-ITEM DESCRIPTION.—Each reimburse23 ment made by a prescription drug plan or MA–PD 

24 plan under subsection (a) shall include a line-item 
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1 description of the items for which the reimbursement 

2 is made. 

3 (2) TIMING OF REIMBURSEMENTS.—A prescrip4 tion drug plan or MA–PD plan must make a reim5 bursement under subsection (a) to a retroactive LIS 

6 enrollment beneficiary, with respect to a claim, not 

7 later than 45 days after— 

8 (A) in the case of a beneficiary described 

9 in subsection (c)(4)(A)(i), the date on which the 

10 plan receives notice from the Secretary that the 

11 beneficiary is eligible for assistance described in 

12 such subsection; or 

13 (B) in the case of a beneficiary described 

14 in subsection (c)(4)(A)(ii), the date on which 

15 the beneficiary files the claim with the plan. 

16 (3) REPORTING REQUIREMENT.—For each 

17 month beginning with January 2011, each prescrip18 tion drug plan and each MA–PD plan shall report 

19 to the Secretary the following: 

20 (A) The number of claims the plan has re21 adjudicated during the month due to a bene22 ficiary becoming retroactively eligible for sub23 sidies available under section 1860D–14 of the 

24 Social Security Act. 
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1 (B) The total value of the readjudicated 

2 claim amount for the month. 

3 (C) The Medicare Health Insurance Claims 

4 Number of beneficiaries for whom claims were 

5 readjudicated. 

6 (D) For the claims described in subpara7 graphs (A) and (B), an attestation to the Ad8 ministrator of the Centers for Medicare & Med9 icaid Services of the total amount of reimburse10 ment the plan has provided to beneficiaries for 

11 premiums and cost-sharing that the beneficiary 

12 overpaid for which the plan received payment 

13 from the Centers for Medicare & Medicaid Serv14 ices. 

15 (c) DEFINITIONS.—For purposes of this section: 

16 (1) COVERED DRUG COSTS.—The term ‘‘cov17 ered drug costs’’ means, with respect to a retroactive 

18 LIS enrollment beneficiary enrolled under a pre19 scription drug plan under part D of title XVIII of 

20 the Social Security Act (or an MA–PD plan under 

21 part C of such title), the amount by which— 

22 (A) the costs incurred by such beneficiary 

23 during the retroactive coverage period of the 

24 beneficiary for covered part D drugs, premiums, 

25 and cost-sharing under such title; exceeds 
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1 (B) such costs that would have been in2 curred by such beneficiary during such period if 

3 the beneficiary had been both enrolled in the 

4 plan and recognized by such plan as qualified 

5 during such period for the low income subsidy 

6 under section 1860D–14 of the Social Security 

7 Act to which the individual is entitled. 

8 (2) ELIGIBLE THIRD PARTY.—The term ‘‘eligi9 ble third party’’ means, with respect to a retroactive 

10 LIS enrollment beneficiary, an organization or other 

11 third party that is owed payment on behalf of such 

12 beneficiary for covered drug costs incurred by such 

13 beneficiary during the retroactive coverage period of 

14 such beneficiary. 

15 (3) RETROACTIVE COVERAGE PERIOD.—The 

16 term ‘‘retroactive coverage period’’ means— 

17 (A) with respect to a retroactive LIS en18 rollment beneficiary described in paragraph 

19 (4)(A)(i), the period— 

20 (i) beginning on the effective date of 

21 the assistance described in such paragraph 

22 for which the individual is eligible; and 

23 (ii) ending on the date the plan effec24 tuates the status of such individual as so 

25 eligible; and 
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1 (B) with respect to a retroactive LIS en2 rollment beneficiary described in paragraph 

3 (4)(A)(ii), the period— 

4 (i) beginning on the date the indi5 vidual is both entitled to benefits under 

6 part A, or enrolled under part B, of title 

7 XVIII of the Social Security Act and eligi8 ble for medical assistance under a State 

9 plan under title XIX of such Act; and 

10 (ii) ending on the date the plan effec11 tuates the status of such individual as a 

12 full-benefit dual eligible individual (as de13 fined in section 1935(c)(6) of such Act). 

14 (4) RETROACTIVE LIS ENROLLMENT BENE15 FICIARY.— 

16 (A) IN GENERAL.—The term ‘‘retroactive 

17 LIS enrollment beneficiary’’ means an indi18 vidual who— 

19 (i) is enrolled in a prescription drug 

20 plan under part D of title XVIII of the So21 cial Security Act (or an MA–PD plan 

22 under part C of such title) and subse23 quently becomes eligible as a full-benefit 

24 dual eligible individual (as defined in sec25 tion 1935(c)(6) of such Act), an individual 
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1 receiving a low-income subsidy under sec2 tion 1860D–14 of such Act, an individual 

3 receiving assistance under the Medicare 

4 Savings Program implemented under 

5 clauses (i), (iii), and (iv) of section 

6 1902(a)(10)(E) of such Act, or an indi7 vidual receiving assistance under the sup8 plemental security income program under 

9 section 1611 of such Act; or 

10 (ii) subject to subparagraph (B)(i), is 

11 a full-benefit dual eligible individual (as 

12 defined in section 1935(c)(6) of such Act) 

13 who is automatically enrolled in such a 

14 plan under section 1860D–1(b)(1)(C) of 

15 such Act. 

16 (B) EXCEPTION FOR BENEFICIARIES EN17 ROLLED IN RFP PLAN.— 

18 (i) IN GENERAL.—In no case shall an 

19 individual described in subparagraph 

20 (A)(ii) include an individual who is en21 rolled, pursuant to a RFP contract de22 scribed in clause (ii), in a prescription 

23 drug plan offered by the sponsor of such 

24 plan awarded such contract. 
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1 (ii) RFP CONTRACT DESCRIBED.— 

2 The RFP contract described in this section 

3 is a contract entered into between the Sec4 retary and a sponsor of a prescription drug 

5 plan pursuant to the Centers for Medicare 

6 & Medicaid Services’ request for proposals 

7 issued on February 17, 2009, relating to 

8 Medicare part D retroactive coverage for 

9 certain low income beneficiaries, or a simi10 lar subsequent request for proposals. 

11 SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT. 

12 (a) IN GENERAL.—Section 1860D–1(b)(1)(C) of the 

13 Social Security Act (42 U.S.C. 1395w–101(b)(1)(C)) is 

14 amended by adding after ‘‘PDP region’’ the following: ‘‘or 

15 through use of an intelligent assignment process that is 

16 designed to maximize the access of such individual to nec17 essary prescription drugs while minimizing costs to such 

18 individual and to the program under this part to the great19 est extent possible. In the case the Secretary enrolls such 

20 individuals through use of an intelligent assignment proc21 ess, such process shall take into account the extent to 

22 which prescription drugs necessary for the individual are 

23 covered in the case of a PDP sponsor of a prescription 

24 drug plan that uses a formulary, the use of prior author25 ization or other restrictions on access to coverage of such 
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1 prescription drugs by such a sponsor, and the overall qual2 ity of a prescription drug plan as measured by quality rat3 ings established by the Secretary’’. 

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

5 subsection (a) shall take effect for contract years begin6 ning with 2012. 

7 SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC 

8 ENROLLMENT PROCESS FOR CERTAIN SUB9 SIDY ELIGIBLE INDIVIDUALS. 

10 (a) SPECIAL ENROLLMENT PERIOD.—Section 

11 1860D–1(b)(3)(D) of the Social Security Act (42 U.S.C. 

12 1395w–101(b)(3)(D)) is amended to read as follows: 

13 ‘‘(D) SUBSIDY ELIGIBLE INDIVIDUALS.— 

14 In the case of an individual (as determined by 

15 the Secretary) who is determined under sub16 paragraph (B) of section 1860D–14(a)(3) to be 

17 a subsidy eligible individual.’’. 

18 (b) AUTOMATIC ENROLLMENT.—Section 1860D– 

19 1(b)(1) of the Social Security Act (42 U.S.C. 1395w– 

20 101(b)(1)) is amended by adding at the end the following 

21 new subparagraph: 

22 ‘‘(D) SPECIAL RULE FOR SUBSIDY ELIGI23 BLE INDIVIDUALS.—The process established 

24 under subparagraph (A) shall include, in the 

25 case of an individual described in section 
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1 1860D–1(b)(3)(D) who fails to enroll in a pre2 scription drug plan or an MA–PD plan during 

3 the special enrollment established under such 

4 section applicable to such individual, the appli5 cation of the assignment process described in 

6 subparagraph (C) to such individual in the 

7 same manner as such assignment process ap8 plies to a part D eligible individual described in 

9 such subparagraph (C). Nothing in the previous 

10 sentence shall prevent an individual described in 

11 such sentence from declining enrollment in a 

12 plan determined appropriate by the Secretary 

13 (or in the program under this part) or from 

14 changing such enrollment.’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall apply to subsidy determinations made 

17 for months beginning with January 2011. 

18 SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO RE19 BATE AND QUALITY BONUS PAYMENTS IN 

20 CALCULATION OF LOW INCOME SUBSIDY 

21 BENCHMARK. 

22 (a) IN GENERAL.—Section 1860D–14(b)(2)(B)(iii) 

23 of the Social Security Act (42 U.S.C. 1395w– 

24 114(b)(2)(B)(iii)) is amended by inserting before the pe25 riod the following: ‘‘before the application of the monthly 
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1 rebate computed under section 1854(b)(1)(C)(i) for that 

2 plan and year involved and, in the case of a qualifying 

3 plan in a qualifying county, before the application of the 

4 increase under section 1853(o) for that plan and year in5 volved’’. 

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

7 subsection (a) shall apply to subsidy determinations made 

8 for months beginning with January 2011. 

9 Subtitle B—Reducing Health 

10 Disparities 

11 SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN 

12 MEDICARE. 

13 (a) ENSURING EFFECTIVE COMMUNICATION BY THE

14 CENTERS FOR MEDICARE & MEDICAID SERVICES.— 

15 (1) STUDY ON MEDICARE PAYMENTS FOR LAN16 GUAGE SERVICES.—The Secretary of Health and 

17 Human Services shall conduct a study that examines 

18 the extent to which Medicare service providers uti19 lize, offer, or make available language services for 

20 beneficiaries who are limited English proficient and 

21 ways that Medicare should develop payment systems 

22 for language services. 

23 (2) ANALYSES.—The study shall include an 

24 analysis of each of the following: 
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1 (A) How to develop and structure appro2 priate payment systems for language services 

3 for all Medicare service providers. 

4 (B) The feasibility of adopting a payment 

5 methodology for on-site interpreters, including 

6 interpreters who work as independent contrac7 tors and interpreters who work for agencies 

8 that provide on-site interpretation, pursuant to 

9 which such interpreters could directly bill Medi10 care for services provided in support of physi11 cian office services for an LEP Medicare pa12 tient. 

13 (C) The feasibility of Medicare contracting 

14 directly with agencies that provide off-site inter15 pretation including telephonic and video inter16 pretation pursuant to which such contractors 

17 could directly bill Medicare for the services pro18 vided in support of physician office services for 

19 an LEP Medicare patient. 

20 (D) The feasibility of modifying the exist21 ing Medicare resource-based relative value scale 

22 (RBRVS) by using adjustments (such as multi23 pliers or add-ons) when a patient is LEP. 

24 (E) How each of options described in a 

25 previous paragraph would be funded and how 
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1 such funding would affect physician payments, 

2 a physician’s practice, and beneficiary cost3 sharing. 

4 (F) The extent to which providers under 

5 parts A and B of title XVIII of the Social Secu6 rity Act, MA organizations offering Medicare 

7 Advantage plans under part C of such title and 

8 PDP sponsors of a prescription drug plan 

9 under part D of such title utilize, offer, or make 

10 available language services for beneficiaries with 

11 limited English proficiency. 

12 (G) The nature and type of language serv13 ices provided by States under title XIX of the 

14 Social Security Act and the extent to which 

15 such services could be utilized by beneficiaries 

16 and providers under title XVIII of such Act. 

17 (H) The extent to which interpreters and 

18 translators providing services to Medicare bene19 ficiaries under title XVIII of such Act are 

20 trained or accredited. 

21 (3) VARIATION IN PAYMENT SYSTEM DE22 SCRIBED.—The payment systems described in para23 graph (2)(A) may allow variations based upon types 

24 of service providers, available delivery methods, and 
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1 costs for providing language services including such 

2 factors as— 

3 (A) the type of language services provided 

4 (such as provision of health care or health care 

5 related services directly in a non-English lan6 guage by a bilingual provider or use of an inter7 preter); 

8 (B) type of interpretation services provided 

9 (such as in-person, telephonic, video interpreta10 tion); 

11 (C) the methods and costs of providing 

12 language services (including the costs of pro13 viding language services with internal staff or 

14 through contract with external independent con15 tractors or agencies, or both); 

16 (D) providing services for languages not 

17 frequently encountered in the United States; 

18 and 

19 (E) providing services in rural areas. 

20 (4) REPORT.—The Secretary shall submit a re21 port on the study conducted under subsection (a) to 

22 appropriate committees of Congress not later than 

23 12 months after the date of the enactment of this 

24 Act. 
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1 (5) EXEMPTION FROM PAPERWORK REDUCTION

2 ACT.—Chapter 35 of title 44, United States Code 

3 (commonly known as the ‘‘Paperwork Reduction 

4 Act’’), shall not apply for purposes of carrying out 

5 this subsection. 

6 (6) AUTHORIZATION OF APPROPRIATIONS.— 

7 The Secretary shall provide for the transfer, from 

8 the Federal Supplementary Medical Insurance Trust 

9 Fund under section 1841 of the Social Security Act 

10 (42 U.S.C. 1395t) of $2,000,000 for purposes of 

11 carrying out this subsection. 

12 (b) HEALTH PLANS.—Section 1857(g)(1) of the So13 cial Security Act (42 U.S.C. 1395w–27(g)(1)) is amend14 ed— 

15 (1) by striking ‘‘or’’ at the end of subparagraph 

16 (F); 

17 (2) by adding ‘‘or’’ at the end of subparagraph 

18 (G); and 

19 (3) by inserting after subparagraph (G) the fol20 lowing new subparagraph: 

21 ‘‘(H) fails substantially to provide lan22 guage services to limited English proficient 

23 beneficiaries enrolled in the plan that are re24 quired under law;’’. 
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1 SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR 

2 MEDICARE BENEFICIARIES WITH LIMITED 

3 ENGLISH PROFICIENCY BY PROVIDING REIM4 BURSEMENT FOR CULTURALLY AND LINGUIS5 TICALLY APPROPRIATE SERVICES. 

6 (a) IN GENERAL.—Not later than 6 months after the 

7 date of the completion of the study described in section 

8 1221(a) of this Act, the Secretary, acting through the 

9 Centers for Medicare & Medicaid Services and the Center 

10 for Medicare and Medicaid Innovation established under 

11 section 1115A of the Social Security Act (as added by sec12 tion 1907) and consistent with the applicable provisions 

13 of such section, shall carry out a demonstration program 

14 under which the Secretary shall award not fewer than 24 

15 3-year grants to eligible Medicare service providers (as de16 scribed in subsection (b)(1)) to improve effective commu17 nication between such providers and Medicare bene18 ficiaries who are living in communities where racial and 

19 ethnic minorities, including populations that face language 

20 barriers, are underserved with respect to such services. In 

21 designing and carrying out the demonstration the Sec22 retary shall take into consideration the results of the study 

23 conducted under section 1221(a) of this Act and adjust, 

24 as appropriate, the distribution of grants so as to better 

25 target Medicare beneficiaries who are in the greatest need 

26 of language services. The Secretary shall not authorize a 
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1 grant larger than $500,000 over three years for any grant2 ee. 

3 (b) ELIGIBILITY; PRIORITY.— 

4 (1) ELIGIBILITY.—To be eligible to receive a 

5 grant under subsection (a) an entity shall— 

6 (A) be— 

7 (i) a provider of services under part A 

8 of title XVIII of the Social Security Act; 

9 (ii) a service provider under part B of 

10 such title; 

11 (iii) a part C organization offering a 

12 Medicare part C plan under part C of such 

13 title; or 

14 (iv) a PDP sponsor of a prescription 

15 drug plan under part D of such title; and 

16 (B) prepare and submit to the Secretary 

17 an application, at such time, in such manner, 

18 and accompanied by such additional informa19 tion as the Secretary may require. 

20 (2) PRIORITY.— 

21 (A) DISTRIBUTION.—To the extent fea22 sible, in awarding grants under this section, the 

23 Secretary shall award— 

24 (i) at least 6 grants to providers of 

25 services described in paragraph (1)(A)(i); 
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1 (ii) at least 6 grants to service pro2 viders described in paragraph (1)(A)(ii); 

3 (iii) at least 6 grants to organizations 

4 described in paragraph (1)(A)(iii); and 

5 (iv) at least 6 grants to sponsors de6 scribed in paragraph (1)(A)(iv). 

7 (B) FOR COMMUNITY ORGANIZATIONS.— 

8 The Secretary shall give priority to applicants 

9 that have developed partnerships with commu10 nity organizations or with agencies with experi11 ence in language access. 

12 (C) VARIATION IN GRANTEES.—The Sec13 retary shall also ensure that the grantees under 

14 this section represent, among other factors— 

15 (i) different types of language services 

16 provided and of service providers and orga17 nizations under parts A through D of title 

18 XVIII of the Social Security Act; 

19 (ii) variations in languages needed 

20 and their frequency of use; 

21 (iii) urban and rural settings; 

22 (iv) at least two geographic regions, 

23 as defined by the Secretary; and 

24 (v) at least two large metropolitan 

25 statistical areas with diverse populations. 
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1 (c) USE OF FUNDS.— 

2 (1) IN GENERAL.—A grantee shall use grant 

3 funds received under this section to pay for the pro4 vision of competent language services to Medicare 

5 beneficiaries who are limited English proficient. 

6 Competent interpreter services may be provided 

7 through on-site interpretation, telephonic interpreta8 tion, or video interpretation or direct provision of 

9 health care or health care related services by a bilin10 gual health care provider. A grantee may use bilin11 gual providers, staff, or contract interpreters. A 

12 grantee may use grant funds to pay for competent 

13 translation services. A grantee may use up to 10 

14 percent of the grant funds to pay for administrative 

15 costs associated with the provision of competent lan16 guage services and for reporting required under sub17 section (e). 

18 (2) ORGANIZATIONS.—Grantees that are part C 

19 organizations or PDP sponsors must ensure that 

20 their network providers receive at least 50 percent of 

21 the grant funds to pay for the provision of com22 petent language services to Medicare beneficiaries 

23 who are limited English proficient, including physi24 cians and pharmacies. 
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1 (3) DETERMINATION OF PAYMENTS FOR LAN2 GUAGE SERVICES.—Payments to grantees shall be 

3 calculated based on the estimated numbers of lim4 ited English proficient Medicare beneficiaries in a 

5 grantee’s service area utilizing— 

6 (A) data on the numbers of limited 

7 English proficient individuals who speak 

8 English less than ‘‘very well’’ from the most re9 cently available data from the Bureau of the 

10 Census or other State-based study the Sec11 retary determines likely to yield accurate data 

12 regarding the number of such individuals served 

13 by the grantee; or 

14 (B) the grantee’s own data if the grantee 

15 routinely collects data on Medicare bene16 ficiaries’ primary language in a manner deter17 mined by the Secretary to yield accurate data 

18 and such data shows greater numbers of limited 

19 English proficient individuals than the data list20 ed in subparagraph (A). 

21 (4) LIMITATIONS.— 

22 (A) REPORTING.—Payments shall only be 

23 provided under this section to grantees that re24 port their costs of providing language services 

25 as required under subsection (e) and may be 
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1 modified annually at the discretion of the Sec2 retary. If a grantee fails to provide the reports 

3 under such section for the first year of a grant, 

4 the Secretary may terminate the grant and so5 licit applications from new grantees to partici6 pate in the subsequent two years of the dem7 onstration program. 

8 (B) TYPE OF SERVICES.— 

9 (i) IN GENERAL.—Subject to clause 

10 (ii), payments shall be provided under this 

11 section only to grantees that utilize com12 petent bilingual staff or competent inter13 preter or translation services which— 

14 (I) if the grantee operates in a 

15 State that has statewide health care 

16 interpreter standards, meet the State 

17 standards currently in effect; or 

18 (II) if the grantee operates in a 

19 State that does not have statewide 

20 health care interpreter standards, uti21 lizes competent interpreters who fol22 low the National Council on Inter23 preting in Health Care’s Code of Eth24 ics and Standards of Practice. 
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1 (ii) EXEMPTIONS.—The requirements 

2 of clause (i) shall not apply— 

3 (I) in the case of a Medicare ben4 eficiary who is limited English pro5 ficient (who has been informed in the 

6 beneficiary’s primary language of the 

7 availability of free interpreter and 

8 translation services) and who requests 

9 the use of family, friends, or other 

10 persons untrained in interpretation or 

11 translation and the grantee documents 

12 the request in the beneficiary’s record; 

13 and 

14 (II) in the case of a medical 

15 emergency where the delay directly as16 sociated with obtaining a competent 

17 interpreter or translation services 

18 would jeopardize the health of the pa19 tient. 

20 Nothing in clause (ii)(II) shall be con21 strued to exempt emergency rooms or simi22 lar entities that regularly provide health 

23 care services in medical emergencies from 

24 having in place systems to provide com-
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1 petent interpreter and translation services 

2 without undue delay. 

3 (d) ASSURANCES.—Grantees under this section 

4 shall— 

5 (1) ensure that appropriate clinical and support 

6 staff receive ongoing education and training in lin7 guistically appropriate service delivery; 

8 (2) ensure the linguistic competence of bilingual 

9 providers; 

10 (3) offer and provide appropriate language serv11 ices at no additional charge to each patient with lim12 ited English proficiency at all points of contact, in 

13 a timely manner during all hours of operation; 

14 (4) notify Medicare beneficiaries of their right 

15 to receive language services in their primary lan16 guage; 

17 (5) post signage in the languages of the com18 monly encountered group or groups present in the 

19 service area of the organization; and 

20 (6) ensure that— 

21 (A) primary language data are collected 

22 for recipients of language services and are con23 sistent with standards developed under section 

24 1709(b)(3)(B)(iv) of the Public Health Service 

25 Act, as added by section 2402 of this Act, to 
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1 the extent such standards are available upon 

2 the initiation of the demonstration; and 

3 (B) consistent with the privacy protections 

4 provided under the regulations promulgated 

5 pursuant to section 264(c) of the Health Insur6 ance Portability and Accountability Act of 1996 

7 (42 U.S.C. 1320d–2 note), if the recipient of 

8 language services is a minor or is incapacitated, 

9 the primary language of the parent or legal 

10 guardian is collected and utilized. 

11 (e) REPORTING REQUIREMENTS.—Grantees under 

12 this section shall provide the Secretary with reports at the 

13 conclusion of the each year of a grant under this section. 

14 Each report shall include at least the following informa15 tion: 

16 (1) The number of Medicare beneficiaries to 

17 whom language services are provided. 

18 (2) The languages of those Medicare bene19 ficiaries. 

20 (3) The types of language services provided 

21 (such as provision of services directly in non-English 

22 language by a bilingual health care provider or use 

23 of an interpreter). 

24 (4) Type of interpretation (such as in-person, 

25 telephonic, or video interpretation). 
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1 (5) The methods of providing language services 

2 (such as staff or contract with external independent 

3 contractors or agencies). 

4 (6) The length of time for each interpretation 

5 encounter. 

6 (7) The costs of providing language services 

7 (which may be actual or estimated, as determined by 

8 the Secretary). 

9 (8) An account of the training or accreditation 

10 of bilingual staff, interpreters, or translators pro11 viding services under this demonstration. 

12 (f) NO COST SHARING.—Limited English proficient 

13 Medicare beneficiaries shall not have to pay cost-sharing 

14 or co-pays for language services provided through this 

15 demonstration program. 

16 (g) EVALUATION AND REPORT.—The Secretary shall 

17 conduct an evaluation of the demonstration program 

18 under this section and shall submit to the appropriate 

19 committees of Congress a report not later than 1 year 

20 after the completion of the program. The report shall in21 clude the following: 

22 (1) An analysis of the patient outcomes and 

23 costs of furnishing care to the limited English pro24 ficient Medicare beneficiaries participating in the 

25 project as compared to such outcomes and costs for 
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1 limited English proficient Medicare beneficiaries not 

2 participating. 

3 (2) The effect of delivering culturally and lin4 guistically appropriate services on beneficiary access 

5 to care, utilization of services, efficiency and cost-ef6 fectiveness of health care delivery, patient satisfac7 tion, and select health outcomes. 

8 (3) The extent to which bilingual staff, inter9 preters, and translators providing services under 

10 such demonstration were trained or accredited and 

11 the nature of accreditation or training needed by 

12 type of provider, service, or other category as deter13 mined by the Secretary to ensure the provision of 

14 high-quality interpretation, translation, or other lan15 guage services to Medicare beneficiaries if such serv16 ices are expanded pursuant to subsection (c) of sec17 tion 1907 of this Act. 

18 (4) Recommendations, if any, regarding the ex19 tension of such project to the entire Medicare pro20 gram. 

21 (h) ACCREDITATION OR TRAINING FOR PROVIDERS

22 OF INTERPRETATION, TRANSLATION OR LANGUAGE

23 SERVICES IN MEDICARE.— 

24 (1) IN GENERAL.— 
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1 (A) DESIGNATION OF STANDARDS.—If the 

2 Secretary, pursuant to section 1907(c) of this 

3 Act, expands the model initially developed 

4 through the demonstration program under this 

5 section, the Secretary shall use the results of 

6 the study under section 1221 and the dem7 onstration under this section to designate 

8 standards for training or accreditation. The 

9 Secretary may designate one or more training 

10 or accreditation organizations, as appropriate 

11 for the nature and type of interpretation and 

12 translation services provided to Medicare bene13 ficiaries to ensure that payments are made only 

14 for approved services by trained or accredited 

15 language services providers. 

16 (B) ALTERNATIVES TO TRAINING OR AC17 CREDITATION.—If the Secretary designates one 

18 or more training or accreditation organiza19 tions but determines that accreditation is not 

20 available in all languages for which payments 

21 may be initiated, the Secretary shall provide 

22 payments for and accept alternatives to train23 ing or accreditation for certain languages, in24 cluding languages of lesser diffusion. The Sec25 retary must ensure that the alternatives to
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1 training or accreditation provide, at a min2 imum— 

3 (i) a determination that the inter4 preter is proficient and able to commu5 nicate information accurately in both 

6 English and in the language for which in7 terpreting is needed; 

8 (ii) an attestation from the interpreter 

9 to comply with and adhere to the role of 

10 an interpreter as defined by the National 

11 Code of Ethics and National Standards of 

12 Practice as published by the National 

13 Council on Interpreting in Health Care; 

14 and 

15 (iii) an attestation to adhere to 

16 HIPAA privacy and security law, as de17 fined in section 3009(a)(2) of the Public 

18 Health Service Act, to the same extent as 

19 the healthcare provider for whom inter20 preting is provided. 

21 (C) MODIFIERS, ADD-ONS, AND OTHER

22 FORMS OF PAYMENT.—If the Secretary decides 

23 that modifiers, add-ons, or other forms of pay24 ment may be made for the provision of services 

25 directly by bilingual providers, the Secretary 
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1 shall designate standards to ensure the com2 petency of such providers delivering such serv3 ices in a non-English language. 

4 (2) CONSULTATION WITH STAKEHOLDERS AND

5 CONSIDERATIONS FOR ACCREDITATION OR TRAIN6 ING.— 

7 (A) CONSULTATION.—In designating ac8 creditation or training requirements under this 

9 subsection, the Secretary shall consult with pa10 tients, providers, organizations that advocate on 

11 behalf of limited English proficient individuals, 

12 and other individuals or entities determined ap13 propriate by the Secretary. 

14 (B) CONSIDERATIONS.—In designating ac15 creditation or training requirements under this 

16 section, the Secretary shall consider, as appro17 priate— 

18 (i) standards for qualifications of 

19 health care interpreters who interpret in20 frequently encountered languages; 

21 (ii) standards for qualifications of 

22 health care interpreters who interpret in 

23 languages of lesser diffusion; 

24 (iii) standards for training of inter25 preters; and
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1 (iv) standards for continuing edu2 cation of interpreters. 

3 (i) GENERAL PROVISIONS.—Nothing in this section 

4 shall be construed to limit otherwise existing obligations 

5 of recipients of Federal financial assistance under title VI 

6 of the Civil Rights Act of 1964 (42 U.S.C. 2000(d) et 

7 seq.) or any other statute. 

8 (j) APPROPRIATIONS.—There are appropriated to 

9 carry out this section, in equal parts from the Federal 

10 Hospital Insurance Trust Fund and the Federal Supple11 mentary Medical Insurance Trust Fund, $16,000,000 for 

12 each fiscal year of the demonstration program. 

13 SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS 

14 SERVICES. 

15 (a) IN GENERAL.—The Secretary of Health and 

16 Human Services shall enter into an arrangement with the 

17 Institute of Medicine under which the Institute will pre18 pare and publish, not later than 3 years after the date 

19 of the enactment of this Act, a report on the impact of 

20 language access services on the health and health care of 

21 limited English proficient populations. 

22 (b) CONTENTS.—Such report shall include— 

23 (1) recommendations on the development and 

24 implementation of policies and practices by health 
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1 care organizations and providers for limited English 

2 proficient patient populations; 

3 (2) a description of the effect of providing lan4 guage access services on quality of health care and 

5 access to care and reduced medical error; and 

6 (3) a description of the costs associated with or 

7 savings related to provision of language access serv8 ices. 

9 SEC. 1224. DEFINITIONS. 

10 In this subtitle: 

11 (1) BILINGUAL.—The term ‘‘bilingual’’ with re12 spect to an individual means a person who has suffi13 cient degree of proficiency in two languages and can 

14 ensure effective communication can occur in both 

15 languages. 

16 (2) COMPETENT INTERPRETER SERVICES.—The 

17 term ‘‘competent interpreter services’’ means a 

18 trans-language rendition of a spoken message in 

19 which the interpreter comprehends the source lan20 guage and can speak comprehensively in the target 

21 language to convey the meaning intended in the 

22 source language. The interpreter knows health and 

23 health-related terminology and provides accurate in24 terpretations by choosing equivalent expressions that 

25 convey the best matching and meaning to the source 
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1 language and captures, to the greatest possible ex2 tent, all nuances intended in the source message. 

3 (3) COMPETENT TRANSLATION SERVICES.—The 

4 term ‘‘competent translation services’’ means a 

5 trans-language rendition of a written document in 

6 which the translator comprehends the source lan7 guage and can write comprehensively in the target 

8 language to convey the meaning intended in the 

9 source language. The translator knows health and 

10 health-related terminology and provides accurate 

11 translations by choosing equivalent expressions that 

12 convey the best matching and meaning to the source 

13 language and captures, to the greatest possible ex14 tent, all nuances intended in the source document. 

15 (4) EFFECTIVE COMMUNICATION.—The term 

16 ‘‘effective communication’’ means an exchange of in17 formation between the provider of health care or 

18 health care-related services and the limited English 

19 proficient recipient of such services that enables lim20 ited English proficient individuals to access, under21 stand, and benefit from health care or health care22 related services. 

23 (5) INTERPRETING/INTERPRETATION.—The 

24 terms ‘‘interpreting’’ and ‘‘interpretation’’ mean the 
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1 transmission of a spoken message from one language 

2 into another, faithfully, accurately, and objectively. 

3 (6) HEALTH CARE SERVICES.—The term 

4 ‘‘health care services’’ means services that address 

5 physical as well as mental health conditions in all 

6 care settings. 

7 (7) HEALTH CARE-RELATED SERVICES.—The 

8 term ‘‘health care-related services’’ means human or 

9 social services programs or activities that provide ac10 cess, referrals or links to health care. 

11 (8) LANGUAGE ACCESS.—The term ‘‘language 

12 access’’ means the provision of language services to 

13 an LEP individual designed to enhance that individ14 ual’s access to, understanding of or benefit from 

15 health care or health care-related services. 

16 (9) LANGUAGE SERVICES.—The term ‘‘lan17 guage services’’ means provision of health care serv18 ices directly in a non-English language, interpreta19 tion, translation, and non-English signage. 

20 (10) LIMITED ENGLISH PROFICIENT.—The 

21 term ‘‘limited English proficient’’ or ‘‘LEP’’ with re22 spect to an individual means an individual who 

23 speaks a primary language other than English and 

24 who cannot speak, read, write or understand the 

25 English language at a level that permits the indi-
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1 vidual to effectively communicate with clinical or 

2 nonclinical staff at an entity providing health care or 

3 health care related services. 

4 (11) MEDICARE BENEFICIARY.—The term 

5 ‘‘Medicare beneficiary’’ means an individual entitled 

6 to benefits under part A of title XVIII of the Social 

7 Security Act or enrolled under part B of such title. 

8 (12) MEDICARE PROGRAM.—The term ‘‘Medi9 care program’’ means the programs under parts A 

10 through D of title XVIII of the Social Security Act. 

11 (13) SERVICE PROVIDER.—The term ‘‘service 

12 provider’’ includes all suppliers, providers of services, 

13 or entities under contract to provide coverage, items 

14 or services under any part of title XVIII of the So15 cial Security Act. 

16 Subtitle C—Miscellaneous 

17 Improvements 

18 SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS 

19 PROCESS. 

20 Section 1833(g)(5) of the Social Security Act (42 

21 U.S.C. 1395l(g)(5)), as amended by section 141 of the 

22 Medicare Improvements for Patients and Providers Act of 

23 2008 (Public Law 110–275), is amended by striking ‘‘De24 cember 31, 2009’’ and inserting ‘‘December 31, 2011’’. 
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1 SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNO2 SUPPRESSIVE DRUGS FOR KIDNEY TRANS3 PLANT PATIENTS AND OTHER RENAL DIALY4 SIS PROVISIONS. 

5 (a) PROVISION OF APPROPRIATE COVERAGE OF IM6 MUNOSUPPRESSIVE DRUGS UNDER THE MEDICARE PRO7 GRAM FOR KIDNEY TRANSPLANT RECIPIENTS.— 

8 (1) CONTINUED ENTITLEMENT TO IMMUNO9 SUPPRESSIVE DRUGS.— 

10 (A) KIDNEY TRANSPLANT RECIPIENTS.— 

11 Section 226A(b)(2) of the Social Security Act 

12 (42 U.S.C. 426–1(b)(2)) is amended by insert13 ing ‘‘(except for coverage of immunosuppressive 

14 drugs under section 1861(s)(2)(J))’’ before ‘‘, 

15 with the thirty-sixth month’’. 

16 (B) APPLICATION.—Section 1836 of such 

17 Act (42 U.S.C. 1395o) is amended— 

18 (i) by striking ‘‘Every individual who’’ 

19 and inserting ‘‘(a) IN GENERAL.—Every 

20 individual who’’; and 

21 (ii) by adding at the end the following 

22 new subsection: 

23 ‘‘(b) SPECIAL RULES APPLICABLE TO INDIVIDUALS

24 ONLY ELIGIBLE FOR COVERAGE OF IMMUNOSUPPRESSIVE

25 DRUGS.— 
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1 ‘‘(1) IN GENERAL.—In the case of an individual 

2 whose eligibility for benefits under this title has 

3 ended on or after January 1, 2012, except for the 

4 coverage of immunosuppressive drugs by reason of 

5 section 226A(b)(2), the following rules shall apply: 

6 ‘‘(A) The individual shall be deemed to be 

7 enrolled under this part for purposes of receiv8 ing coverage of such drugs. 

9 ‘‘(B) The individual shall be responsible 

10 for providing for payment of the portion of the 

11 premium under section 1839 which is not cov12 ered under the Medicare savings program (as 

13 defined in section 1144(c)(7)) in order to re14 ceive such coverage. 

15 ‘‘(C) The provision of such drugs shall be 

16 subject to the application of— 

17 ‘‘(i) the deductible under section 

18 1833(b); and 

19 ‘‘(ii) the coinsurance amount applica20 ble for such drugs (as determined under 

21 this part). 

22 ‘‘(D) If the individual is an inpatient of a 

23 hospital or other entity, the individual is enti24 tled to receive coverage of such drugs under 

25 this part. 
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1 ‘‘(2) ESTABLISHMENT OF PROCEDURES IN

2 ORDER TO IMPLEMENT COVERAGE.—The Secretary 

3 shall establish procedures for— 

4 ‘‘(A) identifying individuals that are enti5 tled to coverage of immunosuppressive drugs by 

6 reason of section 226A(b)(2); and 

7 ‘‘(B) distinguishing such individuals from 

8 individuals that are enrolled under this part for 

9 the complete package of benefits under this 

10 part.’’. 

11 (C) TECHNICAL AMENDMENT TO CORRECT

12 DUPLICATE SUBSECTION DESIGNATION.—Sub13 section (c) of section 226A of such Act (42 

14 U.S.C. 426–1), as added by section 

15 201(a)(3)(D)(ii) of the Social Security Inde16 pendence and Program Improvements Act of 

17 1994 (Public Law 103–296; 108 Stat. 1497), is 

18 redesignated as subsection (d). 

19 (2) EXTENSION OF SECONDARY PAYER RE20 QUIREMENTS FOR ESRD BENEFICIARIES.—Section 

21 1862(b)(1)(C) of such Act (42 U.S.C. 

22 1395y(b)(1)(C)) is amended by adding at the end 

23 the following new sentence: ‘‘With regard to im24 munosuppressive drugs furnished on or after the 

25 date of the enactment of the Affordable Health Care 
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1 for America Act, this subparagraph shall be applied 

2 without regard to any time limitation.’’. 

3 (b) MEDICARE COVERAGE FOR ESRD PATIENTS.— 

4 Section 1881 of such Act is further amended— 

5 (1) in subsection (b)(14)(B)(iii), by inserting ‘‘, 

6 including oral drugs that are not the oral equivalent 

7 of an intravenous drug (such as oral phosphate bind8 ers and calcimimetics),’’ after ‘‘other drugs and 

9 biologicals’’; 

10 (2) in subsection (b)(14)(E)(ii)— 

11 (A) in the first sentence— 

12 (i) by striking ‘‘a one-time election to 

13 be excluded from the phase-in’’ and insert14 ing ‘‘an election, with respect to 2011, 

15 2012, or 2013, to be excluded from the 

16 phase-in (or the remainder of the phase17 in)’’; and 

18 (ii) by adding before the period at the 

19 end the following: ‘‘for such year and for 

20 each subsequent year during the phase-in 

21 described in clause (i)’’; and 

22 (B) in the second sentence— 

23 (i) by striking ‘‘January 1, 2011’’ and 

24 inserting ‘‘the first date of such year’’; and 
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1 (ii) by inserting ‘‘and at a time’’ after 

2 ‘‘form and manner’’; and 

3 (3) in subsection (h)(4)(E), by striking ‘‘lesser’’ 

4 and inserting ‘‘greater’’. 

5 SEC. 1233. VOLUNTARY ADVANCE CARE PLANNING CON6 SULTATION. 

7 (a) IN GENERAL.—Section 1861 of the Social Secu8 rity Act (42 U.S.C. 1395x) is amended— 

9 (1) in subsection (s)(2)— 

10 (A) by striking ‘‘and’’ at the end of sub11 paragraph (DD); 

12 (B) by adding ‘‘and’’ at the end of sub13 paragraph (EE); and 

14 (C) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(FF) voluntary advance care planning con17 sultation (as defined in subsection (hhh)(1));’’; and 

18 (2) by adding at the end the following new sub19 section: 

20 ‘‘Voluntary Advance Care Planning Consultation 

21 ‘‘(hhh)(1) Subject to paragraphs (3) and (4), the 

22 term ‘voluntary advance care planning consultation’ 

23 means an optional consultation between the individual and 

24 a practitioner described in paragraph (2) regarding ad-
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1 vance care planning. Such consultation may include the 

2 following, as specified by the Secretary: 

3 ‘‘(A) An explanation by the practitioner of ad4 vance care planning, including a review of key ques5 tions and considerations, advance directives (includ6 ing living wills and durable powers of attorney) and 

7 their uses. 

8 ‘‘(B) An explanation by the practitioner of the 

9 role and responsibilities of a health care proxy and 

10 of the continuum of end-of-life services and supports 

11 available, including palliative care and hospice, and 

12 benefits for such services and supports that are 

13 available under this title. 

14 ‘‘(C) An explanation by the practitioner of phy15 sician orders regarding life sustaining treatment or 

16 similar orders, in States where such orders or simi17 lar orders exist. 

18 ‘‘(2) A practitioner described in this paragraph is— 

19 ‘‘(A) a physician (as defined in subsection 

20 (r)(1)); and 

21 ‘‘(B) another health care professional (as speci22 fied by the Secretary and who has the authority 

23 under State law to sign orders for life sustaining 

24 treatments, such as a nurse practitioner or physician 

25 assistant). 
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1 ‘‘(3) An individual may receive the voluntary advance 

2 care planning care planning consultation provided for 

3 under this subsection no more than once every 5 years 

4 unless there is a significant change in the health or health5 related condition of the individual. 

6 ‘‘(4) For purposes of this section, the term ‘order re7 garding life sustaining treatment’ means, with respect to 

8 an individual, an actionable medical order relating to the 

9 treatment of that individual that effectively communicates 

10 the individual’s preferences regarding life sustaining treat11 ment, is signed and dated by a practitioner, and is in a 

12 form that permits it to be followed by health care profes13 sionals across the continuum of care.’’. 

14 (b) CONSTRUCTION.—The voluntary advance care 

15 planning consultation described in section 1861(hhh) of 

16 the Social Security Act, as added by subsection (a), shall 

17 be completely optional. Nothing in this section shall— 

18 (1) require an individual to complete an ad19 vance directive, an order for life sustaining treat20 ment, or other advance care planning document; 

21 (2) require an individual to consent to restric22 tions on the amount, duration, or scope of medical 

23 benefits an individual is entitled to receive under 

24 this title; or 
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1 (3) encourage the promotion of suicide or as2 sisted suicide. 

3 (c) PAYMENT.—Section 1848(j)(3) of such Act (42 

4 U.S.C. 1395w–4(j)(3)) is amended by inserting 

5 ‘‘(2)(FF),’’ after ‘‘(2)(EE),’’. 

6 (d) FREQUENCY LIMITATION.—Section 1862(a) of 

7 such Act (42 U.S.C. 1395y(a)) is amended— 

8 (1) in paragraph (1)— 

9 (A) in subparagraph (N), by striking 

10 ‘‘and’’ at the end; 

11 (B) in subparagraph (O) by striking the 

12 semicolon at the end and inserting ‘‘, and’’; and 

13 (C) by adding at the end the following new 

14 subparagraph: 

15 ‘‘(P) in the case of voluntary advance care 

16 planning consultations (as defined in paragraph 

17 (1) of section 1861(hhh)), which are performed 

18 more frequently than is covered under such sec19 tion;’’; and 

20 (2) in paragraph (7), by striking ‘‘or (K)’’ and 

21 inserting ‘‘(K), or (P)’’. 

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

23 this section shall apply to consultations furnished on or 

24 after January 1, 2011. 
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1 SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND 

2 WAIVER OF LIMITED ENROLLMENT PENALTY 

3 FOR TRICARE BENEFICIARIES. 

4 (a) PART B SPECIAL ENROLLMENT PERIOD.— 

5 (1) IN GENERAL.—Section 1837 of the Social 

6 Security Act (42 U.S.C. 1395p) is amended by add7 ing at the end the following new subsection: 

8 ‘‘(l)(1) In the case of any individual who is a covered 

9 beneficiary (as defined in section 1072(5) of title 10, 

10 United States Code) at the time the individual is entitled 

11 to hospital insurance benefits under part A under section 

12 226(b) or section 226A and who is eligible to enroll but 

13 who has elected not to enroll (or to be deemed enrolled) 

14 during the individual’s initial enrollment period, there 

15 shall be a special enrollment period described in paragraph 

16 (2). 

17 ‘‘(2) The special enrollment period described in this 

18 paragraph, with respect to an individual, is the 12-month 

19 period beginning on the day after the last day of the initial 

20 enrollment period of the individual or, if later, the 12- 

21 month period beginning with the month the individual is 

22 notified of enrollment under this section. 

23 ‘‘(3) In the case of an individual who enrolls during 

24 the special enrollment period provided under paragraph 

25 (1), the coverage period under this part shall begin on the 

26 first day of the month in which the individual enrolls or, 
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1 at the option of the individual, on the first day of the sec2 ond month following the last month of the individual’s ini3 tial enrollment period. 

4 ‘‘(4) The Secretary of Defense shall establish a meth5 od for identifying individuals described in paragraph (1) 

6 and providing notice to them of their eligibility for enroll7 ment during the special enrollment period described in 

8 paragraph (2).’’. 

9 (2) EFFECTIVE DATE.—The amendment made 

10 by paragraph (1) shall apply to elections made on or 

11 after the date of the enactment of this Act. 

12 (b) WAIVER OF INCREASE OF PREMIUM.— 

13 (1) IN GENERAL.—Section 1839(b) of the So14 cial Security Act (42 U.S.C. 1395r(b)) is amended 

15 by striking ‘‘section 1837(i)(4)’’ and inserting ‘‘sub16 section (i)(4) or (l) of section 1837’’. 

17 (2) EFFECTIVE DATE.— 

18 (A) IN GENERAL.—The amendment made 

19 by paragraph (1) shall apply with respect to 

20 elections made on or after the date of the en21 actment of this Act. 

22 (B) REBATES FOR CERTAIN DISABLED

23 AND ESRD BENEFICIARIES.— 

24 (i) IN GENERAL.—With respect to 

25 premiums for months on or after January 
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1 2005 and before the month of the enact2 ment of this Act, no increase in the pre3 mium shall be effected for a month in the 

4 case of any individual who is a covered 

5 beneficiary (as defined in section 1072(5) 

6 of title 10, United States Code) at the time 

7 the individual is entitled to hospital insur8 ance benefits under part A of title XVIII 

9 of the Social Security Act under section 

10 226(b) or 226A of such Act, and who is el11 igible to enroll, but who has elected not to 

12 enroll (or to be deemed enrolled), during 

13 the individual’s initial enrollment period, 

14 and who enrolls under this part within the 

15 12-month period that begins on the first 

16 day of the month after the month of notifi17 cation of entitlement under this part. 

18 (ii) CONSULTATION WITH DEPART19 MENT OF DEFENSE.—The Secretary of 

20 Health and Human Services shall consult 

21 with the Secretary of Defense in identi22 fying individuals described in this para23 graph. 

24 (iii) REBATES.—The Secretary of 

25 Health and Human Services shall establish 
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1 a method for providing rebates of premium 

2 increases paid for months on or after Jan3 uary 1, 2005, and before the month of the 

4 enactment of this Act for which a penalty 

5 was applied and collected. 

6 SEC. 1235. EXCEPTION FOR USE OF MORE RECENT TAX 

7 YEAR IN CASE OF GAINS FROM SALE OF PRI8 MARY RESIDENCE IN COMPUTING PART B IN9 COME-RELATED PREMIUM. 

10 (a) IN GENERAL.—Section 1839(i)(4)(C)(ii)(II) of 

11 the Social Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) 

12 is amended by inserting ‘‘sale of primary residence,’’ after 

13 ‘‘divorce of such individual,’’. 

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

15 subsection (a) shall apply to premiums and payments for 

16 years beginning with 2011. 

17 SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PA18 TIENT DECISIONS AIDS. 

19 (a) IN GENERAL.—The Secretary of Health and 

20 Human Services, acting through the Center for Medicare 

21 and Medicaid Innovation established under section 1115A 

22 of the Social Security Act (as added by section 1907) and 

23 consistent with the applicable provisions of such section, 

24 shall establish a shared decision making demonstration 

25 program (in this subsection referred to as the ‘‘program’’) 
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1 under the Medicare program using patient decision aids 

2 to meet the objective of improving the understanding by 

3 Medicare beneficiaries of their medical treatment options, 

4 as compared to comparable Medicare beneficiaries who do 

5 not participate in a shared decision making process using 

6 patient decision aids. 

7 (b) SITES.— 

8 (1) ENROLLMENT.—The Secretary shall enroll 

9 in the program not more than 30 eligible providers 

10 who have experience in implementing, and have in11 vested in the necessary infrastructure to implement, 

12 shared decision making using patient decision aids. 

13 (2) APPLICATION.—An eligible provider seeking 

14 to participate in the program shall submit to the 

15 Secretary an application at such time and containing 

16 such information as the Secretary may require. 

17 (3) PREFERENCE.—In enrolling eligible pro18 viders in the program, the Secretary shall give pref19 erence to eligible providers that— 

20 (A) have documented experience in using 

21 patient decision aids for the conditions identi22 fied by the Secretary and in using shared deci23 sion making; 

24 (B) have the necessary information tech25 nology infrastructure to collect the information 
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1 required by the Secretary for reporting pur2 poses; and 

3 (C) are trained in how to use patient deci4 sion aids and shared decision making. 

5 (c) FOLLOW-UP COUNSELING VISIT.— 

6 (1) IN GENERAL.—An eligible provider partici7 pating in the program shall routinely schedule Medi8 care beneficiaries for a counseling visit after the 

9 viewing of such a patient decision aid to answer any 

10 questions the beneficiary may have with respect to 

11 the medical care of the condition involved and to as12 sist the beneficiary in thinking through how their 

13 preferences and concerns relate to their medical 

14 care. 

15 (2) PAYMENT FOR FOLLOW-UP COUNSELING

16 VISIT.—The Secretary shall establish procedures for 

17 making payments for such counseling visits provided 

18 to Medicare beneficiaries under the program. Such 

19 procedures shall provide for the establishment— 

20 (A) of a code (or codes) to represent such 

21 services; and 

22 (B) of a single payment amount for such 

23 service that includes the professional time of 

24 the health care provider and a portion of the 

25 reasonable costs of the infrastructure of the eli-
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1 gible provider such as would be made under the 

2 applicable payment systems to that provider for 

3 similar covered services. 

4 (d) COSTS OF AIDS.—An eligible provider partici5 pating in the program shall be responsible for the costs 

6 of selecting, purchasing, and incorporating such patient 

7 decision aids into the provider’s practice, and reporting 

8 data on quality and outcome measures under the program. 

9 (e) FUNDING.—The Secretary shall provide for the 

10 transfer from the Federal Supplementary Medical Insur11 ance Trust Fund established under section 1841 of the 

12 Social Security Act (42 U.S.C. 1395t) of such funds as 

13 are necessary for the costs of carrying out the program. 

14 (f) WAIVER AUTHORITY.—The Secretary may waive 

15 such requirements of titles XI and XVIII of the Social 

16 Security Act (42 U.S.C. 1301 et seq. and 1395 et seq.) 

17 as may be necessary for the purpose of carrying out the 

18 program. 

19 (g) REPORT.—Not later than 12 months after the 

20 date of completion of the program, the Secretary shall sub21 mit to Congress a report on such program, together with 

22 recommendations for such legislation and administrative 

23 action as the Secretary determines to be appropriate. The 

24 final report shall include an evaluation of the impact of 

25 the use of the program on health quality, utilization of 
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1 health care services, and on improving the quality of life 

2 of such beneficiaries. 

3 (h) DEFINITIONS.—In this section: 

4 (1) ELIGIBLE PROVIDER.—The term ‘‘eligible 

5 provider’’ means the following: 

6 (A) A primary care practice. 

7 (B) A specialty practice. 

8 (C) A multispecialty group practice. 

9 (D) A hospital. 

10 (E) A rural health clinic. 

11 (F) A Federally qualified health center (as 

12 defined in section 1861(aa)(4) of the Social Se13 curity Act (42 U.S.C. 1395x(aa)(4)). 

14 (G) An integrated delivery system. 

15 (H) A State cooperative entity that in16 cludes the State government and at least one 

17 other health care provider which is set up for 

18 the purpose of testing shared decision making 

19 and patient decision aids. 

20 (2) PATIENT DECISION AID.—The term ‘‘pa21 tient decision aid’’ means an educational tool (such 

22 as the Internet, a video, or a pamphlet) that helps 

23 patients (or, if appropriate, the family caregiver of 

24 the patient) understand and communicate their be25 liefs and preferences related to their treatment op-
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1 tions, and to decide with their health care provider 

2 what treatments are best for them based on their 

3 treatment options, scientific evidence, circumstances, 

4 beliefs, and preferences. 

5 (3) SHARED DECISION MAKING.—The term 

6 ‘‘shared decision making’’ means a collaborative 

7 process between patient and clinician that engages 

8 the patient in decision making, provides patients 

9 with information about trade-offs among treatment 

10 options, and facilitates the incorporation of patient 

11 preferences and values into the medical plan. 

12 TITLE III—PROMOTING PRI13 MARY CARE, MENTAL 

14 HEALTH SERVICES, AND CO15 ORDINATED CARE 

16 SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT 

17 PROGRAM. 

18 Title XVIII of the Social Security Act is amended by 

19 inserting after section 1866D, as added by section 

20 1152(f), the following new section: 

21 ‘‘ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM

22 ‘‘SEC. 1866E. (a) ESTABLISHMENT.— 

23 ‘‘(1) IN GENERAL.— The Secretary shall conduct a 

24 pilot program (in this section referred to as the ‘pilot pro25 gram’) to test different payment incentive models, includ26 ing (to the extent practicable) the specific payment incen-
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1 tive models described in subsection (c), designed to reduce 

2 the growth of expenditures and improve health outcomes 

3 in the provision of items and services under this title to 

4 applicable beneficiaries (as defined in subsection (e)) by 

5 qualifying accountable care organizations (as defined in 

6 subsection (b)(1)) in order to— 

7 ‘‘(A) promote accountability for a patient popu8 lation and coordinate items and services under parts 

9 A and B (and may include Part D, if the Secretary 

10 determines appropriate); 

11 ‘‘(B) encourage investment in infrastructure 

12 and redesigned care processes for high quality and 

13 efficient service delivery; and 

14 ‘‘(C) reward physician practices and other phy15 sician organizational models for the provision of high 

16 quality and efficient health care services. 

17 ‘‘(2) SCOPE.—The Secretary shall set specific goals 

18 for the number of accountable care organizations, partici19 pating practitioners, and patients served in the initial tests 

20 under the pilot program to ensure that the pilot program 

21 is of sufficient size and scope to— 

22 ‘‘(A) test the approach involved in a variety of 

23 settings, including urban, rural, and underserved 

24 areas; and 
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1 ‘‘(B) subject to subsection (g)(1), disseminate 

2 such approach rapidly on a national basis. 

3 To the extent that the Secretary finds a qualifying ac4 countable care organization model to be successful in im5 proving quality and reducing costs, the Secretary shall 

6 seek to implement such models on as large a geographic 

7 scale as practical and economical. 

8 ‘‘(b) QUALIFYING ACCOUNTABLE CARE ORGANIZA9 TIONS (ACOS).— 

10 ‘‘(1) QUALIFYING ACO DEFINED.—In this sec11 tion: 

12 ‘‘(A) IN GENERAL.—The terms ‘qualifying 

13 accountable care organization’ and ‘qualifying 

14 ACO’ mean a group of physicians or other phy15 sician organizational model (as defined in sub16 paragraph (D)) that— 

17 ‘‘(i) is organized at least in part for 

18 the purpose of providing physicians’ serv19 ices; and 

20 ‘‘(ii) meets such criteria as the Sec21 retary determines to be appropriate to par22 ticipate in the pilot program, including the 

23 criteria specified in paragraph (2). 

24 ‘‘(B) INCLUSION OF OTHER PROVIDERS OF

25 SERVICES AND SUPPLIERS.—Nothing in this 
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1 subsection shall be construed as preventing a 

2 qualifying ACO from including a hospital or 

3 any other provider of services or supplier fur4 nishing items or services for which payment 

5 may be made under this title that is affiliated 

6 with the ACO under an arrangement structured 

7 so that such provider or supplier participates in 

8 the pilot program and shares in any incentive 

9 payments under the pilot program. 

10 ‘‘(C) PHYSICIAN.—The term ‘physician’ in11 cludes, except as the Secretary may otherwise 

12 provide, any individual who furnishes services 

13 for which payment may be made as physicians’ 

14 services under this title. 

15 ‘‘(D) OTHER PHYSICIAN ORGANIZATIONAL

16 MODEL.—The term ‘other physician organiza17 tion model’ means, with respect to a qualifying 

18 ACO any model of organization under which 

19 physicians enter into agreements with other 

20 providers of services for the purposes of partici21 pation in the pilot program in order to provide 

22 high quality and efficient health care services 

23 and share in any incentive payments under such 

24 program. 
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1 ‘‘(E) OTHER SERVICES.—Nothing in this 

2 paragraph shall be construed as preventing a 

3 qualifying ACO from furnishing items or serv4 ices, for which payment may not be made under 

5 this title, for purposes of achieving performance 

6 goals under the pilot program. 

7 ‘‘(2) QUALIFYING CRITERIA.—The following are 

8 criteria described in this paragraph for an organized 

9 group of physicians to be a qualifying ACO: 

10 ‘‘(A) The group has a legal structure that 

11 would allow the group to receive and distribute 

12 incentive payments under this section. 

13 ‘‘(B) The group includes a sufficient num14 ber of primary care physicians (regardless of 

15 specialty) for the applicable beneficiaries for 

16 whose care the group is accountable (as deter17 mined by the Secretary). 

18 ‘‘(C) The group reports on quality meas19 ures in such form, manner, and frequency as 

20 specified by the Secretary (which may be for 

21 the group, for providers of services and sup22 pliers, or both). 

23 ‘‘(D) The group reports to the Secretary 

24 (in a form, manner and frequency as specified 

25 by the Secretary) such data as the Secretary 
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1 determines appropriate to monitor and evaluate 

2 the pilot program. 

3 ‘‘(E) The group provides notice to applica4 ble beneficiaries regarding the pilot program (as 

5 determined appropriate by the Secretary). 

6 ‘‘(F) The group contributes to a best prac7 tices network or website, that shall be main8 tained by the Secretary for the purpose of shar9 ing strategies on quality improvement, care co10 ordination, and efficiency that the groups be11 lieve are effective. 

12 ‘‘(G) The group utilizes patient-centered 

13 processes of care, including those that empha14 size patient and caregiver involvement in plan15 ning and monitoring of ongoing care manage16 ment plan. 

17 ‘‘(H) The group meets other criteria deter18 mined to be appropriate by the Secretary. 

19 ‘‘(c) SPECIFIC PAYMENT INCENTIVE MODELS.—The 

20 specific payment incentive models described in this sub21 section are the following: 

22 ‘‘(1) PERFORMANCE TARGET MODEL.—Under 

23 the performance target model under this paragraph 

24 (in this paragraph referred to as the ‘performance 

25 target model’): 
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1 ‘‘(A) IN GENERAL.—A qualifying ACO 

2 qualifies to receive an incentive payment if ex3 penditures for items and services for applicable 

4 beneficiaries are less than a target spending 

5 level or a target rate of growth. The incentive 

6 payment shall be made only if savings are 

7 greater than would result from normal variation 

8 in expenditures for items and services covered 

9 under parts A and B (and may include Part D, 

10 if the Secretary determines appropriate). 

11 ‘‘(B) COMPUTATION OF PERFORMANCE

12 TARGET.— 

13 ‘‘(i) IN GENERAL.—The Secretary 

14 shall establish a performance target for 

15 each qualifying ACO comprised of a base 

16 amount (described in clause (ii)) increased 

17 to the current year by an adjustment fac18 tor (described in clause (iii)). Such a tar19 get may be established on a per capita 

20 basis or adjusted for risk, as the Secretary 

21 determines to be appropriate. 

22 ‘‘(ii) BASE AMOUNT.—For purposes of 

23 clause (i), the base amount in this sub24 paragraph is equal to the average total 

25 payments (or allowed charges) under parts 
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1 A and B (and may include part D, if the 

2 Secretary determines appropriate) for ap3 plicable beneficiaries for whom the quali4 fying ACO furnishes items and services in 

5 a base period determined by the Secretary. 

6 Such base amount may be determined on 

7 a per capita basis or adjusted for risk. 

8 ‘‘(iii) ADJUSTMENT FACTOR.—For 

9 purposes of clause (i), the adjustment fac10 tor in this clause may equal an annual per 

11 capita amount that reflects changes in ex12 penditures from the period of the base 

13 amount to the current year that would rep14 resent an appropriate performance target 

15 for applicable beneficiaries (as determined 

16 by the Secretary). 

17 ‘‘(iv) REBASING.—Under this model 

18 the Secretary shall periodically rebase the 

19 base expenditure amount described in 

20 clause (ii). 

21 ‘‘(C) MEETING TARGET.— 

22 ‘‘(i) IN GENERAL.—Subject to clause 

23 (ii), a qualifying ACO that meets or ex24 ceeds annual quality and performance tar25 gets for a year shall receive an incentive 
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1 payment for such year equal to a portion 

2 (as determined appropriate by the Sec3 retary) of the amount by which payments 

4 under this title for such year are estimated 

5 to be below the performance target for 

6 such year, as determined by the Secretary. 

7 The Secretary may establish a cap on in8 centive payments for a year for a quali9 fying ACO. 

10 ‘‘(ii) LIMITATION.— The Secretary 

11 shall limit incentive payments to each 

12 qualifying ACO under this paragraph as 

13 necessary to ensure that the aggregate ex14 penditures with respect to applicable bene15 ficiaries for such ACOs under this title (in16 clusive of incentive payments described in 

17 this subparagraph) do not exceed the 

18 amount that the Secretary estimates would 

19 be expended for such ACO for such bene20 ficiaries if the pilot program under this 

21 section were not implemented. 

22 ‘‘(D) REPORTING AND OTHER REQUIRE23 MENTS.—In carrying out such model, the Sec24 retary may (as the Secretary determines to be 

25 appropriate) incorporate reporting require-
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1 ments, incentive payments, and penalties re2 lated to the physician quality reporting initia3 tive (PQRI), electronic prescribing, electronic 

4 health records, and other similar initiatives 

5 under section 1848, and may use alternative 

6 criteria than would otherwise apply under such 

7 section for determining whether to make such 

8 payments. The incentive payments described in 

9 this subparagraph shall not be included in the 

10 limit described in subparagraph (C)(ii) or in the 

11 performance target model described in this 

12 paragraph. 

13 ‘‘(2) PARTIAL CAPITATION MODEL.— 

14 ‘‘(A) IN GENERAL.—Subject to subpara15 graph (B), a partial capitation model described 

16 in this paragraph (in this paragraph referred to 

17 as a ‘partial capitation model’) is a model in 

18 which a qualifying ACO would be at financial 

19 risk for some, but not all, of the items and serv20 ices covered under parts A and B (and may in21 clude part D, if the Secretary determines ap22 propriate), such as at risk for some or all physi23 cians’ services or all items and services under 

24 part B. The Secretary may limit a partial capi25 tation model to ACOs that are highly integrated 
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1 systems of care and to ACOs capable of bearing 

2 risk, as determined to be appropriate by the 

3 Secretary. 

4 ‘‘(B) NO ADDITIONAL PROGRAM EXPENDI5 TURES.—Payments to a qualifying ACO for 

6 items and services under this title for applicable 

7 beneficiaries for a year under the partial capita8 tion model shall be established in a manner that 

9 does not result in spending more for such ACO 

10 for such beneficiaries than would otherwise be 

11 expended for such ACO for such beneficiaries 

12 for such year if the pilot program were not im13 plemented, as estimated by the Secretary. 

14 ‘‘(3) OTHER PAYMENT MODELS.— 

15 ‘‘(A) IN GENERAL.—Subject to subpara16 graph (B), the Secretary may develop other 

17 payment models that meet the goals of this 

18 pilot program to improve quality and efficiency. 

19 ‘‘(B) NO ADDITIONAL PROGRAM EXPENDI20 TURES.—Subparagraph (B) of paragraph (2) 

21 shall apply to a payment model under subpara22 graph (A) in a similar manner as such subpara23 graph (B) applies to the payment model under 

24 paragraph (2). 

25 ‘‘(d) ANNUAL QUALITY TARGETS.— 
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1 ‘‘(1) IN GENERAL.—The Secretary shall estab2 lish annual quality targets that qualifying ACOs 

3 must meet to receive incentive payments, operate at 

4 financial risk, or otherwise participate in alternative 

5 financing models under this section. The Secretary 

6 shall establish a process for developing annual tar7 gets based on ACO reporting of multiple quality 

8 measures. In selecting measures the Secretary 

9 shall— 

10 ‘‘(A) for years one and two of each ACOs 

11 participation in the pilot program established 

12 by this section, require reporting of a starter 

13 set of measures focused on clinical care, care 

14 coordination and patient experience of care; and 

15 ‘‘(B) for each subsequent year, require re16 porting of a more comprehensive set of clinical 

17 outcomes measures, care coordination measures 

18 and patient experience of care measures. 

19 ‘‘(2) MEASURE SELECTION.—To the extent fea20 sible, the Secretary shall select measures that reflect 

21 national priorities for quality improvement and pa22 tient-centered care consistent with the measures de23 veloped under section 1192(c)(1). 

24 ‘‘(e) APPLICABLE BENEFICIARIES.— 
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1 ‘‘(1) IN GENERAL.—In this section, the term 

2 ‘applicable beneficiary’ means, with respect to a 

3 qualifying ACO, an individual who— 

4 ‘‘(A) is enrolled under part B and entitled 

5 to benefits under part A; 

6 ‘‘(B) is not enrolled in a Medicare Advan7 tage plan under part C or a PACE program 

8 under section 1894; and 

9 ‘‘(C) meets such other criteria as the Sec10 retary determines appropriate, which may in11 clude criteria relating to frequency of contact 

12 with physicians in the ACO 

13 ‘‘(2) FOLLOWING APPLICABLE BENE14 FICIARIES.—The Secretary may monitor data on ex15 penditures and quality of services under this title 

16 after an applicable beneficiary discontinues receiving 

17 services under this title through a qualifying ACO. 

18 ‘‘(f) IMPLEMENTATION.— 

19 ‘‘(1) STARTING DATE.—The pilot program shall 

20 begin no later than January 1, 2012. An agreement 

21 with a qualifying ACO under the pilot program may 

22 cover a multi-year period of between 3 and 5 years. 

23 ‘‘(2) WAIVER.—The Secretary may waive such 

24 provisions of this title (including section 1877) and 
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1 title XI in the manner the Secretary determines nec2 essary in order implement the pilot program. 

3 ‘‘(3) PERFORMANCE RESULTS REPORTS.—The 

4 Secretary shall report performance results to quali5 fying ACOs under the pilot program at least annu6 ally. 

7 ‘‘(4) LIMITATIONS ON REVIEW.—There shall be 

8 no administrative or judicial review under section 

9 1869, section 1878, or otherwise of— 

10 ‘‘(A) the elements, parameters, scope, and 

11 duration of the pilot program; 

12 ‘‘(B) the selection of qualifying ACOs for 

13 the pilot program; 

14 ‘‘(C) the establishment of targets, meas15 urement of performance, determinations with 

16 respect to whether savings have been achieved 

17 and the amount of savings; 

18 ‘‘(D) determinations regarding whether, to 

19 whom, and in what amounts incentive payments 

20 are paid; and 

21 ‘‘(E) decisions about the extension of the 

22 program under subsection (h), expansion of the 

23 program under subsection (i) or extensions 

24 under subsection (j) or (k). 
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1 ‘‘(5) ADMINISTRATION.—Chapter 35 of title 44, 

2 United States Code, shall not apply to this section. 

3 ‘‘(g) EVALUATION; MONITORING.— 

4 ‘‘(1) IN GENERAL.—The Secretary shall evalu5 ate the payment incentive model for each qualifying 

6 ACO under the pilot program to assess impacts on 

7 beneficiaries, providers of services, suppliers and the 

8 program under this title. The Secretary shall make 

9 such evaluation publicly available within 60 days of 

10 the date of completion of such report. 

11 ‘‘(2) MONITORING.—The Inspector General of 

12 the Department of Health and Human Services shall 

13 provide for monitoring of the operation of ACOs 

14 under the pilot program with regard to violations of 

15 section 1877 (popularly known as the ‘Stark law’). 

16 ‘‘(h) EXTENSION OF PILOT AGREEMENT WITH SUC17 CESSFUL ORGANIZATIONS.— 

18 ‘‘(1) REPORTS TO CONGRESS.—Not later than 

19 2 years after the date the first agreement is entered 

20 into under this section, and biennially thereafter for 

21 six years, the Secretary shall submit to Congress 

22 and make publicly available a report on the use of 

23 ACO payment models under the pilot program. Each 

24 report shall address the impact of the use of those 
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1 models on expenditures, access, and quality under 

2 this title. 

3 ‘‘(2) EXTENSION.—Subject to the report pro4 vided under paragraph (1), with respect to a quali5 fying ACO, the Secretary may extend the duration 

6 of the agreement for such ACO under the pilot pro7 gram as the Secretary determines appropriate if— 

8 ‘‘(A) the ACO receives incentive payments 

9 with respect to any of the first 4 years of the 

10 pilot agreement and is consistently meeting 

11 quality standards or 

12 ‘‘(B) the ACO is consistently exceeding 

13 quality standards and is not increasing spend14 ing under the program. 

15 ‘‘(3) TERMINATION.—The Secretary may termi16 nate an agreement with a qualifying ACO under the 

17 pilot program if such ACO did not receive incentive 

18 payments or consistently failed to meet quality 

19 standards in any of the first 3 years under the pro20 gram. 

21 ‘‘(i) EXPANSION TO ADDITIONAL ACOS.— 

22 ‘‘(1) TESTING AND REFINEMENT OF PAYMENT

23 INCENTIVE MODELS.—Subject to the evaluation de24 scribed in subsection (g), the Secretary may enter 

25 into agreements under the pilot program with addi-
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1 tional qualifying ACOs to further test and refine 

2 payment incentive models with respect to qualifying 

3 ACOs. 

4 ‘‘(2) EXPANDING USE OF SUCCESSFUL MODELS

5 TO PROGRAM IMPLEMENTATION.— 

6 ‘‘(A) IN GENERAL.—Subject to subpara7 graph (B), the Secretary may issue regulations 

8 to implement, on a permanent basis, 1 or more 

9 models if, and to the extent that, such models 

10 are beneficial to the program under this title, as 

11 determined by the Secretary. 

12 ‘‘(B) CERTIFICATION.—The Chief Actuary 

13 of the Centers for Medicare & Medicaid Serv14 ices shall certify that 1 or more of such models 

15 described in subparagraph (A) would result in 

16 estimated spending that would be less than 

17 what spending would otherwise be estimated to 

18 be in the absence of such expansion. 

19 ‘‘(j) TREATMENT OF PHYSICIAN GROUP PRACTICE

20 DEMONSTRATION.— 

21 ‘‘(1) EXTENSION.—The Secretary may enter in 

22 to an agreement with a qualifying ACO under the 

23 demonstration under section 1866A, subject to re24 basing and other modifications deemed appropriate 
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1 by the Secretary, until the pilot program under this 

2 section is operational. 

3 ‘‘(2) TRANSITION.—For purposes of extension 

4 of an agreement with a qualifying ACO under sub5 section (h)(2), the Secretary shall treat receipt of an 

6 incentive payment for a year by an organization 

7 under the physician group practice demonstration 

8 pursuant to section 1866A as a year for which an 

9 incentive payment is made under such subsection, as 

10 long as such practice group practice organization 

11 meets the criteria under subsection (b)(2). 

12 ‘‘(k) ADDITIONAL PROVISIONS.— 

13 ‘‘(1) AUTHORITY FOR SEPARATE INCENTIVE

14 ARRANGEMENTS.—The Secretary may create sepa15 rate incentive arrangements (including using mul16 tiple years of data, varying thresholds, varying 

17 shared savings amounts, and varying shared savings 

18 limits) for different categories of qualifying ACOs to 

19 reflect variation in average annual attributable ex20 penditures and other matters the Secretary deems 

21 appropriate. 

22 ‘‘(2) ENCOURAGEMENT OF PARTICIPATION OF

23 SMALLER ORGANIZATIONS.—In order to encourage 

24 the participation of smaller accountable care organi25 zations under the pilot program, the Secretary may 
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1 limit a qualifying ACO’s exposure to high cost pa2 tients under the program. 

3 ‘‘(3) INVOLVEMENT IN PRIVATE PAYER AND

4 OTHER THIRD PARTY ARRANGEMENTS.—The Sec5 retary may give preference to ACOs who are partici6 pating in similar arrangements with other payers. 

7 ‘‘(4) ANTIDISCRIMINATION LIMITATION.—The 

8 Secretary shall not enter into an agreement with an 

9 entity to provide health care items or services under 

10 the pilot program, or with an entity to administer 

11 the program, unless such entity guarantees that it 

12 will not deny, limit, or condition the coverage or pro13 vision of benefits under the program, for individuals 

14 eligible to be enrolled under such program, based on 

15 any health status-related factor described in section 

16 2702(a)(1) of the Public Health Service Act. 

17 ‘‘(5) FUNDING.—For purposes of administering 

18 and carrying out the pilot program, other than for 

19 payments for items and services furnished under this 

20 title and incentive payments under subsection (c)(1), 

21 in addition to funds otherwise appropriated, there 

22 are appropriated to the Secretary for the Center for 

23 Medicare & Medicaid Services Program Management 

24 Account $25,000,000 for each of fiscal years 2010 

25 through 2014 and $20,000,000 for fiscal year 2015. 
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1 Amounts appropriated under this paragraph for a 

2 fiscal year shall be available until expended. 

3 ‘‘(6) NO DUPLICATION IN PAYMENTS TO PHYSI4 CIANS IN MULTIPLE PILOTS.—The Secretary shall 

5 not make payments under this section to any physi6 cian group that is paid under section 1866F (relat7 ing to medical homes) or section 1866G (relating to 

8 independence at home).’’. 

9 SEC. 1302. MEDICAL HOME PILOT PROGRAM. 

10 (a) IN GENERAL.—Title XVIII of the Social Security 

11 Act is amended by inserting after section 1866E, as in12 serted by section 1301, the following new section: 

13 ‘‘MEDICAL HOME PILOT PROGRAM

14 ‘‘SEC. 1866F. (a) ESTABLISHMENT AND MEDICAL

15 HOME MODELS.— 

16 ‘‘(1) ESTABLISHMENT OF PILOT PROGRAM.— 

17 The Secretary shall establish a medical home pilot 

18 program (in this section referred to as the ‘pilot pro19 gram’) for the purpose of evaluating the feasibility 

20 and advisability of reimbursing qualified patient-cen21 tered medical homes for furnishing medical home 

22 services (as defined under subsection (b)(1)) to 

23 beneficiaries (as defined in subsection (b)(4)) and to 

24 targeted high need beneficiaries (as defined in sub25 section (c)(1)(C)). 
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1 ‘‘(2) SCOPE.—Subject to subsection (g), the 

2 Secretary shall set specific goals for the number of 

3 practices and communities, and the number of pa4 tients served, under the pilot program in the initial 

5 tests to ensure that the pilot program is of sufficient 

6 size and scope to— 

7 ‘‘(A) test the approach involved in a vari8 ety of settings, including urban, rural, and un9 derserved areas; and 

10 ‘‘(B) subject to subsection (e)(1), dissemi11 nate such approach rapidly on a national basis. 

12 To the extent that the Secretary finds a medical 

13 home model to be successful in improving quality 

14 and reducing costs, the Secretary shall implement 

15 such model on as large a geographic scale as prac16 tical and economical. 

17 ‘‘(3) MODELS OF MEDICAL HOMES IN THE

18 PILOT PROGRAM.—The pilot program shall evaluate 

19 each of the following medical home models: 

20 ‘‘(A) INDEPENDENT PATIENT-CENTERED

21 MEDICAL HOME MODEL.—Independent patient22 centered medical home model under subsection 

23 (c). 
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1 ‘‘(B) COMMUNITY-BASED MEDICAL HOME

2 MODEL.—Community-based medical home 

3 model under subsection (d). 

4 ‘‘(4) PARTICIPATION OF NURSE PRACTITIONERS

5 AND PHYSICIAN ASSISTANTS.— 

6 ‘‘(A) Nothing in this section shall be con7 strued as preventing a nurse practitioner from 

8 leading a patient centered medical home so long 

9 as— 

10 ‘‘(i) all the requirements of this sec11 tion are met; and 

12 ‘‘(ii) the nurse practitioner is acting 

13 in a manner that is consistent with State 

14 law. 

15 ‘‘(B) Nothing in this section shall be con16 strued as preventing a physician assistant from 

17 participating in a patient centered medical 

18 home so long as— 

19 ‘‘(i) all the requirements of this sec20 tion are met; and 

21 ‘‘(ii) the physician assistant is acting 

22 in a manner that is consistent with State 

23 law. 

24 ‘‘(b) DEFINITIONS.—For purposes of this section: 
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1 ‘‘(1) PATIENT-CENTERED MEDICAL HOME

2 SERVICES.—The term ‘patient-centered medical 

3 home services’ means services that— 

4 ‘‘(A) provide beneficiaries with direct and 

5 ongoing access to a primary care or principal 

6 care physician or nurse practitioner who accepts 

7 responsibility for providing first contact, contin8 uous and comprehensive care to such bene9 ficiary; 

10 ‘‘(B) coordinate the care provided to a ben11 eficiary by a team of individuals at the practice 

12 level across office, provider of services, and 

13 home settings led by a primary care or principal 

14 care physician or nurse practitioner, as needed 

15 and appropriate; 

16 ‘‘(C) provide for all the patient’s health 

17 care needs or take responsibility for appro18 priately arranging care with other qualified 

19 physicians or providers for all stages of life; 

20 ‘‘(D) provide continuous access to care and 

21 communication with participating beneficiaries; 

22 ‘‘(E) provide support for patient self-man23 agement, proactive and regular patient moni24 toring, support for family caregivers, use pa-
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1 tient-centered processes, and coordination with 

2 community resources; 

3 ‘‘(F) integrate readily accessible, clinically 

4 useful information on participating patients 

5 that enables the practice to treat such patients 

6 comprehensively and systematically; and 

7 ‘‘(G) implement evidence-based guidelines 

8 and apply such guidelines to the identified 

9 needs of beneficiaries over time and with the in10 tensity needed by such beneficiaries. 

11 ‘‘(2) PRIMARY CARE.—The term ‘primary care’ 

12 means health care that is provided by a physician, 

13 nurse practitioner, or physician assistant who prac14 tices in the field of family medicine, general internal 

15 medicine, geriatric medicine, or pediatric medicine. 

16 ‘‘(3) PRINCIPAL CARE.—The term ‘principal 

17 care’ means integrated, accessible health care that is 

18 provided by a physician who is a medical specialist 

19 or subspecialist that addresses the majority of the 

20 personal health care needs of patients with chronic 

21 conditions requiring the specialist’s or subspecialist’s 

22 expertise, and for whom the specialist or sub23 specialist assumes care management. 
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1 ‘‘(4) BENEFICIARIES.—The term ‘beneficiaries’ 

2 means, with respect to a qualifying medical home, 

3 an individual who— 

4 ‘‘(A) is enrolled under part B and entitled 

5 to benefits under part A; 

6 ‘‘(B) is not enrolled in a Medicare Advan7 tage plan under part C or a PACE program 

8 under section 1894; and 

9 ‘‘(C) meets such other criteria as the Sec10 retary determines appropriate. 

11 ‘‘(c) INDEPENDENT PATIENT-CENTERED MEDICAL

12 HOME MODEL.— 

13 ‘‘(1) IN GENERAL.— 

14 ‘‘(A) PAYMENT AUTHORITY.—Under the 

15 independent patient-centered medical home 

16 model under this subsection, the Secretary shall 

17 make payments for medical home services fur18 nished by an independent patient-centered med19 ical home (as defined in subparagraph (B)) 

20 pursuant to paragraph (3) for targeted high 

21 need beneficiaries (as defined in subparagraph 

22 (C)). 

23 ‘‘(B) INDEPENDENT PATIENT-CENTERED

24 MEDICAL HOME DEFINED.—In this section, the 

25 term ‘independent patient-centered medical 
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1 home’ means a physician-directed or nurse2 practitioner-directed practice that is qualified 

3 under paragraph (2) as— 

4 ‘‘(i) providing beneficiaries with pa5 tient-centered medical home services; and 

6 ‘‘(ii) meets such other requirements as 

7 the Secretary may specify. 

8 ‘‘(C) TARGETED HIGH NEED BENEFICIARY

9 DEFINED.—For purposes of this subsection, the 

10 term ‘targeted high need beneficiary’ means a 

11 beneficiary who, based on a risk score as speci12 fied by the Secretary, is generally within the 

13 upper 50th percentile of Medicare beneficiaries. 

14 ‘‘(D) BENEFICIARY ELECTION TO PARTICI15 PATE.—The Secretary shall determine an ap16 propriate method of ensuring that beneficiaries 

17 have agreed to participate in the pilot program. 

18 ‘‘(E) IMPLEMENTATION.—The pilot pro19 gram under this subsection shall begin no later 

20 than 12 months after the date of the enactment 

21 of this section and shall operate for 5 years. 

22 ‘‘(2) QUALIFICATION PROCESS FOR PATIENT23 CENTERED MEDICAL HOMES.—The Secretary shall 

24 establish a process for practices to qualify as med25 ical homes. 
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1 ‘‘(3) PAYMENT.— 

2 ‘‘(A) ESTABLISHMENT OF METHOD3 OLOGY.—The Secretary shall establish a meth4 odology for the payment for medical home serv5 ices furnished by independent patient-centered 

6 medical homes. Under such methodology, the 

7 Secretary shall adjust payments to medical 

8 homes based on beneficiary risk scores to en9 sure that higher payments are made for higher 

10 risk beneficiaries. 

11 ‘‘(B) PER BENEFICIARY PER MONTH PAY12 MENTS.—Under such payment methodology, the 

13 Secretary shall pay independent patient-cen14 tered medical homes a monthly fee for each tar15 geted high need beneficiary who consents to re16 ceive medical home services through such med17 ical home. 

18 ‘‘(C) PROSPECTIVE PAYMENT.—The fee 

19 under subparagraph (B) shall be paid on a pro20 spective basis. 

21 ‘‘(D) AMOUNT OF PAYMENT.—In deter22 mining the amount of such fee, the Secretary 

23 shall consider the following: 

24 ‘‘(i) The clinical work and practice ex25 penses involved in providing the medical 
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1 home services provided by the independent 

2 patient-centered medical home (such as 

3 providing increased access, care coordina4 tion, population disease management, and 

5 teaching self-care skills for managing 

6 chronic illnesses) for which payment is not 

7 made under this title as of the date of the 

8 enactment of this section. 

9 ‘‘(ii) Allow for differential payments 

10 based on capabilities of the independent 

11 patient-centered medical home. 

12 ‘‘(iii) Use appropriate risk-adjustment 

13 in determining the amount of the per bene14 ficiary per month payment under this 

15 paragraph in a manner that ensures that 

16 higher payments are made for higher risk 

17 beneficiaries. 

18 ‘‘(4) ENCOURAGING PARTICIPATION OF VARI19 ETY OF PRACTICES.—The pilot program under this 

20 subsection shall be designed to include the participa21 tion of physicians in practices with fewer than 10 

22 full-time equivalent physicians, as well as physicians 

23 in larger practices, particularly in underserved and 

24 rural areas, as well as federally qualified health cen25 ters, and rural health centers. 
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1 ‘‘(d) COMMUNITY-BASED MEDICAL HOME MODEL.— 

2 ‘‘(1) IN GENERAL.— 

3 ‘‘(A) AUTHORITY FOR PAYMENTS.—Under 

4 the community-based medical home model 

5 under this subsection (in this section referred to 

6 as the ‘CBMH model’), the Secretary shall 

7 make payments for the furnishing of medical 

8 home services by a community-based medical 

9 home (as defined in subparagraph (B)) pursu10 ant to paragraph (5)(B) for beneficiaries. 

11 ‘‘(B) COMMUNITY-BASED MEDICAL HOME

12 DEFINED.—In this section, the term ‘commu13 nity-based medical home’ means a nonprofit 

14 community-based or State-based organization or 

15 a State that is certified under paragraph (2) as 

16 meeting the following requirements: 

17 ‘‘(i) The organization provides bene18 ficiaries with medical home services. 

19 ‘‘(ii) The organization provides med20 ical home services under the supervision of 

21 and in close collaboration with the primary 

22 care or principal care physician, nurse 

23 practitioner, or physician assistant des24 ignated by the beneficiary as his or her 

25 community-based medical home provider. 
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1 ‘‘(iii) The organization employs com2 munity health workers, including nurses or 

3 other non-physician practitioners, lay 

4 health workers, or other persons as deter5 mined appropriate by the Secretary, that 

6 assist the primary or principal care physi7 cian, nurse practitioner, or physician as8 sistant in chronic care management activi9 ties such as teaching self-care skills for 

10 managing chronic illnesses, transitional 

11 care services, care plan setting, nutritional 

12 counseling, medication therapy manage13 ment services for patients with multiple 

14 chronic diseases, or help beneficiaries ac15 cess the health care and community-based 

16 resources in their local geographic area. 

17 ‘‘(iv) The organization meets such 

18 other requirements as the Secretary may 

19 specify. 

20 ‘‘(2) QUALIFICATION PROCESS FOR COMMU21 NITY-BASED MEDICAL HOMES.—The Secretary shall 

22 establish a process to provide for the review and 

23 qualification of community-based medical homes 

24 pursuant to criteria established by the Secretary. 
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1 ‘‘(3) DURATION.—The pilot program for com2 munity-based medical homes under this subsection 

3 shall start no later than 2 years after the date of the 

4 enactment of this section. Each demonstration site 

5 under the pilot program shall operate for a period 

6 of up to 5 years after the initial implementation 

7 phase, without regard to the receipt of a initial im8 plementation funding under paragraph (6). 

9 ‘‘(4) PREFERENCE.—In selecting sites for the 

10 CBMH model, the Secretary shall give preference to 

11 applications which seek to eliminate health dispari12 ties, as defined in section 3171 of the Public Health 

13 Service Act and may give preference to any of the 

14 following: 

15 ‘‘(A) Applications that propose to coordi16 nate health care items and services under this 

17 title for chronically ill beneficiaries who rely, for 

18 primary care, on small physician or nurse prac19 titioner practices, federally qualified health cen20 ters, rural health clinics, or other settings with 

21 limited resources and scope of services. 

22 ‘‘(B) Applications that include other third23 party payors that furnish medical home services 

24 for chronically ill patients covered by such 

25 third-party payors. 
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1 ‘‘(C) Applications from States that propose 

2 to use the medical home model to coordinate 

3 health care services for— 

4 ‘‘(i) individuals enrolled under this 

5 title; 

6 ‘‘(ii) individuals enrolled under title 

7 XIX; and 

8 ‘‘(iii) full-benefit dual eligible individ9 uals (as defined in section 1935(c)(6)), 

10 with chronic diseases across a variety of health 

11 care settings. 

12 ‘‘(5) PAYMENTS.— 

13 ‘‘(A) ESTABLISHMENT OF METHOD14 OLOGY.—The Secretary shall establish a meth15 odology for the payment for medical home serv16 ices furnished under the CBMH model. 

17 ‘‘(B) PER BENEFICIARY PER MONTH PAY18 MENTS.—Under such payment methodology, the 

19 Secretary shall make two separate monthly pay20 ments for each beneficiary who consents to re21 ceive medical home services through such med22 ical home, as follows: 

23 ‘‘(i) PAYMENT TO COMMUNITY-BASED

24 ORGANIZATION.—One monthly payment to 
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1 a community-based or State-based organi2 zation or State. 

3 ‘‘(ii) PAYMENT TO PRIMARY OR PRIN4 CIPAL CARE PRACTICE.—One monthly pay5 ment to the primary or principal care prac6 tice for such beneficiary. 

7 ‘‘(C) PROSPECTIVE PAYMENT.—The pay8 ments under subparagraph (B) shall be paid on 

9 a prospective basis. 

10 ‘‘(D) AMOUNT OF PAYMENT.—In deter11 mining the amount of such payment under sub12 paragraph (B), the Secretary shall consider the 

13 following: 

14 ‘‘(i) The clinical work and practice ex15 penses involved in providing the medical 

16 home services provided by the primary or 

17 principal care practice (such as providing 

18 increased access, care coordination, care 

19 planning, population disease management, 

20 and teaching self-care skills for managing 

21 chronic illnesses) for which payment is not 

22 made under this title as of the date of the 

23 enactment of this section. 

24 ‘‘(ii) Use appropriate risk-adjustment 

25 in determining the amount of the per bene-
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1 ficiary per month payment under this 

2 paragraph. 

3 ‘‘(iii) In the case of the models de4 scribed in subparagraphs (B) and (C) of 

5 paragraph (4), the Secretary may deter6 mine an appropriate payment amount. 

7 ‘‘(6) INITIAL IMPLEMENTATION FUNDING.— 

8 The Secretary may make available initial implemen9 tation funding to a non-profit community based or 

10 State-based organization or a State that is partici11 pating in the pilot program under this subsection. 

12 Such organization shall provide the Secretary with a 

13 detailed implementation plan that includes how such 

14 funds will be used. The Secretary shall select a terri15 tory of the United States as one of the locations in 

16 which to implement the pilot program under this 

17 subsection, unless no organization in a territory is 

18 able to comply with the requirements under para19 graph (1)(B). 

20 ‘‘(e) EXPANSION OF PROGRAM.— 

21 ‘‘(1) EVALUATION OF COST AND QUALITY.— 

22 The Secretary shall evaluate the pilot program to 

23 determine— 

24 ‘‘(A) the extent to which medical homes re25 sult in— 
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1 ‘‘(i) improvement in the quality and 

2 coordination of items and services under 

3 this title, particularly with regard to the 

4 care of complex patients; 

5 ‘‘(ii) improvement in reducing health 

6 disparities; 

7 ‘‘(iii) reductions in preventable hos8 pitalizations; 

9 ‘‘(iv) prevention of readmissions; 

10 ‘‘(v) reductions in emergency room 

11 visits; 

12 ‘‘(vi) improvement in health outcomes, 

13 including patient functional status where 

14 applicable; 

15 ‘‘(vii) improvement in patient satisfac16 tion; 

17 ‘‘(viii) improved efficiency of care such 

18 as reducing duplicative diagnostic tests and 

19 laboratory tests; and 

20 ‘‘(ix) reductions in health care ex21 penditures; and 

22 ‘‘(B) the feasability and advisability of re23 imbursing medical homes for medical home 

24 services under this title on a permanent basis. 
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1 ‘‘(2) REPORT.—Not later than 60 days after 

2 the date of completion of the evaluation under para3 graph (1), the Secretary shall submit to Congress 

4 and make available to the public a report on the 

5 findings of the evaluation under paragraph (1) and 

6 the extent to which standards for the certification of 

7 medical homes need to be periodically updated. 

8 ‘‘(3) EXPANSION OF PROGRAM.— 

9 ‘‘(A) IN GENERAL.—Subject to the results 

10 of the evaluation under paragraph (1) and sub11 paragraph (B), the Secretary may issue regula12 tions to implement, on a permanent basis, one 

13 or more models, if, and to the extent that such 

14 model or models, are beneficial to the program 

15 under this title, including that such implemen16 tation will improve quality of care, as deter17 mined by the Secretary. 

18 ‘‘(B) CERTIFICATION REQUIREMENT.—The 

19 Secretary may not issue such regulations unless 

20 the Chief Actuary of the Centers for Medicare 

21 & Medicaid Services certifies that the expansion 

22 of the components of the pilot program de23 scribed in subparagraph (A) would result in es24 timated spending under this title that would be 

25 no more than the level of spending that the 
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1 Secretary estimates would otherwise be spent 

2 under this title in the absence of such expan3 sion. 

4 ‘‘(C) UPDATED STANDARDS.—The Sec5 retary shall periodically review and update the 

6 standards for qualification as an independent 

7 patient centered medical home and as a com8 munity based medical home and shall establish 

9 a process for ensuring that medical homes meet 

10 such updated standards, as applicable 

11 ‘‘(f) ADMINISTRATIVE PROVISIONS.— 

12 ‘‘(1) NO DUPLICATION IN PAYMENTS FOR INDI13 VIDUALS IN MEDICAL HOMES.—During any month, 

14 the Secretary may not make payments under this 

15 section under more than one model or through more 

16 than one medical home under any model for the fur17 nishing of medical home services to an individual. 

18 ‘‘(2) NO EFFECT ON PAYMENT FOR MEDICAL

19 VISITS.—Payments made under this section are in 

20 addition to, and have no effect on the amount of, 

21 payment for medical visits made under this title 

22 ‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, 

23 United States Code, shall not apply to this section. 

24 ‘‘(4) NO DUPLICATION IN PHYSICIAN PILOT

25 PARTICIPATION.—The Secretary shall not make pay-
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1 ments to an independent or community based med2 ical home both under this section and section 1866E 

3 or 1866G, unless the pilot program under this sec4 tion has been implemented on a permanent basis 

5 under subsection (e)(3). 

6 ‘‘(5) WAIVER.—The Secretary may waive such 

7 provisions of this title and title XI in the manner the 

8 Secretary determines necessary in order to imple9 ment this section. 

10 ‘‘(g) FUNDING.— 

11 ‘‘(1) OPERATIONAL COSTS.—For purposes of 

12 administering and carrying out the pilot program 

13 (including the design, implementation, technical as14 sistance for and evaluation of such program), in ad15 dition to funds otherwise available, there shall be 

16 transferred from the Federal Supplementary Medical 

17 Insurance Trust Fund under section 1841 to the 

18 Secretary for the Centers for Medicare & Medicaid 

19 Services Program Management Account $6,000,000 

20 for each of fiscal years 2010 through 2014. 

21 Amounts appropriated under this paragraph for a 

22 fiscal year shall be available until expended. 

23 ‘‘(2) PATIENT-CENTERED MEDICAL HOME

24 SERVICES.—In addition to funds otherwise available, 

25 there shall be available to the Secretary for the Cen-
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1 ters for Medicare & Medicaid Services, from the 

2 Federal Supplementary Medical Insurance Trust 

3 Fund under section 1841— 

4 ‘‘(A) $200,000,000 for each of fiscal years 

5 2010 through 2014 for payments for medical 

6 home services under subsection (c)(3); and 

7 ‘‘(B) $125,000,000 for each of fiscal years 

8 2012 through 2016, for payments under sub9 section (d)(5). 

10 Amounts available under this paragraph for a fiscal 

11 year shall be available until expended. 

12 ‘‘(3) INITIAL IMPLEMENTATION.—In addition 

13 to funds otherwise available, there shall be available 

14 to the Secretary for the Centers for Medicare & 

15 Medicaid Services, from the Federal Supplementary 

16 Medical Insurance Trust Fund under section 1841, 

17 $2,500,000 for each of fiscal years 2010 through 

18 2012, under subsection (d)(6). Amounts available 

19 under this paragraph for a fiscal year shall be avail20 able until expended. 

21 ‘‘(h) TREATMENT OF TRHCA MEDICARE MEDICAL

22 HOME DEMONSTRATION FUNDING.— 

23 ‘‘(1) In addition to funds otherwise available for 

24 payment of medical home services under subsection 

25 (c)(3), there shall also be available the amount pro-
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1 vided in subsection (g) of section 204 of division B 

2 of the Tax Relief and Health Care Act of 2006 (42 

3 U.S.C. 1395b–1 note), as added by section 133 of 

4 the Medicare Improvements for Patients and Pro5 viders Act of 2008 (Public Law 110–275). 

6 ‘‘(2) Notwithstanding section 1302(c) of the Af7 fordable Health Care for America Act, in addition to 

8 funds provided in paragraph (1) and subsection 

9 (g)(2)(A), the funding for medical home services 

10 that would otherwise have been available if such sec11 tion 204 medical home demonstration had been im12 plemented (without regard to subsection (g) of such 

13 section) shall be available to the independent pa14 tient-centered medical home model described in sub15 section (c).’’. 

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

17 this section shall apply to services furnished on or after 

18 the date of the enactment of this Act. 

19 (c) CONFORMING REPEAL.—Section 204 of division 

20 B of the Tax Relief and Health Care Act of 2006 (42 

21 U.S.C. 1395b–1 note), as amended by section 133(a)(2) 

22 of the Medicare Improvements for Patients and Providers 

23 Act of 2008 (Public Law 110–275), is repealed. 
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1 SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY 

2 CARE SERVICES. 

3 (a) IN GENERAL.—Section 1833 of the Social Secu4 rity Act is amended by inserting after subsection (o) the 

5 following new subsection: 

6 ‘‘(p) PRIMARY CARE PAYMENT INCENTIVES.— 

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

8 services (as defined in paragraph (2)) furnished on 

9 or after January 1, 2011, by a primary care practi10 tioner (as defined in paragraph (3)) for which 

11 amounts are payable under section 1848, in addition 

12 to the amount otherwise paid under this part there 

13 shall also be paid to the practitioner (or to an em14 ployer or facility in the cases described in clause (A) 

15 of section 1842(b)(6)) (on a monthly or quarterly 

16 basis) from the Federal Supplementary Medical In17 surance Trust Fund an amount equal 5 percent (or 

18 10 percent if the practitioner predominately fur19 nishes such services in an area that is designated 

20 (under section 332(a)(1)(A) of the Public Health 

21 Service Act) as a primary care health professional 

22 shortage area. 

23 ‘‘(2) PRIMARY CARE SERVICES DEFINED.—In 

24 this subsection, the term ‘primary care services’— 

25 ‘‘(A) mean evaluation and management 

26 services, without regard to the specialty of the 
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1 physician furnishing the services, that are pro2 cedure codes (for services covered under this 

3 title) for— 

4 ‘‘(i) services in the category des5 ignated Evaluation and Management in the 

6 Health Care Common Procedure Coding 

7 System (established by the Secretary under 

8 section 1848(c)(5) as of December 31, 

9 2009, and as subsequently modified by the 

10 Secretary); and 

11 ‘‘(ii) preventive services (as defined in 

12 section 1861(iii) for which payment is 

13 made under this section; and 

14 ‘‘(B) includes services furnished by another 

15 health care professional that would be described 

16 in subparagraph (A) if furnished by a physi17 cian. 

18 ‘‘(3) PRIMARY CARE PRACTITIONER DE19 FINED.—In this subsection, the term ‘primary care 

20 practitioner’— 

21 ‘‘(A) means a physician or other health 

22 care practitioner (including a nurse practi23 tioner) who— 

24 ‘‘(i) specializes in family medicine, 

25 general internal medicine, general pediat-
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1 rics, geriatrics, or obstetrics and gyne2 cology; and 

3 ‘‘(ii) has allowed charges for primary 

4 care services that account for at least 50 

5 percent of the physician’s or practitioner’s 

6 total allowed charges under section 1848, 

7 as determined by the Secretary for the 

8 most recent period for which data are 

9 available; and 

10 ‘‘(B) includes a physician assistant who is 

11 under the supervision of a physician described 

12 in subparagraph (A). 

13 ‘‘(4) LIMITATION ON REVIEW.—There shall be 

14 no administrative or judicial review under section 

15 1869, section 1878, or otherwise, respecting— 

16 ‘‘(A) any determination or designation 

17 under this subsection; 

18 ‘‘(B) the identification of services as pri19 mary care services under this subsection; and 

20 ‘‘(C) the identification of a practitioner as 

21 a primary care practitioner under this sub22 section. 

23 ‘‘(5) COORDINATION WITH OTHER PAY24 MENTS.— 
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1 ‘‘(A) WITH OTHER PRIMARY CARE INCEN2 TIVES.—The provisions of this subsection shall 

3 not be taken into account in applying sub4 sections (m) and (u) and any payment under 

5 such subsections shall not be taken into account 

6 in computing payments under this subsection. 

7 ‘‘(B) WITH QUALITY INCENTIVES.—Pay8 ments under this subsection shall not be taken 

9 into account in determining the amounts that 

10 would otherwise be paid under this part for 

11 purposes of section 1834(g)(2)(B).’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) Section 1833(m) of such Act (42 U.S.C. 

14 1395l(m)) is amended by redesignating paragraph 

15 (4) as paragraph (5) and by inserting after para16 graph (3) the following new paragraph: 

17 ‘‘(4) The provisions of this subsection shall not be 

18 taken into account in applying subsections (m) or (u) and 

19 any payment under such subsections shall not be taken 

20 into account in computing payments under this sub21 section.’’. 

22 (2) Section 1848(m)(5)(B) of such Act (42 

23 U.S.C. 1395w–4(m)(5)(B)) is amended by inserting 

24 ‘‘, (p),’’ after ‘‘(m)’’. 
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1 (3) Section 1848(o)(1)(B)(iv) of such Act (42 

2 U.S.C. 1395w–4(o)(1)(B)(iv)) is amended by insert3 ing ‘‘primary care’’ before ‘‘health professional 

4 shortage area’’. 

5 SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CER6 TIFIED NURSE-MIDWIVES. 

7 (a) IN GENERAL.—Section 1833(a)(1)(K) of the So8 cial Security Act (42 U.S.C.1395l(a)(1)(K)) is amended 

9 by striking ‘‘(but in no event’’ and all that follows through 

10 ‘‘performed by a physician)’’. 

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

12 subsection (a) shall apply to services furnished on or after 

13 January 1, 2011. 

14 SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR 

15 PREVENTIVE SERVICES. 

16 (a) MEDICARE COVERED PREVENTIVE SERVICES DE17 FINED.—Section 1861 of the Social Security Act (42 

18 U.S.C. 1395x), as amended by section 1233(a)(1)(B), is 

19 amended by adding at the end the following new sub20 section: 

21 ‘‘Medicare Covered Preventive Services 

22 ‘‘(iii)(1) Subject to the succeeding provisions of this 

23 subsection, the term ‘Medicare covered preventive services’ 

24 means the following: 
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1 ‘‘(A) Prostate cancer screening tests (as defined 

2 in subsection (oo)). 

3 ‘‘(B) Colorectal cancer screening tests (as de4 fined in subsection (pp). 

5 ‘‘(C) Diabetes outpatient self-management 

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

7 ‘‘(D) Screening for glaucoma for certain indi8 viduals (as described in subsection (s)(2)(U)). 

9 ‘‘(E) Medical nutrition therapy services for cer10 tain individuals (as described in subsection 

11 (s)(2)(V)). 

12 ‘‘(F) An initial preventive physical examination 

13 (as defined in subsection (ww)). 

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

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

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

17 subsection (yy)). 

18 ‘‘(I) Ultrasound screening for abdominal aortic 

19 aneurysm for certain individuals (as described in 

20 subsection (s)(2)(AA)). 

21 ‘‘(J) Federally approved and recommended vac22 cines and their administration as described in sub23 section (s)(10). 

24 ‘‘(K) Screening mammography (as defined in 

25 subsection (jj)). 
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1 ‘‘(L) Screening pap smear and screening pelvic 

2 exam (as defined in subsection (nn)). 

3 ‘‘(M) Bone mass measurement (as defined in 

4 subsection (rr)). 

5 ‘‘(N) Kidney disease education services (as de6 fined in subsection (ggg)). 

7 ‘‘(O) Additional preventive services (as defined 

8 in subsection (ddd)). 

9 ‘‘(2) With respect to specific Medicare covered pre10 ventive services, the limitations and conditions described 

11 in the provisions referenced in paragraph (1) with respect 

12 to such services shall apply.’’. 

13 (b) PAYMENT AND ELIMINATION OF COST-SHAR14 ING.— 

15 (1) IN GENERAL.— 

16 (A) IN GENERAL.—Section 1833(a) of the 

17 Social Security Act (42 U.S.C. 1395l(a)) is 

18 amended by adding after and below paragraph 

19 (9) the following: 

20 ‘‘With respect to Medicare covered preventive services, in 

21 any case in which the payment rate otherwise provided 

22 under this part is computed as a percent of less than 100 

23 percent of an actual charge, fee schedule rate, or other 

24 rate, such percentage shall be increased to 100 percent.’’. 
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1 (B) APPLICATION TO SIGMOIDOSCOPIES

2 AND COLONOSCOPIES.—Section 1834(d) of such 

3 Act (42 U.S.C. 1395m(d)) is amended— 

4 (i) in paragraph (2)(C), by amending 

5 clause (ii) to read as follows: 

6 ‘‘(ii) NO COINSURANCE.—In the case 

7 of a beneficiary who receives services de8 scribed in clause (i), there shall be no coin9 surance applied.’’; and 

10 (ii) in paragraph (3)(C), by amending 

11 clause (ii) to read as follows: 

12 ‘‘(ii) NO COINSURANCE.—In the case 

13 of a beneficiary who receives services de14 scribed in clause (i), there shall be no coin15 surance applied.’’. 

16 (2) ELIMINATION OF COINSURANCE IN OUT17 PATIENT HOSPITAL SETTINGS.— 

18 (A) EXCLUSION FROM OPD FEE SCHED19 ULE.—Section 1833(t)(1)(B)(iv) of the Social 

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

21 amended by striking ‘‘screening mammography 

22 (as defined in section 1861(jj)) and diagnostic 

23 mammography’’ and inserting ‘‘diagnostic 

24 mammograms and Medicare covered preventive 

25 services (as defined in section 1861(iii)(1))’’. 
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1 (B) CONFORMING AMENDMENTS.—Section 

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

3 U.S.C. 1395l(a)(2)) is amended— 

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

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

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

7 ‘‘and’’ at the end; and 

8 (iii) by adding at the end the fol9 lowing new subparagraph: 

10 ‘‘(H) with respect to additional preventive 

11 services (as defined in section 1861(ddd)) fur12 nished by an outpatient department of a hos13 pital, the amount determined under paragraph 

14 (1)(W);’’. 

15 (3) WAIVER OF APPLICATION OF DEDUCTIBLE

16 FOR ALL PREVENTIVE SERVICES.—The first sen17 tence of section 1833(b) of the Social Security Act 

18 (42 U.S.C. 1395l(b)) is amended— 

19 (A) in clause (1), by striking ‘‘items and 

20 services described in section 1861(s)(10)(A)’’ 

21 and inserting ‘‘Medicare covered preventive 

22 services (as defined in section 1861(iii))’’; 

23 (B) by inserting ‘‘and’’ before ‘‘(4)’’; and 

24 (C) by striking clauses (5) through (8). 
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1 (4) APPLICATION TO PROVIDERS OF SERV2 ICES.—Section 1866(a)(2)(A)(ii) of such Act (42 

3 U.S.C. 1395cc(a)(2)(A)(ii)) is amended by inserting 

4 ‘‘other than for Medicare covered preventive services 

5 and’’ after ‘‘for such items and services (’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to services furnished on or after 

8 January 1, 2011. 

9 (d) PREVENTIVE SERVICES.— 

10 (1) REPORT TO CONGRESS ON BARRIERS TO

11 PREVENTIVE SERVICES.—Not later than 12 months 

12 after the date of the enactment of this Act, the Sec13 retary of Health and Human Services shall report to 

14 Congress on barriers, if any, facing Medicare bene15 ficiaries in accessing the benefit to abdominal aortic 

16 aneurysm screening and other preventative services 

17 through the Welcome to Medicare Physical Exam. 

18 (2) ABDOMINAL AORTIC ANEURYSM SCREEN AC19 CESS.—The Secretary shall, to the extent practical, 

20 identify and implement policies promoting proper 

21 use of abdominal aortic aneurysm screening among 

22 Medicare beneficiaries at risk for such aneurysms. 
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1 SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL 

2 CANCER SCREENING TESTS REGARDLESS OF 

3 CODING, SUBSEQUENT DIAGNOSIS, OR ANCIL4 LARY TISSUE REMOVAL. 

5 (a) IN GENERAL.—Section 1833 of the Social Secu6 rity Act (42 U.S.C. 1395l(b)), as amended by section 

7 1305(b), is further amended— 

8 (1) in subsection (a), in the sentence added by 

9 section 1305(b)(1)(A), by inserting ‘‘(including serv10 ices described in the last sentence of section 

11 1833(b))’’ after ‘‘preventive services’’; and 

12 (2) in subsection (b), by adding at the end the 

13 following new sentence: ‘‘Clause (1) of the first sen14 tence of this subsection shall apply with respect to 

15 a colorectal cancer screening test regardless of the 

16 code that is billed for the establishment of a diag17 nosis as a result of the test, or for the removal of 

18 tissue or other matter or other procedure that is fur19 nished in connection with, as a result of, and in the 

20 same clinical encounter as, the screening test.’’. 

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

22 subsection (a) shall apply to items and services furnished 

23 on or after January 1, 2011. 
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1 SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERV2 ICES FROM COVERAGE UNDER THE MEDI3 CARE SKILLED NURSING FACILITY PROSPEC4 TIVE PAYMENT SYSTEM AND CONSOLIDATED 

5 PAYMENT. 

6 (a) IN GENERAL.—Section 1888(e)(2)(A)(ii) of the 

7 Social Security Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is 

8 amended by inserting ‘‘clinical social worker services,’’ 

9 after ‘‘qualified psychologist services,’’. 

10 (b) CONFORMING AMENDMENT.—Section 

11 1861(hh)(2) of the Social Security Act (42 U.S.C. 

12 1395x(hh)(2)) is amended by striking ‘‘and other than 

13 services furnished to an inpatient of a skilled nursing facil14 ity which the facility is required to provide as a require15 ment for participation’’. 

16 (c) EFFECTIVE DATE.—The amendments made by 

17 this section shall apply to items and services furnished on 

18 or after October 1, 2010. 

19 SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERA20 PIST SERVICES AND MENTAL HEALTH COUN21 SELOR SERVICES. 

22 (a) COVERAGE OF MARRIAGE AND FAMILY THERA23 PIST SERVICES.— 

24 (1) COVERAGE OF SERVICES.—Section 

25 1861(s)(2) of the Social Security Act (42 U.S.C. 
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1 1395x(s)(2)), as amended by section 1235, is 

2 amended— 

3 (A) in subparagraph (EE), by striking 

4 ‘‘and’’ at the end; 

5 (B) in subparagraph (FF), by adding 

6 ‘‘and’’ at the end; and 

7 (C) by adding at the end the following new 

8 subparagraph: 

9 ‘‘(GG) marriage and family therapist serv10 ices (as defined in subsection (jjj));’’. 

11 (2) DEFINITION.—Section 1861 of the Social 

12 Security Act (42 U.S.C. 1395x), as amended by sec13 tions 1233 and 1305, is amended by adding at the 

14 end the following new subsection: 

15 ‘‘Marriage and Family Therapist Services 

16 ‘‘(jjj)(1) The term ‘marriage and family therapist 

17 services’ means services performed by a marriage and 

18 family therapist (as defined in paragraph (2)) for the diag19 nosis and treatment of mental illnesses, which the mar20 riage and family therapist is legally authorized to perform 

21 under State law (or the State regulatory mechanism pro22 vided by State law) of the State in which such services 

23 are performed, as would otherwise be covered if furnished 

24 by a physician or as incident to a physician’s professional 

25 service, but only if no facility or other provider charges 
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1 or is paid any amounts with respect to the furnishing of 

2 such services. 

3 ‘‘(2) The term ‘marriage and family therapist’ means 

4 an individual who— 

5 ‘‘(A) possesses a master’s or doctoral degree 

6 which qualifies for licensure or certification as a 

7 marriage and family therapist pursuant to State 

8 law; 

9 ‘‘(B) after obtaining such degree has performed 

10 at least 2 years of clinical supervised experience in 

11 marriage and family therapy; and 

12 ‘‘(C) is licensed or certified as a marriage and 

13 family therapist in the State in which marriage and 

14 family therapist services are performed.’’. 

15 (3) PROVISION FOR PAYMENT UNDER PART

16 B.—Section 1832(a)(2)(B) of the Social Security 

17 Act (42 U.S.C. 1395k(a)(2)(B)) is amended by add18 ing at the end the following new clause: 

19 ‘‘(v) marriage and family therapist 

20 services;’’. 

21 (4) AMOUNT OF PAYMENT.— 

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

23 the Social Security Act (42 U.S.C. 1395l(a)(1)) 

24 is amended— 
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1 (i) by striking ‘‘and’’ before ‘‘(W)’’; 

2 and 

3 (ii) by inserting before the semicolon 

4 at the end the following: ‘‘, and (X) with 

5 respect to marriage and family therapist 

6 services under section 1861(s)(2)(GG), the 

7 amounts paid shall be 80 percent of the 

8 lesser of the actual charge for the services 

9 or 75 percent of the amount determined 

10 for payment of a psychologist under clause 

11 (L)’’. 

12 (B) DEVELOPMENT OF CRITERIA WITH RE13 SPECT TO CONSULTATION WITH A HEALTH

14 CARE PROFESSIONAL.—The Secretary of Health 

15 and Human Services shall, taking into consider16 ation concerns for patient confidentiality, de17 velop criteria with respect to payment for mar18 riage and family therapist services for which 

19 payment may be made directly to the marriage 

20 and family therapist under part B of title 

21 XVIII of the Social Security Act (42 U.S.C. 

22 1395j et seq.) under which such a therapist 

23 must agree to consult with a patient’s attending 

24 or primary care physician or nurse practitioner 

25 in accordance with such criteria. 
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1 (5) EXCLUSION OF MARRIAGE AND FAMILY

2 THERAPIST SERVICES FROM SKILLED NURSING FA3 CILITY PROSPECTIVE PAYMENT SYSTEM.—Section 

4 1888(e)(2)(A)(ii) of the Social Security Act (42 

5 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 

6 1307(a), is amended by inserting ‘‘marriage and 

7 family therapist services (as defined in subsection 

8 (jjj)(1)),’’ after ‘‘clinical social worker services,’’. 

9 (6) COVERAGE OF MARRIAGE AND FAMILY

10 THERAPIST SERVICES PROVIDED IN RURAL HEALTH

11 CLINICS AND FEDERALLY QUALIFIED HEALTH CEN12 TERS.—Section 1861(aa)(1)(B) of the Social Secu13 rity Act (42 U.S.C. 1395x(aa)(1)(B)) is amended by 

14 striking ‘‘or by a clinical social worker (as defined 

15 in subsection (hh)(1)),’’ and inserting ‘‘, by a clinical 

16 social worker (as defined in subsection (hh)(1)), or 

17 by a marriage and family therapist (as defined in 

18 subsection (jjj)(2)),’’. 

19 (7) INCLUSION OF MARRIAGE AND FAMILY

20 THERAPISTS AS PRACTITIONERS FOR ASSIGNMENT

21 OF CLAIMS.—Section 1842(b)(18)(C) of the Social 

22 Security Act (42 U.S.C. 1395u(b)(18)(C)) is amend23 ed by adding at the end the following new clause: 

24 ‘‘(vii) A marriage and family therapist (as de25 fined in section 1861(jjj)(2)).’’. 
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1 (b) COVERAGE OF MENTAL HEALTH COUNSELOR

2 SERVICES.— 

3 (1) COVERAGE OF SERVICES.—Section 

4 1861(s)(2) of the Social Security Act (42 U.S.C. 

5 1395x(s)(2)), as previously amended, is further 

6 amended— 

7 (A) in subparagraph (FF), by striking 

8 ‘‘and’’ at the end; 

9 (B) in subparagraph (GG), by inserting 

10 ‘‘and’’ at the end; and 

11 (C) by adding at the end the following new 

12 subparagraph: 

13 ‘‘(HH) mental health counselor services (as de14 fined in subsection (kkk)(1));’’. 

15 (2) DEFINITION.—Section 1861 of the Social 

16 Security Act (42 U.S.C. 1395x), as previously 

17 amended, is amended by adding at the end the fol18 lowing new subsection: 

19 ‘‘Mental Health Counselor Services 

20 ‘‘(kkk)(1) The term ‘mental health counselor services’ 

21 means services performed by a mental health counselor (as 

22 defined in paragraph (2)) for the diagnosis and treatment 

23 of mental illnesses which the mental health counselor is 

24 legally authorized to perform under State law (or the 

25 State regulatory mechanism provided by the State law) of 
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1 the State in which such services are performed, as would 

2 otherwise be covered if furnished by a physician or as inci3 dent to a physician’s professional service, but only if no 

4 facility or other provider charges or is paid any amounts 

5 with respect to the furnishing of such services. 

6 ‘‘(2) The term ‘mental health counselor’ means an 

7 individual who— 

8 ‘‘(A) possesses a master’s or doctor’s degree 

9 which qualifies the individual for licensure or certifi10 cation for the practice of mental health counseling in 

11 the State in which the services are performed; 

12 ‘‘(B) after obtaining such a degree has per13 formed at least 2 years of supervised mental health 

14 counselor practice; and 

15 ‘‘(C) is licensed or certified as a mental health 

16 counselor or professional counselor by the State in 

17 which the services are performed.’’. 

18 (3) PROVISION FOR PAYMENT UNDER PART

19 B.—Section 1832(a)(2)(B) of the Social Security 

20 Act (42 U.S.C. 1395k(a)(2)(B)), as amended by 

21 subsection (a)(3), is further amended— 

22 (A) by striking ‘‘and’’ at the end of clause 

23 (iv); 

24 (B) by adding ‘‘and’’ at the end of clause 

25 (v); and 
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1 (C) by adding at the end the following new 

2 clause: 

3 ‘‘(vi) mental health counselor serv4 ices;’’. 

5 (4) AMOUNT OF PAYMENT.— 

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

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

8 1395l(a)(1)), as amended by subsection (a), is 

9 further amended— 

10 (i) by striking ‘‘and’’ before ‘‘(X)’’; 

11 and 

12 (ii) by inserting before the semicolon 

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

14 respect to mental health counselor services 

15 under section 1861(s)(2)(HH), the 

16 amounts paid shall be 80 percent of the 

17 lesser of the actual charge for the services 

18 or 75 percent of the amount determined 

19 for payment of a psychologist under clause 

20 (L)’’. 

21 (B) DEVELOPMENT OF CRITERIA WITH RE22 SPECT TO CONSULTATION WITH A PHYSICIAN.— 

23 The Secretary of Health and Human Services 

24 shall, taking into consideration concerns for pa25 tient confidentiality, develop criteria with re-
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1 spect to payment for mental health counselor 

2 services for which payment may be made di3 rectly to the mental health counselor under part 

4 B of title XVIII of the Social Security Act (42 

5 U.S.C. 1395j et seq.) under which such a coun6 selor must agree to consult with a patient’s at7 tending or primary care physician in accordance 

8 with such criteria. 

9 (5) EXCLUSION OF MENTAL HEALTH COUN10 SELOR SERVICES FROM SKILLED NURSING FACILITY

11 PROSPECTIVE PAYMENT SYSTEM.—Section 

12 1888(e)(2)(A)(ii) of the Social Security Act (42 

13 U.S.C. 1395yy(e)(2)(A)(ii)), as amended by section 

14 1307(a) and subsection (a), is amended by inserting 

15 ‘‘mental health counselor services (as defined in sec16 tion 1861(kkk)(1)),’’ after ‘‘marriage and family 

17 therapist services (as defined in subsection 

18 (jjj)(1)),’’. 

19 (6) COVERAGE OF MENTAL HEALTH COUN20 SELOR SERVICES PROVIDED IN RURAL HEALTH

21 CLINICS AND FEDERALLY QUALIFIED HEALTH CEN22 TERS.—Section 1861(aa)(1)(B) of the Social Secu23 rity Act (42 U.S.C. 1395x(aa)(1)(B)), as amended 

24 by subsection (a), is amended by striking ‘‘or by a 

25 marriage and family therapist (as defined in sub-
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1 section (jjj)(2)),’’ and inserting ‘‘by a marriage and 

2 family therapist (as defined in subsection (jjj)(2)), 

3 or a mental health counselor (as defined in sub4 section (kkk)(2)),’’. 

5 (7) INCLUSION OF MENTAL HEALTH COUN6 SELORS AS PRACTITIONERS FOR ASSIGNMENT OF

7 CLAIMS.—Section 1842(b)(18)(C) of the Social Se8 curity Act (42 U.S.C. 1395u(b)(18)(C)), as amended 

9 by subsection (a)(7), is amended by adding at the 

10 end the following new clause: 

11 ‘‘(viii) A mental health counselor (as defined in 

12 section 1861(kkk)(2)).’’. 

13 (c) EFFECTIVE DATE.—The amendments made by 

14 this section shall apply to items and services furnished on 

15 or after January 1, 2011. 

16 SEC. 1309. EXTENSION OF PHYSICIAN FEE SCHEDULE MEN17 TAL HEALTH ADD-ON. 

18 Section 138(a)(1) of the Medicare Improvements for 

19 Patients and Providers Act of 2008 (Public Law 110–275) 

20 is amended by striking ‘‘December 31, 2009’’ and insert21 ing ‘‘December 31, 2011’’. 

22 SEC. 1310. EXPANDING ACCESS TO VACCINES. 

23 (a) IN GENERAL.—Paragraph (10) of section 

24 1861(s) of the Social Security Act (42 U.S.C. 1395w(s)) 

25 is amended to read as follows: 
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1 ‘‘(10) federally approved and recommended vac2 cines (as defined in subsection (lll)) and their re3 spective administration;’’. 

4 (b) FEDERALLY APPROVED AND RECOMMENDED

5 VACCINES DEFINED.—Section 1861 of such Act is further 

6 amended by adding at the end the following new sub7 section: 

8 ‘‘Federally Approved and Recommended Vaccines 

9 ‘‘(lll) The term ‘federally approved and recommended 

10 vaccine’ means a vaccine that— 

11 ‘‘(1) is licensed under section 351 of the Public 

12 Health Service Act, approved under the Federal 

13 Food, Drug, and Cosmetic Act, or authorized for 

14 emergency use under section 564 of the Federal, 

15 Food, Drug, and Cosmetic Act; and 

16 ‘‘(2) is recommended by the Director of the 

17 Centers for Disease Control and Prevention.’’. 

18 (c) CONFORMING AMENDMENTS.— 

19 (1) Section 1833 of such Act (42 U.S.C. 1395l) 

20 is amended, in each of subsections (a)(1)(B), 

21 (a)(2)(G), and (a)(3)(A), by striking 

22 ‘‘1861(s)(10)(A)’’ and inserting ‘‘1861(s)(10)’’ each 

23 place it appears. 

24 (2) Section 1842(o)(1)(A)(iv) of such Act (42 

25 U.S.C. 1395u(o)(1)(A)(iv)) is amended— 
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1 (A) by striking ‘‘subparagraph (A) or (B) 

2 of’’; and 

3 (B) by inserting before the period the fol4 lowing: ‘‘and before January 1, 2011, and influ5 enza vaccines furnished on or after January 1, 

6 2011’’. 

7 (3) Section 1847A(c)(6) of such Act (42 U.S.C. 

8 1395w–3a(c)(6)) is amended— 

9 (A) in subparagraph (D)(i), by inserting ‘‘, 

10 including a vaccine furnished on or after Janu11 ary 1, 2010’’; and 

12 (B) by the following new paragraph: 

13 ‘‘(H) IMPLEMENTATION.—Chapter 35 of 

14 title 44, United States Code, shall not apply to 

15 manufacturer provision of information pursuant 

16 to section 1927(b)(3)(A)(iii) or subsection 

17 (f)(2) for purposes of implementation of this 

18 section.’’. 

19 (4) Section 1860D–2(e)(1) of such Act (42 

20 U.S.C. 1395w–102(e)(1)) is amended by striking 

21 ‘‘such term includes a vaccine’’ and all that follows 

22 through ‘‘its administration) and’’. 

23 (5) Section 1861(ww)(2)(A) of such Act (42 

24 U.S.C. 1395x(ww)(2)(A))) is amended by striking 

25 ‘‘Pneumococcal, influenza, and hepatitis B vaccine 
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1 and administration’’ and inserting ‘‘federally ap2 proved or authorized vaccines (as defined in sub3 section (lll)) and their respective administration’’. 

4 (6) Section 1927(b)(3)(A)(iii) of such Act (42 

5 U.S.C. 1396r–8(b)(3)(A)(iii)) is amended, in the 

6 matter following subclause (III), by inserting 

7 ‘‘(A)(iv) (including influenza vaccines furnished on 

8 or after January 1, 2011),’’ after ‘‘described in sub9 paragraph’’. 

10 (7) Section 1847A(f) of such Act (42 U.S.C. 

11 1395w–3a(f)) is amended— 

12 (A) by striking ‘‘For’’ and inserting ‘‘(1) 

13 IN GENERAL.—For’’; 

14 (B) by indenting paragraph (1), as redes15 ignated in subparagraph (A), 2 ems to the left; 

16 and— 

17 (C) by adding at the end the following new 

18 paragraph: 

19 ‘‘(2) TREATMENT OF CERTAIN MANUFACTUR20 ERS.—In the case of a manufacturer of a drug or 

21 biological described in subparagraphs (A)(iv), (C), 

22 (D), (E), or (G) of section 1842(o)(1) that does not 

23 have a rebate agreement under section 1927(a), no 

24 payment may be made under this part for such drug 

25 or biological if such manufacturer does not submit 
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1 the information described in section 

2 1927(b)(3)(A)(iii) in the same manner as if the 

3 manufacturer had such a rebate agreement in effect. 

4 Subparagraphs (C) and (D) of section 1927(b)(3) 

5 shall apply to information reported pursuant to the 

6 previous sentence in the same manner as such sub7 paragraphs apply with respect to information re8 ported pursuant to such section.’’.’’. 

9 (d) EFFECTIVE DATES.—The amendments made— 

10 (1) by this section (other than by subsection 

11 (c)(6)) shall apply to vaccines administered on or 

12 after January 1, 2011; and 

13 (2) by subsection (c)(6) shall apply to calendar 

14 quarters beginning on or after January 1, 2010. 

15 SEC. 1311. EXPANSION OF MEDICARE-COVERED PREVEN16 TIVE SERVICES AT FEDERALLY QUALIFIED 

17 HEALTH CENTERS. 

18 (a) IN GENERAL.—Section 1861(aa)(3)(A) of the So19 cial Security Act (42 U.S.C. 1395w (aa)(3)(A)) is amend20 ed to read as follows:

21 ‘‘(A) services of the type described sub22 paragraphs (A) through (C) of paragraph (1) 

23 and services described in section 1861(iii); 

24 and’’. 
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1 (b) EFFECTIVE DATE.—The amendment made by 

2 subsection (a) shall apply not later than January 1, 2011. 

3 SEC. 1312. INDEPENDENCE AT HOME DEMONSTRATION 

4 PROGRAM. 

5 Title XVIII of the Social Security Act is amended by 

6 inserting after section 1866F, as inserted by section 1302, 

7 the following new section: 

8 ‘‘INDEPENDENCE AT HOME MEDICAL PRACTICE

9 DEMONSTRATION PROGRAM

10 ‘‘SEC. 1866G. (a) ESTABLISHMENT.— 

11 ‘‘(1) IN GENERAL.—The Secretary shall con12 duct a demonstration program (in this section re13 ferred to as the ‘demonstration program’) to test a 

14 payment incentive and service delivery model that 

15 utilizes physician and nurse practitioner directed 

16 home-based primary care teams designed to reduce 

17 expenditures and improve health outcomes in the 

18 provision of items and services under this title to ap19 plicable beneficiaries (as defined in subsection (d)). 

20 ‘‘(2) REQUIREMENT.—The demonstration pro21 gram shall test whether a model described in para22 graph (1), which is accountable for providing com23 prehensive, coordinated, continuous, and accessible 

24 care to high-need populations at home and coordi25 nating health care across all treatment settings, re26 sults in— 
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1 ‘‘(A) reducing preventable hospitalizations; 

2 ‘‘(B) preventing hospital readmissions; 

3 ‘‘(C) reducing emergency room visits; 

4 ‘‘(D) improving health outcomes commen5 surate with the beneficiaries’ stage of chronic 

6 illness; 

7 ‘‘(E) improving the efficiency of care, such 

8 as by reducing duplicative diagnostic and lab9 oratory tests; 

10 ‘‘(F) reducing the cost of health care serv11 ices covered under this title; and 

12 ‘‘(G) achieving beneficiary and family care13 giver satisfaction. 

14 ‘‘(b) INDEPENDENCE AT HOME MEDICAL PRAC15 TICE.— 

16 ‘‘(1) INDEPENDENCE AT HOME MEDICAL PRAC17 TICE DEFINED.—In this section: 

18 ‘‘(A) IN GENERAL.—The term ‘independ19 ence at home medical practice’ means a legal 

20 entity that— 

21 ‘‘(i) is comprised of an individual phy22 sician or nurse practitioner or group of 

23 physicians and nurse practitioners that 

24 provides care as part of a team that in25 cludes physicians, nurses, physician assist-
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1 ants, pharmacists, and other health and 

2 social services staff as appropriate who 

3 have experience providing home-based pri4 mary care to applicable beneficiaries, make 

5 in-home visits, and are available 24 hours 

6 per day, 7 days per week to carry out 

7 plans of care that are tailored to the indi8 vidual beneficiary’s chronic conditions and 

9 designed to achieve the results in sub10 section (a); 

11 ‘‘(ii) is organized at least in part for 

12 the purpose of providing physicians’ serv13 ices; 

14 ‘‘(iii) has documented experience in 

15 providing home-based primary care serv16 ices to high cost chronically ill bene17 ficiaries, as determined appropriate by the 

18 Secretary; 

19 ‘‘(iv) includes at least 200 applicable 

20 beneficiaries as defined in subsection (d); 

21 ‘‘(v) has entered into an agreement 

22 with the Secretary; 

23 ‘‘(vi) uses electronic health informa24 tion systems, remote monitoring, and mo25 bile diagnostic technology; and 
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1 ‘‘(vii) meets such other criteria as the 

2 Secretary determines to be appropriate to 

3 participate in the demonstration program. 

4 ‘‘(B) PHYSICIAN.—The term ‘physician’ in5 cludes, except as the Secretary may otherwise 

6 provide, any individual who furnishes services 

7 for which payment may be made as physicians’ 

8 services and has the medical training or experi9 ence to fulfill the physician’s role described in 

10 subparagraph (A)(i). 

11 ‘‘(2) PARTICIPATION OF NURSE PRACTITIONERS

12 AND PHYSICIAN ASSISTANTS.—Nothing in this sec13 tion shall be construed to prevent a nurse practi14 tioner or physician assistant from participating in, 

15 or leading, a home-based primary care team as part 

16 of an independence at home medical practice if— 

17 ‘‘(A) all the requirements of this section 

18 are met; 

19 ‘‘(B) the nurse practitioner or physician 

20 assistant, as the case may be, is acting con21 sistent with State law; and 

22 ‘‘(C) the nurse practitioner or physician 

23 assistant has the medical training or experience 

24 to fulfill the nurse practitioner or physician as25 sistant role described in paragraph (1)(A)(i). 
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1 ‘‘(3) INCLUSION OF PROVIDERS AND PRACTI2 TIONERS.—Nothing in this subsection shall be con3 strued as preventing an independence at home med4 ical practice from including a provider of services or 

5 a participating practitioner described in section 

6 1842(b)(18)(C) that is affiliated with the practice 

7 under an arrangement structured so that such pro8 vider of services or practitioner participates in the 

9 demonstration program and shares in any savings 

10 under the demonstration program. 

11 ‘‘(4) QUALITY AND PERFORMANCE STAND12 ARDS.— 

13 ‘‘(A) IN GENERAL.—An independence at 

14 home medical practice participating in the dem15 onstration program shall report on quality 

16 measures (in such form, manner, and frequency 

17 as specified by the Secretary, which may be for 

18 the group, for providers of services and sup19 pliers, or both) and report to the Secretary (in 

20 a form, manner, and frequency as specified by 

21 the Secretary) such data as the Secretary deter22 mines appropriate to monitor and evaluate the 

23 demonstration program. 

24 ‘‘(B) DEVELOPMENT OF QUALITY PER25 FORMANCE STANDARDS.—The Secretary shall 
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1 develop quality performance standards for inde2 pendence at home medical practices partici3 pating in the demonstration program. 

4 ‘‘(c) SHARED SAVINGS PAYMENT METHODOLOGY.— 

5 ‘‘(1) ESTABLISHMENT OF TARGET SPENDING

6 LEVEL.—The Secretary shall establish annual target 

7 spending levels for items and services covered under 

8 parts A and B furnished to applicable beneficiaries 

9 by qualifying independence at home medical prac10 tices under this section. The Secretary may set an 

11 aggregate target spending level for all qualifying 

12 practices, or may set different target spending levels 

13 for groups of practices or a single practice. Such 

14 target spending levels may be determined on a per 

15 capita basis and shall take into account normal vari16 ation in expenditures for items and services covered 

17 under parts A and B furnished to such beneficiaries. 

18 The target shall also be adjusted for the size of the 

19 practice, number of practices included in the target 

20 spending level, characteristics of applicable bene21 ficiaries and such other factors as the Secretary de22 termines appropriate. The Secretary may periodi23 cally adjust or rebase the target spending level 

24 under this paragraph. 

25 ‘‘(2) SHARED SAVINGS AMOUNTS.— 
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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), qualifying independence at home 

3 medical practices are eligible to receive an in4 centive payment under this section if aggregate 

5 expenditures for a year for applicable bene6 ficiaries are less than the target spending level 

7 for qualifying independence at home medical 

8 practices for such year. An incentive payment 

9 for such year shall be equal to a portion (as de10 termined by the Secretary) of the amount by 

11 which total payments for applicable bene12 ficiaries under parts A and B for such year are 

13 estimated to be less than 5 percent less than 

14 the target spending level for such year, as de15 termined by the Secretary. 

16 ‘‘(B) APPORTIONMENT OF SAVINGS.—The 

17 Secretary shall designate how, and to what ex18 tent, an incentive payment under this section is 

19 to be apportioned among qualifying independ20 ence at home medical practices, taking into ac21 count the size of the practice, characteristics of 

22 the individuals enrolled in each practice, per23 formance on quality performance measures, and 

24 such other factors as the Secretary determines 

25 appropriate. 
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1 ‘‘(3) SAVINGS TO THE MEDICARE PROGRAM.— 

2 The Secretary shall limit incentive payments to each 

3 qualifying independence at home medical practice 

4 under this paragraph, with respect to a year, as nec5 essary to ensure that the aggregate expenditures for 

6 items and services under parts A and B with respect 

7 to applicable beneficiaries for such independence at 

8 home medical practice (inclusive of shared savings 

9 payments) do not exceed the amount that the Sec10 retary estimates would be expended for such items 

11 and services for such beneficiaries during such year 

12 (taking into account normal variation in expendi13 tures and other factors the Secretary deems appro14 priate) if the demonstration program under this sec15 tion were not implemented, minus 5 percent. 

16 ‘‘(d) APPLICABLE BENEFICIARIES.— 

17 ‘‘(1) DEFINITION.—In this section, the term 

18 ‘applicable beneficiary’ means, with respect to a 

19 qualifying independence at home medical practice, 

20 an individual who the practice has determined— 

21 ‘‘(A) is entitled to benefits under part A 

22 and enrolled for benefits under part B; 

23 ‘‘(B) is not enrolled in a Medicare Advan24 tage plan under part C or a PACE program 

25 under section 1894; 
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1 ‘‘(C) has 2 or more chronic illnesses, such 

2 as congestive heart failure, diabetes, other de3 mentias designated by the Secretary, chronic 

4 obstructive pulmonary disease, ischemic heart 

5 disease, stroke, Alzheimer’s Disease and 

6 neurodegenerative diseases, and other diseases 

7 and conditions designated by the Secretary 

8 which result in high costs under this title; 

9 ‘‘(D) within the past 12 months has had a 

10 nonelective hospital admission; 

11 ‘‘(E) within the past 12 months has re12 ceived acute or subacute rehabilitation services; 

13 ‘‘(F) has 2 or more functional depend14 encies requiring the assistance of another per15 son (such as bathing, dressing, toileting, walk16 ing, or feeding); and 

17 ‘‘(G) meets such other criteria as the Sec18 retary determines appropriate. 

19 ‘‘(2) PATIENT ELECTION TO PARTICIPATE.— 

20 The Secretary shall determine an appropriate meth21 od of ensuring that applicable beneficiaries have 

22 agreed to enroll in an independence at home medical 

23 practice under the demonstration program. Enroll24 ment in the demonstration program shall be vol25 untary. 
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1 ‘‘(3) BENEFICIARY ACCESS TO SERVICES.— 

2 Nothing in this section shall be construed as encour3 aging physicians or nurse practitioners to limit ap4 plicable beneficiary access to services covered under 

5 this title and applicable beneficiaries shall not be re6 quired to relinquish access to any benefit under this 

7 title as a condition of receiving services from an 

8 independence at home medical practice. 

9 ‘‘(e) IMPLEMENTATION.— 

10 ‘‘(1) STARTING DATE.—The demonstration pro11 gram shall begin not later than January 1, 2012. An 

12 agreement with an independence at home medical 

13 practice under the demonstration program may 

14 cover not more than a 3-year period. 

15 ‘‘(2) NO PHYSICIAN DUPLICATION IN DEM16 ONSTRATION PARTICIPATION.—The Secretary shall 

17 not pay an independence at home medical practice 

18 under this section that participates in section 1866D 

19 or section 1866E. 

20 ‘‘(3) NO BENEFICIARY DUPLICATION IN DEM21 ONSTRATION PARTICIPATION.—The Secretary shall 

22 ensure that no applicable beneficiary enrolled in an 

23 independence at home medical practice under this 

24 section is participating in the programs under sec25 tion 1866D or section 1866E. 
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1 ‘‘(4) PREFERENCE.—In approving an independ2 ence at home medical practice, the Secretary shall 

3 give preference to practices that are— 

4 ‘‘(A) located in high-cost areas of the 

5 country; 

6 ‘‘(B) have experience in furnishing health 

7 care services to applicable beneficiaries in the 

8 home; and 

9 ‘‘(C) use electronic medical records, health 

10 information technology, and individualized plans 

11 of care. 

12 ‘‘(5) NUMBER OF PRACTICES.— 

13 ‘‘(A) IN GENERAL.—Subject to subpara14 graph (B), the Secretary shall enter into agree15 ments with as many independence at home me16 dial practices as practicable and consistent with 

17 this subsection to test the potential of the inde18 pendence at home medical practice model under 

19 this section in order to achieve the results de20 scribed in subsection (a) across practices serv21 ing varying numbers of applicable beneficiaries. 

22 ‘‘(B) LIMITATION.—In selecting qualified 

23 independence at home medial practices to par24 ticipate under the demonstration program, the 

25 Secretary shall limit the number of applicable 
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1 beneficiaries that may participate in the dem2 onstration program to 10,000. 

3 ‘‘(6) WAIVER.—The Secretary may waive such 

4 provisions of this title and title XI as the Secretary 

5 determines necessary in order to implement the dem6 onstration program. 

7 ‘‘(7) ADMINISTRATION.—Chapter 35 of title 44, 

8 United States Code, shall not apply to this section. 

9 ‘‘(f) EVALUATION AND MONITORING.— 

10 ‘‘(1) IN GENERAL.—The Secretary shall evalu11 ate each independence at home medical practice 

12 under the demonstration program to assess whether 

13 the practice achieved the results described in sub14 section (a). 

15 ‘‘(2) FOLLOWING APPLICABLE BENE16 FICIARIES.—The Secretary may monitor data on ex17 penditures and quality of services under this title 

18 after an applicable beneficiary discontinues receiving 

19 services under this title through a qualifying inde20 pendence at home medical practice. 

21 ‘‘(g) REPORTS TO CONGRESS.—The Secretary shall 

22 conduct an independent evaluation of the demonstration 

23 program and submit to Congress a final report, including 

24 best practices under the demonstration program. Such re25 port shall include an analysis of the demonstration pro-
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1 gram on coordination of care, expenditures under this 

2 title, applicable beneficiary access to services, and the 

3 quality of health care services provided to applicable bene4 ficiaries. 

5 ‘‘(h) FUNDING.—For purposes of administering and 

6 carrying out the demonstration program, other than for 

7 payments for items and services furnished under this title 

8 and shared savings under subsection (c), in addition to 

9 funds otherwise appropriated, there shall be transferred 

10 to the Secretary for the Center for Medicare & Medicaid 

11 Services Program Management Account from the Federal 

12 Hospital Insurance Trust Fund under section 1817 and 

13 the Federal Supplementary Medical Insurance Trust 

14 Fund under section 1841 $5,000,000 for each of fiscal 

15 years 2010 through 2015. Amounts transferred under this 

16 subsection for a fiscal year shall be available until ex17 pended. 

18 ‘‘(i) ANTIDISCRIMINATION LIMITATION.—The Sec19 retary shall not enter into an agreement with an entity 

20 to provide health care items or services under the dem21 onstration program unless such entity guarantees that for 

22 individuals eligible to be enrolled in such program, the en23 tity will not deny, limit, or condition the coverage or provi24 sion of benefits to which the individual would have other-
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1 wise been entitled to on the basis of health status if not 

2 included in this program. 

3 ‘‘(j) TERMINATION.—The Secretary may terminate 

4 an agreement with an independence at home medical prac5 tice if such practice does not receive incentive payments 

6 under subsection (c)(2) or consistently fails to meet qual7 ity standards.’’. 

8 SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDU9 CATORS AS CERTIFIED PROVIDERS FOR PUR10 POSES OF MEDICARE DIABETES OUTPATIENT 

11 SELF-MANAGEMENT TRAINING SERVICES. 

12 (a) IN GENERAL.—Section 1861(qq) of the Social Se13 curity Act (42 U.S.C. 1395x(qq)) is amended— 

14 (1) in paragraph (1), by inserting ‘‘or by a cer15 tified diabetes educator (as defined in paragraph 

16 (3))’’ after ‘‘paragraph (2)(B)’’; and 

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

18 paragraphs: 

19 ‘‘(3) For purposes of paragraph (1), the term 

20 ‘certified diabetes educator’ means an individual 

21 who— 

22 ‘‘(A) is licensed or registered by the State 

23 in which the services are performed as a health 

24 care professional; 
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1 ‘‘(B) specializes in teaching individuals 

2 with diabetes to develop the necessary skills and 

3 knowledge to manage the individual’s diabetic 

4 condition; and 

5 ‘‘(C) is certified as a diabetes educator by 

6 a recognized certifying body (as defined in 

7 paragraph (4)). 

8 ‘‘(4)(A) For purposes of paragraph (3)(C), the 

9 term ‘recognized certifying body’ means— 

10 ‘‘(i) the National Certification Board for 

11 Diabetes Educators, or 

12 ‘‘(ii) a certifying body for diabetes edu13 cators, which is recognized by the Secretary as 

14 authorized to grant certification of diabetes 

15 educators for purposes of this subsection pursu16 ant to standards established by the Secretary, 

17 if the Secretary determines such Board or body, 

18 respectively, meets the requirement of subpara19 graph (B). 

20 ‘‘(B) The National Certification Board for Dia21 betes Educators or a certifying body for diabetes 

22 educators meets the requirement of this subpara23 graph, with respect to the certification of an indi24 vidual, if the Board or body, respectively, is incor25 porated and registered to do business in the United 
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1 States and requires as a condition of such certifi2 cation each of the following: 

3 ‘‘(i) The individual has a qualifying cre4 dential in a specified health care profession. 

5 ‘‘(ii) The individual has professional prac6 tice experience in diabetes self-management 

7 training that includes a minimum number of 

8 hours and years of experience in such training. 

9 ‘‘(iii) The individual has successfully com10 pleted a national certification examination of11 fered by such entity. 

12 ‘‘(iv) The individual periodically renews 

13 certification status following initial certifi14 cation.’’. 

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

16 subsection (a) shall apply to diabetes outpatient self-man17 agement training services furnished on or after the first 

18 day of the first calendar year that is at least 6 months 

19 after the date of the enactment of this Act. 

20 TITLE IV—QUALITY 

21 Subtitle A—Comparative 

22 Effectiveness Research 

23 SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH. 

24 (a) IN GENERAL.—Title XI of the Social Security Act 

25 is amended by adding at the end the following new part: 
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1 ‘‘PART D—COMPARATIVE EFFECTIVENESS RESEARCH

2 ‘‘COMPARATIVE EFFECTIVENESS RESEARCH

3 ‘‘SEC. 1181. (a) CENTER FOR COMPARATIVE EFFEC4 TIVENESS RESEARCH ESTABLISHED.— 

5 ‘‘(1) IN GENERAL.—The Secretary shall estab6 lish within the Agency for Healthcare Research and 

7 Quality a Center for Comparative Effectiveness Re8 search (in this section referred to as the ‘Center’) to 

9 conduct, support, and synthesize research (including 

10 research conducted or supported under section 1013 

11 of the Medicare Prescription Drug, Improvement, 

12 and Modernization Act of 2003) with respect to the 

13 outcomes, effectiveness, and appropriateness of 

14 health care services and procedures in order to iden15 tify the manner in which diseases, disorders, and 

16 other health conditions can most effectively and ap17 propriately be prevented, diagnosed, treated, and 

18 managed clinically. 

19 ‘‘(2) DUTIES.—The Center shall— 

20 ‘‘(A) conduct, support, and synthesize re21 search relevant to the comparative effectiveness 

22 of the full spectrum of health care items, serv23 ices and systems, including pharmaceuticals, 

24 medical devices, medical and surgical proce25 dures, and other medical interventions; 
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1 ‘‘(B) conduct and support systematic re2 views of clinical research, including original re3 search conducted subsequent to the date of the 

4 enactment of this section; 

5 ‘‘(C) continuously develop rigorous sci6 entific methodologies for conducting compara7 tive effectiveness studies, and use such meth8 odologies appropriately; 

9 ‘‘(D) submit to the Comparative Effective10 ness Research Commission, the Secretary, and 

11 Congress appropriate relevant reports described 

12 in subsection (d)(2); 

13 ‘‘(E) not later than one year after the date 

14 of the enactment of this section, enter into an 

15 arrangement under which the Institute of Medi16 cine of the National Academy of Sciences shall 

17 conduct an evaluation and report on standards 

18 of evidence for highly credible research; 

19 ‘‘(F) encourage, as appropriate, the devel20 opment and use of clinical registries and the de21 velopment of clinical effectiveness research data 

22 networks from electronic health records, post 

23 marketing drug and medical device surveillance 

24 efforts, and other forms of electronic health 

25 data; and 
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1 ‘‘(G) appoint clinical perspective advisory 

2 panels for research priorities under this section, 

3 which shall consult with patients and other 

4 stakeholders and advise the Center on research 

5 questions, methods, and evidence gaps in terms 

6 of clinical outcomes for the specific research in7 quiry to be examined with respect to such pri8 ority to ensure that the information produced 

9 from such research is clinically relevant to deci10 sions made by clinicians and patients at the 

11 point of care. 

12 ‘‘(3) POWERS.— 

13 ‘‘(A) OBTAINING OFFICIAL DATA.—The 

14 Center may secure directly from any depart15 ment or agency of the United States informa16 tion necessary to enable it to carry out this sec17 tion. Upon request of the Center, the head of 

18 such department or agency shall furnish that 

19 information to the Center on an agreed upon 

20 schedule. 

21 ‘‘(B) DATA COLLECTION.—In order to 

22 carry out its functions, the Center shall— 

23 ‘‘(i) utilize existing information, both 

24 published and unpublished, where possible, 

25 collected and assessed either by its own 
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1 staff or under other arrangements made in 

2 accordance with this section; 

3 ‘‘(ii) carry out, or award grants or 

4 contracts for, original research and experi5 mentation, where existing information is 

6 inadequate; and 

7 ‘‘(iii) adopt procedures allowing any 

8 interested party to submit information for 

9 the use by the Center in making reports 

10 and recommendations. 

11 In carrying out clause (ii), the Center may 

12 award grants or contracts (or provide for inter13 governmental transfers, as applicable) to pri14 vate entities and governmental agencies with 

15 experience in conducting comparative effective16 ness research, such as the National Institutes 

17 of Health and other relevant Federal health 

18 agencies. 

19 ‘‘(C) ACCESS OF GAO TO INFORMATION.— 

20 The Comptroller General shall have unrestricted 

21 access to all deliberations, records, and non22 proprietary data of the Center and Commission 

23 under subsection (b), immediately upon request. 

24 ‘‘(D) PERIODIC AUDIT.—The Center and 

25 Commission under subsection (b) shall be sub-
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1 ject to periodic audit by the Comptroller Gen2 eral. 

3 ‘‘(b) COMPARATIVE EFFECTIVENESS RESEARCH

4 COMMISSION.— 

5 ‘‘(1) IN GENERAL.—There is established an 

6 independent Comparative Effectiveness Research 

7 Commission (in this section referred to as the ‘Com8 mission’) to advise the Center and evaluate the ac9 tivities carried out by the Center under subsection 

10 (a) to ensure such activities result in highly credible 

11 research and information resulting from such re12 search. 

13 ‘‘(2) DUTIES.—The Commission shall— 

14 ‘‘(A)(i) recommend to the Center national 

15 priorities for research described in subsection 

16 (a) which shall take into account— 

17 ‘‘(I) disease incidence, prevalence, and 

18 burden in the United States; 

19 ‘‘(II) evidence gaps in terms of clinical 

20 outcomes; 

21 ‘‘(III) variations in practice, delivery, 

22 and outcomes by geography, treatment 

23 site, provider type, disability, variation in 

24 age group (including children, adolescents, 

25 adults, and seniors), racial and ethnic 
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1 background, gender, genetic and molecular 

2 subtypes, and other appropriate popu3 lations or subpopulations; and 

4 ‘‘(IV) the potential for new evidence 

5 concerning certain categories, health care 

6 services, or treatments to improve patient 

7 health and well-being, and the quality of 

8 care; and 

9 ‘‘(ii) in making such recommendations con10 sult with a broad array of public and private 

11 stakeholders, including patients and health care 

12 providers and payers; 

13 ‘‘(B) monitor the appropriateness of use of 

14 the CERTF described in subsection (g) with re15 spect to the timely production of comparative 

16 effectiveness research recommended to be a na17 tional priority under subparagraph (A); 

18 ‘‘(C) identify highly credible research 

19 methods and standards of evidence for such re20 search to be considered by the Center; 

21 ‘‘(D) review the methodologies developed 

22 by the center under subsection (a)(2)(C); 

23 ‘‘(E) support forums to increase stake24 holder awareness and permit stakeholder feed25 back on the efforts of the Center to advance 
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1 methods and standards that promote highly 

2 credible research; 

3 ‘‘(F) make recommendations to the Center 

4 for policies that would allow for public access of 

5 data produced under this section, in accordance 

6 with appropriate privacy and proprietary prac7 tices, while ensuring that the information pro8 duced through such data is timely and credible; 

9 ‘‘(G) make recommendations to the Center 

10 for the priority for periodic reviews of previous 

11 comparative effectiveness research and studies 

12 conducted by the Center under subsection (a); 

13 ‘‘(H) at least annually review the processes 

14 of the Center and make reports to Congress 

15 and the President regarding research con16 ducted, supported, or synthesized by the Center 

17 to confirm that the information produced by 

18 such research is objective, credible, consistent 

19 with standards of evidence developed under this 

20 section, and developed through a transparent 

21 process that includes consultations with appro22 priate stakeholders; 

23 ‘‘(I) make recommendations to the Center 

24 for the broad dissemination, consistent with 

25 subsection (e), of the findings of research con-
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1 ducted and supported under this section that 

2 enables clinicians, patients, consumers, and 

3 payers to make more informed health care deci4 sions that improve quality and value; and 

5 ‘‘(J) at least twice each year, hold a public 

6 meeting with an opportunity for stakeholder 

7 input. 

8 The reports under subparagraph (H) shall not be 

9 submitted to the Office of Management and Budget 

10 or to any other Federal agency or executive depart11 ment for any purpose prior to transmittal to Con12 gress and the President. Such reports shall be pub13 lished on the public internet website of the Commis14 sion after the date of such transmittal. 

15 ‘‘(3) COMPOSITION OF COMMISSION.— 

16 ‘‘(A) IN GENERAL.—The members of the 

17 Commission shall consist of— 

18 ‘‘(i) the Director of the Agency for 

19 Healthcare Research and Quality or their 

20 designee; 

21 ‘‘(ii) the Chief Medical Officer of the 

22 Centers for Medicare & Medicaid Services 

23 or their designee; 

24 ‘‘(iii) the Director of the National In25 stitutes of Health or their designee; and 
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1 ‘‘(iv) 16 additional members who shall 

2 represent broad constituencies of stake3 holders including clinicians, patients, re4 searchers, third-party payers, and con5 sumers of Federal and State beneficiary 

6 programs. 

7 Of such members, at least 10 shall be prac8 ticing physicians, health care practitioners, con9 sumers, or patients. 

10 ‘‘(B) QUALIFICATIONS.— 

11 ‘‘(i) DIVERSE REPRESENTATION OF

12 PERSPECTIVES.—The members of the 

13 Commission shall represent a broad range 

14 of perspectives and shall collectively have 

15 experience in the following areas: 

16 ‘‘(I) Epidemiology. 

17 ‘‘(II) Health services research. 

18 ‘‘(III) Bioethics. 

19 ‘‘(IV) Decision sciences. 

20 ‘‘(V) Health disparities. 

21 ‘‘(VI) Health economics. 

22 ‘‘(ii) DIVERSE REPRESENTATION OF

23 HEALTH CARE COMMUNITY.—At least one 

24 member shall represent each of the fol25 lowing health care communities: 
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1 ‘‘(I) Patients. 

2 ‘‘(II) Health care consumers. 

3 ‘‘(III) Practicing Physicians, in4 cluding surgeons. 

5 ‘‘(IV) Other health care practi6 tioners engaged in clinical care. 

7 ‘‘(V) Organizations with proven 

8 expertise in racial and ethnic minority 

9 health research. 

10 ‘‘(VI) Employers. 

11 ‘‘(VII) Public payers. 

12 ‘‘(VIII) Insurance plans. 

13 ‘‘(IX) Clinical researchers who 

14 conduct research on behalf of pharma15 ceutical or device manufacturers. 

16 ‘‘(C) LIMITATION.—No more than 3 of the 

17 Members of the Commission may be representa18 tives of pharmaceutical or device manufacturers 

19 and such representatives shall be clinical re20 searchers described under subparagraph 

21 (B)(ii)(IX). 

22 ‘‘(4) APPOINTMENT.—The Comptroller General 

23 shall appoint the members of the Commission. 

24 ‘‘(5) CHAIRMAN; VICE CHAIRMAN.—The Comp25 troller General shall designate a member of the 
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1 Commission, at the time of appointment of the mem2 ber, as Chairman and a member as Vice Chairman 

3 for that term of appointment, except that in the case 

4 of vacancy of the Chairmanship or Vice Chairman5 ship, the Comptroller General may designate another 

6 member for the remainder of that member’s term. 

7 The Chairman shall serve as an ex officio member 

8 of the National Advisory Council of the Agency for 

9 Health Care Research and Quality under section 

10 931(c)(3)(B) of the Public Health Service Act. 

11 ‘‘(6) TERMS.— 

12 ‘‘(A) IN GENERAL.—Except as provided in 

13 subparagraph (B), each member of the Com14 mission shall be appointed for a term of 4 

15 years. 

16 ‘‘(B) TERMS OF INITIAL APPOINTEES.—Of 

17 the members first appointed— 

18 ‘‘(i) 8 shall be appointed for a term of 

19 4 years; and 

20 ‘‘(ii) 8 shall be appointed for a term 

21 of 3 years. 

22 ‘‘(7) COMPENSATION.—While serving on the 

23 business of the Commission (including travel time), 

24 a member of the Commission shall be entitled to 

25 compensation at the per diem equivalent of the rate 
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1 provided for level IV of the Executive Schedule 

2 under section 5315 of title 5, United States Code; 

3 and while so serving away from home and the mem4 ber’s regular place of business, a member may be al5 lowed travel expenses, as authorized by the Director 

6 of the Commission. 

7 ‘‘(8) DIRECTOR AND STAFF; EXPERTS AND

8 CONSULTANTS.—Subject to such review as the 

9 Comptroller General deems necessary to assure the 

10 efficient administration of the Commission, the Com11 mission may— 

12 ‘‘(A) appoint and set the compensation for 

13 an Executive Director (subject to the approval 

14 of the Comptroller General) and such other per15 sonnel as Federal employees under section 2105 

16 of title 5, United States Code, as may be nec17 essary to carry out its duties (without regard to 

18 the provisions of title 5, United States Code, 

19 governing appointments in the competitive serv20 ice); 

21 ‘‘(B) seek such assistance and support as 

22 may be required in the performance of its du23 ties from appropriate Federal departments and 

24 agencies; 
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1 ‘‘(C) enter into contracts or make other ar2 rangements, as may be necessary for the con3 duct of the work of the Commission (without 

4 regard to section 3709 of the Revised Statutes 

5 (41 U.S.C. 5)); 

6 ‘‘(D) make advance, progress, and other 

7 payments which relate to the work of the Com8 mission; 

9 ‘‘(E) provide transportation and subsist10 ence for persons serving without compensation; 

11 and 

12 ‘‘(F) prescribe such rules and regulations 

13 as it deems necessary with respect to the inter14 nal organization and operation of the Commis15 sion. 

16 ‘‘(9) OBTAINING OFFICIAL DATA.—The Com17 mission may secure directly from any department or 

18 agency of the United States information necessary 

19 to enable the Commission to carry out this section. 

20 Upon request of the Chairman of the Commission, 

21 the head of such department or agency shall furnish 

22 the information to the Commission on an agreed 

23 upon schedule. 

24 ‘‘(10) AVAILABILITY OF REPORTS.—The Com25 mission shall transmit to the Secretary a copy of 
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1 each report submitted under this subsection and 

2 shall make such reports available to the public. 

3 ‘‘(11) COORDINATION.—To enhance effective4 ness and coordination, the Secretary is encouraged, 

5 to the greatest extent possible, to seek coordination 

6 between the Commission and the National Advisory 

7 Council of the Agency for Healthcare Research and 

8 Quality. 

9 ‘‘(12) CONFLICTS OF INTEREST.— 

10 ‘‘(A) IN GENERAL.—In appointing the 

11 members of the Commission or a clinical per12 spective advisory panel described in subsection 

13 (a)(2)(G), the Comptroller General or the Sec14 retary, respectively, shall take into consider15 ation any financial interest (as defined in sub16 paragraph (D)), consistent with this paragraph, 

17 and develop a plan for managing any identified 

18 conflicts. 

19 ‘‘(B) EVALUATION AND CRITERIA.—When 

20 considering an appointment to the Commission 

21 or a clinical perspective advisory panel de22 scribed subsection (a)(2)(G), the Comptroller 

23 General or the Secretary, respectively, shall re24 view the expertise of the individual and the fi25 nancial disclosure report filed by the individual 
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1 pursuant to the Ethics in Government Act of 

2 1978 for each individual under consideration 

3 for the appointment, so as to reduce the likeli4 hood that an appointed individual will later re5 quire a written determination as referred to in 

6 section 208(b)(1) of title 18, United States 

7 Code, a written certification as referred to in 

8 section 208(b)(3) of title 18, United States 

9 Code, or a waiver as referred to in subpara10 graph (D)(iii) for service on the Commission at 

11 a meeting of the Commission. 

12 ‘‘(C) DISCLOSURES; PROHIBITIONS ON

13 PARTICIPATION; WAIVERS.— 

14 ‘‘(i) DISCLOSURE OF FINANCIAL IN15 TEREST.—Prior to a meeting of the Com16 mission or a clinical perspective advisory 

17 panel described in subsection (a)(2)(G) re18 garding a ‘particular matter’ (as that term 

19 is used in section 208 of title 18, United 

20 States Code), each member of the Commis21 sion or the clinical perspective advisory 

22 panel who is a full-time Government em23 ployee or special Government employee 

24 shall disclose to the Comptroller General or 

25 Secretary, respectively, financial interests 
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1 in accordance with requiring a waiver 

2 under section 208(b) of title 18, United 

3 States Code, or other interests as deemed 

4 relevant by the Secretary. 

5 ‘‘(ii) PROHIBITIONS ON PARTICIPA6 TION.—Except as provided under clause 

7 (iii), a member of the Commission or a 

8 clinical perspective advisory panel de9 scribed in subsection (a)(2)(G) may not 

10 participate with respect to a particular 

11 matter considered in meeting of the Com12 mission or the clinical perspective advisory 

13 panel if such member has a financial inter14 est that could be affected by the advice 

15 given to the Secretary with respect to such 

16 matter, excluding interests exempted in 

17 regulations issued by the Director of the 

18 Office of Government Ethics as too remote 

19 or inconsequential to affect the integrity of 

20 the services of the Government officers or 

21 employees to which such regulations apply. 

22 ‘‘(iii) WAIVER.—If the Comptroller 

23 General or Secretary, as applicable, deter24 mines it necessary to afford the Commis25 sion or a clinical perspective advisory panel 
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1 described in subsection (a)(2)(G) essential 

2 expertise, the Comptroller General or Sec3 retary, respectively, may grant a waiver of 

4 the prohibition in clause (ii) to permit a 

5 member described in such subparagraph 

6 to— 

7 ‘‘(I) participate as a non-voting 

8 member with respect to a particular 

9 matter considered in a meeting of the 

10 Commission or a clinical perspective 

11 advisory panel, respectively; or 

12 ‘‘(II) participate as a voting 

13 member with respect to a particular 

14 matter considered in a meeting of the 

15 Commission. 

16 ‘‘(iv) LIMITATION ON WAIVERS AND

17 OTHER EXCEPTIONS.— 

18 ‘‘(I) DETERMINATION OF ALLOW19 ABLE EXCEPTIONS FOR THE COMMIS20 SION.—The number of waivers grant21 ed to members of the Commission 

22 cannot exceed one-half of the total 

23 number of members for the Commis24 sion. 
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1 ‘‘(II) PROHIBITION ON VOTING

2 STATUS ON CLINICAL PERSPECTIVE

3 ADVISORY PANELS.—No voting mem4 ber of any clinical perspective advisory 

5 panel shall be in receipt of a waiver. 

6 No more than two nonvoting members 

7 of any clinical perspective advisory 

8 panel shall receive a waiver. 

9 ‘‘(D) FINANCIAL INTEREST DEFINED.— 

10 For purposes of this paragraph, the term ‘fi11 nancial interest’ means a financial interest 

12 under section 208(a) of title 18, United States 

13 Code. 

14 ‘‘(13) APPLICATION OF FACA.—The Federal 

15 Advisory Committee Act (other than section 14 of 

16 such Act) shall apply to the Commission to the ex17 tent that the provisions of such Act do not conflict 

18 with the requirements of this subsection. 

19 ‘‘(c) RESEARCH REQUIREMENTS.—Any research con20 ducted, supported, or synthesized under this section shall 

21 meet the following requirements: 

22 ‘‘(1) ENSURING TRANSPARENCY, CREDIBILITY, 

23 AND ACCESS.— 

24 ‘‘(A) The establishment of a research agen25 da by the Center shall be informed by the na-
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1 tional priorities for research recommended 

2 under subsection (b)(2)(A). 

3 ‘‘(B) The establishment of the agenda and 

4 conduct of the research shall be insulated from 

5 inappropriate political or stakeholder influence. 

6 ‘‘(C) Methods of conducting such research 

7 shall be scientifically based. 

8 ‘‘(D) Consistent with applicable law, all as9 pects of the prioritization of research, conduct 

10 of the research, and development of conclusions 

11 based on the research shall be transparent to 

12 all stakeholders. 

13 ‘‘(E) Consistent with applicable law, the 

14 process and methods for conducting such re15 search shall be publicly documented and avail16 able to all stakeholders. 

17 ‘‘(F) Throughout the process of such re18 search, the Center shall provide opportunities 

19 for all stakeholders involved to review and pro20 vide public comment on the methods and find21 ings of such research. 

22 ‘‘(G) Such research shall consider advice 

23 given to the Center by the clinical perspective 

24 advisory panel for the particular national re25 search priority. 
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1 ‘‘(2) STAKEHOLDER INPUT.— 

2 ‘‘(A) IN GENERAL.—The Commission shall 

3 consult with patients, health care providers, 

4 health care consumer representatives, and other 

5 appropriate stakeholders with an interest in the 

6 research through a transparent process rec7 ommended by the Commission. 

8 ‘‘(B) SPECIFIC AREAS OF CONSULTA9 TION.—Consultation shall include where 

10 deemed appropriate by the Commission— 

11 ‘‘(i) recommending research priorities 

12 and questions; 

13 ‘‘(ii) recommending research meth14 odologies; and 

15 ‘‘(iii) advising on and assisting with 

16 efforts to disseminate research findings. 

17 ‘‘(C) OMBUDSMAN.—The Secretary shall 

18 designate a patient ombudsman. The ombuds19 man shall— 

20 ‘‘(i) serve as an available point of con21 tact for any patients with an interest in 

22 proposed comparative effectiveness studies 

23 by the Center; and 

24 ‘‘(ii) ensure that any comments from 

25 patients regarding proposed comparative 
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1 effectiveness studies are reviewed by the 

2 Center. 

3 ‘‘(3) TAKING INTO ACCOUNT POTENTIAL DIF4 FERENCES.—Research shall— 

5 ‘‘(A) be designed, as appropriate, to take 

6 into account the potential for differences in the 

7 effectiveness of health care items, services, and 

8 systems used with various subpopulations such 

9 as racial and ethnic minorities, women, dif10 ferent age groups (including children, adoles11 cents, adults, and seniors), individuals with dis12 abilities, and individuals with different 

13 comorbidities and genetic and molecular 

14 subtypes; and— 

15 ‘‘(B) seek, as feasible and appropriate, to 

16 include members of such subpopulations as sub17 jects in the research. 

18 ‘‘(d) PUBLIC ACCESS TO COMPARATIVE EFFECTIVE19 NESS INFORMATION.— 

20 ‘‘(1) IN GENERAL.—Not later than 90 days 

21 after receipt by the Center or Commission, as appli22 cable, of a relevant report described in paragraph 

23 (2) made by the Center, Commission, or clinical per24 spective advisory panel under this section, appro25 priate information contained in such report shall be 
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1 posted on the official public Internet site of the Cen2 ter and of the Commission, as applicable. 

3 ‘‘(2) RELEVANT REPORTS DESCRIBED.—For 

4 purposes of this section, a relevant report is each of 

5 the following submitted by the Center or a grantee 

6 or contractor of the Center: 

7 ‘‘(A) Any interim or progress reports as 

8 deemed appropriate by the Secretary. 

9 ‘‘(B) Stakeholder comments. 

10 ‘‘(C) A final report. 

11 ‘‘(e) DISSEMINATION AND INCORPORATION OF COM12 PARATIVE EFFECTIVENESS INFORMATION.— 

13 ‘‘(1) DISSEMINATION.—The Center shall pro14 vide for the dissemination of appropriate findings 

15 produced by research supported, conducted, or syn16 thesized under this section to health care providers, 

17 patients, vendors of health information technology 

18 focused on clinical decision support, relevant expert 

19 organizations (as defined in subsection (i)(3)(A)), 

20 and Federal and private health plans, and other rel21 evant stakeholders. In disseminating such findings 

22 the Center shall— 

23 ‘‘(A) convey findings of research so that 

24 they are comprehensible and useful to patients 

25 and providers in making health care decisions; 
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1 ‘‘(B) discuss findings and other consider2 ations specific to certain sub-populations, risk 

3 factors, and comorbidities as appropriate; 

4 ‘‘(C) include considerations such as limita5 tions of research and what further research 

6 may be needed, as appropriate; 

7 ‘‘(D) not include any data that the dis8 semination of which would violate the privacy of 

9 research participants or violate any confiden10 tiality agreements made with respect to the use 

11 of data under this section; and 

12 ‘‘(E) assist the users of health information 

13 technology focused on clinical decision support 

14 to promote the timely incorporation of such 

15 findings into clinical practices and promote the 

16 ease of use of such incorporation. 

17 ‘‘(2) DISSEMINATION PROTOCOLS AND STRATE18 GIES.—The Center shall develop protocols and strat19 egies for the appropriate dissemination of research 

20 findings in order to ensure effective communication 

21 of findings and the use and incorporation of such 

22 findings into relevant activities for the purpose of in23 forming higher quality and more effective and effi24 cient decisions regarding medical items and services. 

25 In developing and adopting such protocols and strat-
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1 egies, the Center shall consult with stakeholders con2 cerning the types of dissemination that will be most 

3 useful to the end users of information and may pro4 vide for the utilization of multiple formats for con5 veying findings to different audiences, including dis6 semination to individuals with limited English pro7 ficiency. 

8 ‘‘(f) REPORTS TO CONGRESS.— 

9 ‘‘(1) ANNUAL REPORTS.—Beginning not later 

10 than one year after the date of the enactment of this 

11 section, the Director of the Agency of Healthcare 

12 Research and Quality shall submit to Congress an 

13 annual report on the activities of the Center, as well 

14 as the research, conducted under this section. Each 

15 such report shall include a discussion of the Center’s 

16 compliance with subsection (c)(3)(B), including any 

17 reasons for lack of compliance with such subsection. 

18 ‘‘(2) RECOMMENDATION FOR FAIR SHARE PER

19 CAPITA AMOUNT FOR ALL-PAYER FINANCING.—Be20 ginning not later than December 31, 2011, the Sec21 retary shall submit to Congress an annual rec22 ommendation for a fair share per capita amount de23 scribed in subsection (c)(1) of section 9511 of the 

24 Internal Revenue Code of 1986 for purposes of 

25 funding the CERTF under such section. 
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1 ‘‘(3) ANALYSIS AND REVIEW.—Not later than 

2 December 31, 2013, the Secretary, in consultation 

3 with the Commission, shall submit to Congress a re4 port on all activities conducted or supported under 

5 this section as of such date. Such report shall in6 clude an evaluation of the overall costs of such ac7 tivities and an analysis of the backlog of any re8 search proposals approved by the Center but not 

9 funded. 

10 ‘‘(g) FUNDING OF COMPARATIVE EFFECTIVENESS

11 RESEARCH.—For fiscal year 2010 and each subsequent 

12 fiscal year, amounts in the Comparative Effectiveness Re13 search Trust Fund (referred to in this section as the 

14 ‘CERTF’) under section 9511 of the Internal Revenue 

15 Code of 1986 shall be available in accordance with such 

16 section, without the need for further appropriations and 

17 without fiscal year limitation, to carry out this section. 

18 ‘‘(h) CONSTRUCTION.— 

19 ‘‘(1) COVERAGE.—Nothing in this section shall 

20 be construed— 

21 ‘‘(A) to permit the Center or Commission 

22 to mandate coverage, reimbursement, or other 

23 policies for any public or private payer; or 

24 ‘‘(B) as preventing the Secretary from cov25 ering the routine costs of clinical care received 
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1 by an individual entitled to, or enrolled for, ben2 efits under title XVIII, XIX, or XXI in the case 

3 where such individual is participating in a clin4 ical trial and such costs would otherwise be cov5 ered under such title with respect to the bene6 ficiary. 

7 ‘‘(2) REPORTS AND FINDINGS.—None of the re8 ports submitted under this section or research find9 ings disseminated by the Center or Commission shall 

10 be construed as mandates, for payment, coverage, or 

11 treatment. 

12 ‘‘(3) PROTECTING THE PHYSICIAN-PATIENT RE13 LATIONSHIP.—Nothing in this section shall be con14 strued to authorize any Federal officer or employee 

15 to exercise any supervision or control over the prac16 tice of medicine. 

17 ‘‘(i) CONSULTATION WITH RELEVANT EXPERT OR18 GANIZATIONS.— 

19 ‘‘(1) CONSULTATION PRIOR TO INITIATION OF

20 RESEARCH.—Prior to recommending priorities or 

21 initiating research described in this section, the 

22 Commission or the Center shall consult with the rel23 evant expert organizations responsible for standards 

24 and protocols of clinical excellence. Such consulta-
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1 tion shall be consistent with the processes estab2 lished under subsection (c)(2). 

3 ‘‘(2) CONSULTATION IN DISSEMINATION OF RE4 SEARCH.—Any dissemination of research from the 

5 Commission or the Center and findings made by the 

6 Commission or the Center shall be consistent with 

7 processes established under subsection (e) and 

8 shall— 

9 ‘‘(A) be based upon evidence-based medi10 cine; and 

11 ‘‘(B) take into consideration standards and 

12 protocols of clinical excellence developed by rel13 evant expert organizations. 

14 ‘‘(3) DEFINITIONS.—For purposes of this sub15 section: 

16 ‘‘(A) RELEVANT EXPERT ORGANIZA17 TIONS.—The term ‘relevant expert organization’ 

18 means an organization with expertise in the rig19 orous application of evidence-based scientific 

20 methods for the design of clinical studies, the 

21 interpretation of clinical data, and the develop22 ment of national clinical practice guidelines, in23 cluding a voluntary health organization, clinical 

24 specialty, or other professional organization 

25 that represents physicians based on the field of 
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1 medicine in which each such physician practices 

2 or is board certified. 

3 ‘‘(B) STANDARDS AND PROTOCOLS OF

4 CLINICAL EXCELLENCE.—The term ‘standards 

5 and protocols of clinical excellence’ means clin6 ical or practice guidelines that consist of a set 

7 of directions or principles that is based on evi8 dence and is designed to assist a health care 

9 practitioner with decisions about appropriate di10 agnostic, therapeutic, or other clinical proce11 dures for specific clinical circumstances. 

12 ‘‘(j) RESEARCH MAY NOT BE USED TO DENY OR RA13 TION CARE.—Nothing in this section shall be construed 

14 to make more stringent or otherwise change the standards 

15 or requirements for coverage of items and services under 

16 this Act.’’. 

17 (b) COMPARATIVE EFFECTIVENESS RESEARCH

18 TRUST FUND; FINANCING FOR THE TRUST FUND.—For 

19 the provision establishing a Comparative Effectiveness Re20 search Trust Fund and financing such Trust Fund, see 

21 section 1802. 
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1 Subtitle B—Nursing Home 

2 Transparency 

3 PART 1—IMPROVING TRANSPARENCY OF INFOR4 MATION ON SKILLED NURSING FACILITIES, 

5 NURSING FACILITIES, AND OTHER LONG6 TERM CARE FACILITIES 

7 SEC. 1411. REQUIRED DISCLOSURE OF OWNERSHIP AND 

8 ADDITIONAL DISCLOSABLE PARTIES INFOR9 MATION. 

10 (a) IN GENERAL.—Section 1124 of the Social Secu11 rity Act (42 U.S.C. 1320a–3) is amended by adding at 

12 the end the following new subsection: 

13 ‘‘(c) REQUIRED DISCLOSURE OF OWNERSHIP AND

14 ADDITIONAL DISCLOSABLE PARTIES INFORMATION.— 

15 ‘‘(1) DISCLOSURE.—A facility (as defined in 

16 paragraph (6)(B)) shall have the information de17 scribed in paragraph (3) available— 

18 ‘‘(A) during the period beginning on the 

19 date of the enactment of this subsection and 

20 ending on the date such information is made 

21 available to the public under section 1411(b) of 

22 the Affordable Health Care for America Act, 

23 for submission to the Secretary, the Inspector 

24 General of the Department of Health and 

25 Human Services, the State in which the facility 
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1 is located, and the State long-term care om2 budsman in the case where the Secretary, the 

3 Inspector General, the State, or the State long4 term care ombudsman requests such informa5 tion; and 

6 ‘‘(B) beginning on the effective date of the 

7 final regulations promulgated under paragraph 

8 (4)(A), for reporting such information in ac9 cordance with such final regulations. 

10 Nothing in subparagraph (A) shall be construed as 

11 authorizing a facility to dispose of or delete informa12 tion described in such subparagraph after the effec13 tive date of the final regulations promulgated under 

14 paragraph (4)(A). 

15 ‘‘(2) PUBLIC AVAILABILITY OF INFORMATION.— 

16 During the period described in paragraph (1)(A), a 

17 facility shall— 

18 ‘‘(A) make the information described in 

19 paragraph (3) available to the public upon re20 quest and update such information as may be 

21 necessary to reflect changes in such informa22 tion; and 

23 ‘‘(B) post a notice of the availability of 

24 such information in the lobby of the facility in 

25 a prominent manner. 
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1 ‘‘(3) INFORMATION DESCRIBED.— 

2 ‘‘(A) IN GENERAL.—The following infor3 mation is described in this paragraph: 

4 ‘‘(i) The information described in sub5 sections (a) and (b), subject to subpara6 graph (C). 

7 ‘‘(ii) The identity of and information 

8 on— 

9 ‘‘(I) each member of the gov10 erning body of the facility, including 

11 the name, title, and period of service 

12 of each such member; 

13 ‘‘(II) each person or entity who is 

14 an officer, director, member, partner, 

15 trustee, or managing employee of the 

16 facility, including the name, title, and 

17 date of start of service of each such 

18 person or entity; and 

19 ‘‘(III) each person or entity who 

20 is an additional disclosable party of 

21 the facility. 

22 ‘‘(iii) A description of the organiza23 tional structure and the relationship of 

24 each person and entity described in sub-
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1 clauses (II) and (III) of clause (ii) to the 

2 facility and to one another. 

3 ‘‘(B) SPECIAL RULE WHERE INFORMATION

4 IS ALREADY REPORTED OR SUBMITTED.—To 

5 the extent that information reported by a facil6 ity to the Internal Revenue Service on Form 

7 990, information submitted by a facility to the 

8 Securities and Exchange Commission, or infor9 mation otherwise submitted to the Secretary or 

10 any other Federal agency contains the informa11 tion described in clauses (i), (ii), or (iii) of sub12 paragraph (A), the Secretary may allow, to the 

13 extent practicable, such Form or such informa14 tion to meet the requirements of paragraph (1) 

15 and to be submitted in a manner specified by 

16 the Secretary. 

17 ‘‘(C) SPECIAL RULE.—In applying sub18 paragraph (A)(i)— 

19 ‘‘(i) with respect to subsections (a) 

20 and (b), ‘ownership or control interest’ 

21 shall include direct or indirect interests, in22 cluding such interests in intermediate enti23 ties; and 

24 ‘‘(ii) subsection (a)(3)(A)(ii) shall in25 clude the owner of a whole or part interest 
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1 in any mortgage, deed of trust, note, or 

2 other obligation secured, in whole or in 

3 part, by the entity or any of the property 

4 or assets thereof, if the interest is equal to 

5 or exceeds 5 percent of the total property 

6 or assets of the entirety. 

7 ‘‘(4) REPORTING.— 

8 ‘‘(A) IN GENERAL.—Not later than the 

9 date that is 2 years after the date of the enact10 ment of this subsection, the Secretary shall pro11 mulgate regulations requiring a facility to re12 port the information described in paragraph (3) 

13 to the Secretary in a standardized format, and 

14 such other regulations as are necessary to carry 

15 out this subsection. Such regulations shall 

16 specify the frequency of reporting, as deter17 mined by the Secretary. Such final regulations 

18 shall also require— 

19 ‘‘(i) the reporting of such information 

20 on or after the first day of the first cal21 endar quarter beginning after the date 

22 that is 90 days after the date on which 

23 such final regulations are published in the 

24 Federal Register; and— 
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1 ‘‘(ii) the certification, as a condition 

2 of participation under the program under 

3 title XVIII or XIX, that such information 

4 is accurate and current. 

5 ‘‘(B) GUIDANCE.—The Secretary shall pro6 vide guidance and technical assistance to States 

7 on how to adopt the standardized format under 

8 subparagraph (A). 

9 ‘‘(5) NO EFFECT ON EXISTING REPORTING RE10 QUIREMENTS.—Nothing in this subsection shall re11 duce, diminish, or alter any reporting requirement 

12 for a facility that is in effect as of the date of the 

13 enactment of this subsection. 

14 ‘‘(6) DEFINITIONS.—In this subsection: 

15 ‘‘(A) ADDITIONAL DISCLOSABLE PARTY.— 

16 The term ‘additional disclosable party’ means, 

17 with respect to a facility, any person or entity 

18 who, through ownership interest, partnership 

19 interest, contract, or otherwise— 

20 ‘‘(i) directly or indirectly exercises 

21 operational, financial, administrative, or 

22 managerial control or direction over the fa23 cility or a part thereof, or provides policies 

24 or procedures for any of the operations of 
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1 the facility, or provides financial or cash 

2 management services to the facility; 

3 ‘‘(ii) leases or subleases real property 

4 to the facility, or owns a whole or part in5 terest equal to or exceeding 5 percent of 

6 the total value of such real property; 

7 ‘‘(iii) lends funds or provides a finan8 cial guarantee to the facility in an amount 

9 which is equal to or exceeds $50,000; or 

10 ‘‘(iv) provides management or admin11 istrative services, clinical consulting serv12 ices, or accounting or financial services to 

13 the facility. 

14 ‘‘(B) FACILITY.—The term ‘facility’ means 

15 a disclosing entity which is— 

16 ‘‘(i) a skilled nursing facility (as de17 fined in section 1819(a)); or 

18 ‘‘(ii) a nursing facility (as defined in 

19 section 1919(a)). 

20 ‘‘(C) MANAGING EMPLOYEE.—The term 

21 ‘managing employee’ means, with respect to a 

22 facility, an individual (including a general man23 ager, business manager, administrator, director, 

24 or consultant) who directly or indirectly man-
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1 ages, advises, or supervises any element of the 

2 practices, finances, or operations of the facility. 

3 ‘‘(D) ORGANIZATIONAL STRUCTURE.—The 

4 term ‘organizational structure’ means, in the 

5 case of— 

6 ‘‘(i) a corporation, the officers, direc7 tors, and shareholders of the corporation 

8 who have an ownership interest in the cor9 poration which is equal to or exceeds 5 

10 percent; 

11 ‘‘(ii) a limited liability company, the 

12 members and managers of the limited li13 ability company (including, as applicable, 

14 what percentage each member and man15 ager has of the ownership interest in the 

16 limited liability company); 

17 ‘‘(iii) a general partnership, the part18 ners of the general partnership; 

19 ‘‘(iv) a limited partnership, the gen20 eral partners and any limited partners of 

21 the limited partnership who have an own22 ership interest in the limited partnership 

23 which is equal to or exceeds 10 percent; 

24 ‘‘(v) a trust, the trustees of the trust; 
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1 ‘‘(vi) an individual, contact informa2 tion for the individual; and 

3 ‘‘(vii) any other person or entity, such 

4 information as the Secretary determines 

5 appropriate.’’. 

6 (b) PUBLIC AVAILABILITY OF INFORMATION.—Not 

7 later than the date that is 1 year after the date on which 

8 the final regulations promulgated under section 

9 1124(c)(4)(A) of the Social Security Act, as added by sub10 section (a), are published in the Federal Register, the in11 formation reported in accordance with such final regula12 tions shall be made available to the public in accordance 

13 with procedures established by the Secretary of Health 

14 and Human Services. 

15 (a) CONFORMING AMENDMENTS.— 

16 (1) SKILLED NURSING FACILITIES.—Section 

17 1819(d)(1) of the Social Security Act (42 U.S.C. 

18 1395i–3(d)(1)) is amended by striking subparagraph 

19 (B) and redesignating subparagraph (C) as subpara20 graph (B). 

21 (2) NURSING FACILITIES.—Section 1919(d)(1) 

22 of the Social Security Act (42 U.S.C. 1396r(d)(1)) 

23 is amended by striking subparagraph (B) and redes24 ignating subparagraph (C) as subparagraph (B). 
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1 SEC. 1412. ACCOUNTABILITY REQUIREMENTS. 

2 (a) EFFECTIVE COMPLIANCE AND ETHICS PRO3 GRAMS.— 

4 (1) SKILLED NURSING FACILITIES.—Section 

5 1819(d)(1) of the Social Security Act (42 U.S.C. 

6 1395i–3(d)(1)), as amended by section 1411(c)(1), 

7 is amended by adding at the end the following new 

8 subparagraph: 

9 ‘‘(C) COMPLIANCE AND ETHICS PRO10 GRAMS.— 

11 ‘‘(i) REQUIREMENT.—On or after the 

12 first day of the first calendar quarter be13 ginning after the date that is 1 year after 

14 the date on which regulations developed 

15 under clause (ii) are published in the Fed16 eral Register, a skilled nursing facility 

17 shall, with respect to the entity that oper18 ates or controls the facility (in this sub19 paragraph referred to as the ‘operating or20 ganization’ or ‘organization’), have in oper21 ation a compliance and ethics program 

22 that is effective in preventing and detect23 ing criminal, civil, and administrative viola24 tions under this Act and in promoting 

25 quality of care consistent with such regula26 tions. 
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1 ‘‘(ii) DEVELOPMENT OF REGULA2 TIONS.— 

3 ‘‘(I) IN GENERAL.—Not later 

4 than the date that is 2 years after the 

5 date of the enactment of this subpara6 graph, the Secretary, in consultation 

7 with the Inspector General of the De8 partment of Health and Human Serv9 ices, shall promulgate regulations for 

10 an effective compliance and ethics 

11 program for operating organizations, 

12 which may include a model compliance 

13 program. 

14 ‘‘(II) DESIGN OF REGULA15 TIONS.—Such regulations with respect 

16 to specific elements or formality of a 

17 program may vary with the size of the 

18 organization, such that larger organi19 zations should have a more formal 

20 and rigorous program and include es21 tablished written policies defining the 

22 standards and procedures to be fol23 lowed by its employees. Such require24 ments shall specifically apply to the 
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1 corporate level management of multi2 unit nursing home chains. 

3 ‘‘(III) EVALUATION.—Not later 

4 than 3 years after the date on which 

5 compliance and ethics programs estab6 lished under this subparagraph are in 

7 operation pursuant to clause (i), the 

8 Secretary shall complete an evaluation 

9 of such programs. Such evaluation 

10 shall determine if such programs led 

11 to changes in deficiency citations, 

12 changes in quality performance, or 

13 changes in other metrics of resident 

14 quality of care. The Secretary shall 

15 submit to Congress a report on such 

16 evaluation and shall include in such 

17 report such recommendations regard18 ing changes in the requirements for 

19 such programs as the Secretary deter20 mines appropriate. 

21 ‘‘(iii) REQUIREMENTS FOR COMPLI22 ANCE AND ETHICS PROGRAMS.—In this 

23 subparagraph, the term ‘compliance and 

24 ethics program’ means, with respect to a 
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1 skilled nursing facility, a program of the 

2 operating organization that— 

3 ‘‘(I) has been reasonably de4 signed, implemented, and enforced so 

5 that it generally will be effective in 

6 preventing and detecting criminal, 

7 civil, and administrative violations 

8 under this Act and in promoting qual9 ity of care; and 

10 ‘‘(II) includes at least the re11 quired components specified in clause 

12 (iv). 

13 ‘‘(iv) REQUIRED COMPONENTS OF

14 PROGRAM.—The required components of a 

15 compliance and ethics program of an orga16 nization are the following: 

17 ‘‘(I) The organization must have 

18 established compliance standards and 

19 procedures to be followed by its em20 ployees, contractors, and other agents 

21 that are reasonably capable of reduc22 ing the prospect of criminal, civil, and 

23 administrative violations under this 

24 Act. 
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1 ‘‘(II) Specific individuals within 

2 high-level personnel of the organiza3 tion must have been assigned overall 

4 responsibility to oversee compliance 

5 with such standards and procedures 

6 and have sufficient resources and au7 thority to assure such compliance. 

8 ‘‘(III) The organization must 

9 have used due care not to delegate 

10 substantial discretionary authority to 

11 individuals whom the organization 

12 knew, or should have known through 

13 the exercise of due diligence, had a 

14 propensity to engage in criminal, civil, 

15 and administrative violations under 

16 this Act. 

17 ‘‘(IV) The organization must 

18 have taken steps to communicate ef19 fectively its standards and procedures 

20 to all employees and other agents, 

21 such as by requiring participation in 

22 training programs or by disseminating 

23 publications that explain in a practical 

24 manner what is required. 
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1 ‘‘(V) The organization must have 

2 taken reasonable steps to achieve com3 pliance with its standards, such as by 

4 utilizing monitoring and auditing sys5 tems reasonably designed to detect 

6 criminal, civil, and administrative vio7 lations under this Act by its employ8 ees and other agents and by having in 

9 place and publicizing a reporting sys10 tem whereby employees and other 

11 agents could report violations by oth12 ers within the organization without 

13 fear of retribution. 

14 ‘‘(VI) The standards must have 

15 been consistently enforced through ap16 propriate disciplinary mechanisms, in17 cluding, as appropriate, discipline of 

18 individuals responsible for the failure 

19 to detect an offense. 

20 ‘‘(VII) After an offense has been 

21 detected, the organization must have 

22 taken all reasonable steps to respond 

23 appropriately to the offense and to 

24 prevent further similar offenses, in25 cluding repayment of any funds to 
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1 which it was not entitled and any nec2 essary modification to its program to 

3 prevent and detect criminal, civil, and 

4 administrative violations under this 

5 Act. 

6 ‘‘(VIII) The organization must 

7 periodically undertake reassessment of 

8 its compliance program to identify 

9 changes necessary to reflect changes 

10 within the organization and its facili11 ties. 

12 ‘‘(v) COORDINATION.—The provisions 

13 of this subparagraph shall apply with re14 spect to a skilled nursing facility in lieu of 

15 section 1874(d).’’. 

16 (2) NURSING FACILITIES.—Section 1919(d)(1) 

17 of the Social Security Act (42 U.S.C. 1396r(d)(1)), 

18 as amended by section 1411(c)(2), is amended by 

19 adding at the end the following new subparagraph: 

20 ‘‘(C) COMPLIANCE AND ETHICS PRO21 GRAM.— 

22 ‘‘(i) REQUIREMENT.—On or after the 

23 first day of the first calendar quarter be24 ginning after the date that is 1 year after 

25 the date on which regulations developed 
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1 under clause (ii) are published in the Fed2 eral Register, a skilled nursing facility 

3 shall, with respect to the entity that oper4 ates or controls the facility (in this sub5 paragraph referred to as the ‘operating or6 ganization’ or ‘organization’), have in oper7 ation a compliance and ethics program 

8 that is effective in preventing and detect9 ing criminal, civil, and administrative viola10 tions under this Act and in promoting 

11 quality of care consistent with such regula12 tions. 

13 ‘‘(iii) DEVELOPMENT OF REGULA14 TIONS.— 

15 ‘‘(I) IN GENERAL.—Not later 

16 than the date that is 2 years after the 

17 date of the enactment of this subpara18 graph, the Secretary, in consultation 

19 with the Inspector General of the De20 partment of Health and Human Serv21 ices, shall promulgate regulations for 

22 an effective compliance and ethics 

23 program for operating organizations, 

24 which may include a model compliance 

25 program. 
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1 ‘‘(II) DESIGN OF REGULA2 TIONS.—Such regulations with respect 

3 to specific elements or formality of a 

4 program may vary with the size of the 

5 organization, such that larger organi6 zations should have a more formal 

7 and rigorous program and include es8 tablished written policies defining the 

9 standards and procedures to be fol10 lowed by its employees. Such require11 ments shall specifically apply to the 

12 corporate level management of multi13 unit nursing home chains. 

14 ‘‘(III) EVALUATION.—Not later 

15 than 3 years after the date on which 

16 compliance and ethics programs estab17 lished under this subparagraph are in 

18 operation pursuant to clause (i), the 

19 Secretary shall complete an evaluation 

20 of such programs. Such evaluation 

21 shall determine if such programs led 

22 to changes in deficiency citations, 

23 changes in quality performance, or 

24 changes in other metrics of resident 

25 quality of care. The Secretary shall 
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1 submit to Congress a report on such 

2 evaluation and shall include in such 

3 report such recommendations regard4 ing changes in the requirements for 

5 such programs as the Secretary deter6 mines appropriate. 

7 ‘‘(v) REQUIREMENTS FOR COMPLI8 ANCE AND ETHICS PROGRAMS.—In this 

9 subparagraph, the term ‘compliance and 

10 ethics program’ means, with respect to a 

11 nursing facility, a program of the oper12 ating organization that— 

13 ‘‘(I) has been reasonably de14 signed, implemented, and enforced so 

15 that it generally will be effective in 

16 preventing and detecting criminal, 

17 civil, and administrative violations 

18 under this Act and in promoting qual19 ity of care; and 

20 ‘‘(II) includes at least the re21 quired components specified in clause 

22 (iv). 

23 ‘‘(vi) REQUIRED COMPONENTS OF

24 PROGRAM.—The required components of a 
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1 compliance and ethics program of an orga2 nization are the following: 

3 ‘‘(I) The organization must have 

4 established compliance standards and 

5 procedures to be followed by its em6 ployees and other agents that are rea7 sonably capable of reducing the pros8 pect of criminal, civil, and administra9 tive violations under this Act. 

10 ‘‘(II) Specific individuals within 

11 high-level personnel of the organiza12 tion must have been assigned overall 

13 responsibility to oversee compliance 

14 with such standards and procedures 

15 and has sufficient resources and au16 thority to assure such compliance. 

17 ‘‘(III) The organization must 

18 have used due care not to delegate 

19 substantial discretionary authority to 

20 individuals whom the organization 

21 knew, or should have known through 

22 the exercise of due diligence, had a 

23 propensity to engage in criminal, civil, 

24 and administrative violations under 

25 this Act. 
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1 ‘‘(IV) The organization must 

2 have taken steps to communicate ef3 fectively its standards and procedures 

4 to all employees and other agents, 

5 such as by requiring participation in 

6 training programs or by disseminating 

7 publications that explain in a practical 

8 manner what is required. 

9 ‘‘(V) The organization must have 

10 taken reasonable steps to achieve com11 pliance with its standards, such as by 

12 utilizing monitoring and auditing sys13 tems reasonably designed to detect 

14 criminal, civil, and administrative vio15 lations under this Act by its employ16 ees and other agents and by having in 

17 place and publicizing a reporting sys18 tem whereby employees and other 

19 agents could report violations by oth20 ers within the organization without 

21 fear of retribution. 

22 ‘‘(VI) The standards must have 

23 been consistently enforced through ap24 propriate disciplinary mechanisms, in25 cluding, as appropriate, discipline of 
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1 individuals responsible for the failure 

2 to detect an offense. 

3 ‘‘(VII) After an offense has been 

4 detected, the organization must have 

5 taken all reasonable steps to respond 

6 appropriately to the offense and to 

7 prevent further similar offenses, in8 cluding repayment of any funds to 

9 which it was not entitled and any nec10 essary modification to its program to 

11 prevent and detect criminal, civil, and 

12 administrative violations under this 

13 Act. 

14 ‘‘(VIII) The organization must 

15 periodically undertake reassessment of 

16 its compliance program to identify 

17 changes necessary to reflect changes 

18 within the organization and its facili19 ties. 

20 ‘‘(vii) COORDINATION.—The provi21 sions of this subparagraph shall apply with 

22 respect to a nursing facility in lieu of sec23 tion 1902(a)(77).’’. 

24 (b) QUALITY ASSURANCE AND PERFORMANCE IM25 PROVEMENT PROGRAM.— 
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1 (1) SKILLED NURSING FACILITIES.—Section 

2 1819(b)(1)(B) of the Social Security Act (42 U.S.C. 

3 1396r(b)(1)(B)) is amended— 

4 (A) by striking ‘‘ASSURANCE’’ and insert5 ing ‘‘ASSURANCE AND QUALITY ASSURANCE

6 AND PERFORMANCE IMPROVEMENT PROGRAM’’; 

7 (B) by designating the matter beginning 

8 with ‘‘A skilled nursing facility’’ as a clause (i) 

9 with the heading ‘‘IN GENERAL.—’’ and the ap10 propriate indentation; 

11 (C) in clause (i) (as so designated by sub12 paragraph (B)), by redesignating clauses (i) 

13 and (ii) as subclauses (I) and (II), respectively; 

14 and 

15 (D) by adding at the end the following new 

16 clause: 

17 ‘‘(ii) QUALITY ASSURANCE AND PER18 FORMANCE IMPROVEMENT PROGRAM.— 

19 ‘‘(I) IN GENERAL.—Not later 

20 than December 31, 2011, the Sec21 retary shall establish and implement a 

22 quality assurance and performance 

23 improvement program (in this clause 

24 referred to as the ‘QAPI program’) 

25 for skilled nursing facilities, including 
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1 multi-unit chains of such facilities. 

2 Under the QAPI program, the Sec3 retary shall establish standards relat4 ing to such facilities and provide tech5 nical assistance to such facilities on 

6 the development of best practices in 

7 order to meet such standards. Not 

8 later than 1 year after the date on 

9 which the regulations are promulgated 

10 under subclause (II), a skilled nursing 

11 facility must submit to the Secretary 

12 a plan for the facility to meet such 

13 standards and implement such best 

14 practices, including how to coordinate 

15 the implementation of such plan with 

16 quality assessment and assurance ac17 tivities conducted under clause (i). 

18 ‘‘(II) REGULATIONS.—The Sec19 retary shall promulgate regulations to 

20 carry out this clause.’’. 

21 (2) NURSING FACILITIES.—Section 

22 1919(b)(1)(B) of the Social Security Act (42 U.S.C. 

23 1396r(b)(1)(B)) is amended— 
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1 (A) by striking ‘‘ASSURANCE’’ and insert2 ing ‘‘ASSURANCE AND QUALITY ASSURANCE

3 AND PERFORMANCE IMPROVEMENT PROGRAM’’; 

4 (B) by designating the matter beginning 

5 with ‘‘A nursing facility’’ as a clause (i) with 

6 the heading ‘‘IN GENERAL.—’’ and the appro7 priate indentation; and 

8 (C) by adding at the end the following new 

9 clause: 

10 ‘‘(ii) QUALITY ASSURANCE AND PER11 FORMANCE IMPROVEMENT PROGRAM.— 

12 ‘‘(I) IN GENERAL.—Not later 

13 than December 31, 2011, the Sec14 retary shall establish and implement a 

15 quality assurance and performance 

16 improvement program (in this clause 

17 referred to as the ‘QAPI program’) 

18 for nursing facilities, including multi19 unit chains of such facilities. Under 

20 the QAPI program, the Secretary 

21 shall establish standards relating to 

22 such facilities and provide technical 

23 assistance to such facilities on the de24 velopment of best practices in order to 

25 meet such standards. Not later than 1 
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1 year after the date on which the regu2 lations are promulgated under sub3 clause (II), a nursing facility must 

4 submit to the Secretary a plan for the 

5 facility to meet such standards and 

6 implement such best practices, includ7 ing how to coordinate the implementa8 tion of such plan with quality assess9 ment and assurance activities con10 ducted under clause (i). 

11 ‘‘(II) REGULATIONS.—The Sec12 retary shall promulgate regulations to 

13 carry out this clause.’’. 

14 (3) PROPOSAL TO REVISE QUALITY ASSURANCE

15 AND PERFORMANCE IMPROVEMENT PROGRAMS.— 

16 The Secretary shall implement policies that modify 

17 and strengthen quality assurance and performance 

18 improvement programs in skilled nursing facilities 

19 and nursing facilities on a periodic basis, as deter20 mined by the Secretary. 

21 (4) FACILITY PLAN.—Not later than 1 year 

22 after the date on which the regulations are promul23 gated under subclause (II) of clause (ii) of sections 

24 1819(b)(1)(B) and 1919(b)(1)(B) of the Social Se25 curity Act, as added by paragraphs (1) and (2), a 
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1 skilled nursing facility and a nursing facility must 

2 submit to the Secretary a plan for the facility to 

3 meet the standards under such regulations and im4 plement such best practices, including how to coordi5 nate the implementation of such plan with quality 

6 assessment and assurance activities conducted under 

7 clause (i) of such sections. 

8 (c) GAO STUDY ON NURSING FACILITY UNDER9 CAPITALIZATION.— 

10 (1) IN GENERAL.—The Comptroller General of 

11 the United States shall conduct a study that exam12 ines the following: 

13 (A) The extent to which corporations that 

14 own or operate large numbers of nursing facili15 ties, taking into account ownership type (includ16 ing private equity and control interests), are 

17 undercapitalizing such facilities. 

18 (B) The effects of such undercapitalization 

19 on quality of care, including staffing and food 

20 costs, at such facilities. 

21 (C) Options to address such undercapital22 ization, such as requirements relating to surety 

23 bonds, liability insurance, or minimum capital24 ization. 
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1 (2) REPORT.—Not later than 18 months after 

2 the date of the enactment of this Act, the Comp3 troller General shall submit to Congress a report on 

4 the study conducted under paragraph (1). 

5 (3) NURSING FACILITY.—In this subsection, the 

6 term ‘‘nursing facility’’ includes a skilled nursing fa7 cility. 

8 SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE. 

9 (a) SKILLED NURSING FACILITIES.— 

10 (1) IN GENERAL.—Section 1819 of the Social 

11 Security Act (42 U.S.C. 1395i–3) is amended— 

12 (A) by redesignating subsection (i) as sub13 section (j); and 

14 (B) by inserting after subsection (h) the 

15 following new subsection: 

16 ‘‘(i) NURSING HOME COMPARE WEBSITE.— 

17 ‘‘(1) INCLUSION OF ADDITIONAL INFORMA18 TION.— 

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

20 ensure that the Department of Health and 

21 Human Services includes, as part of the infor22 mation provided for comparison of nursing 

23 homes on the official Internet website of the 

24 Federal Government for Medicare beneficiaries 

25 (commonly referred to as the ‘Nursing Home 
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1 Compare’ Medicare website) (or a successor 

2 website), the following information in a manner 

3 that is prominent, easily accessible, readily un4 derstandable to consumers of long-term care 

5 services, and searchable: 

6 ‘‘(i) Information that is reported to 

7 the Secretary under section 1124(c)(4). 

8 ‘‘(ii) Information on the ‘Special 

9 Focus Facility program’ (or a successor 

10 program) established by the Centers for 

11 Medicare and Medicaid Services, according 

12 to procedures established by the Secretary. 

13 Such procedures shall provide for the in14 clusion of information with respect to, and 

15 the names and locations of, those facilities 

16 that, since the previous quarter— 

17 ‘‘(I) were newly enrolled in the 

18 program; 

19 ‘‘(II) are enrolled in the program 

20 and have failed to significantly im21 prove; 

22 ‘‘(III) are enrolled in the pro23 gram and have significantly improved; 

24 ‘‘(IV) have graduated from the 

25 program; and 
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1 ‘‘(V) have closed voluntarily or 

2 no longer participate under this title. 

3 ‘‘(iii) Staffing data for each facility 

4 (including resident census data and data 

5 on the hours of care provided per resident 

6 per day) based on data submitted under 

7 subsection (b)(8)(C), including information 

8 on staffing turnover and tenure, in a for9 mat that is clearly understandable to con10 sumers of long-term care services and al11 lows such consumers to compare dif12 ferences in staffing between facilities and 

13 State and national averages for the facili14 ties. Such format shall include— 

15 ‘‘(I) concise explanations of how 

16 to interpret the data (such as a plain 

17 English explanation of data reflecting 

18 ‘nursing home staff hours per resident 

19 day’); 

20 ‘‘(II) differences in types of staff 

21 (such as training associated with dif22 ferent categories of staff); 

23 ‘‘(III) the relationship between 

24 nurse staffing levels and quality of 

25 care; and 
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1 ‘‘(IV) an explanation that appro2 priate staffing levels vary based on 

3 patient case mix. 

4 ‘‘(iv) Links to State internet websites 

5 with information regarding State survey 

6 and certification programs, links to Form 

7 2567 State inspection reports (or a suc8 cessor form) on such websites, information 

9 to guide consumers in how to interpret and 

10 understand such reports, and the facility 

11 plan of correction or other response to 

12 such report. 

13 ‘‘(v) The standardized complaint form 

14 developed under subsection (f)(8), includ15 ing explanatory material on what com16 plaint forms are, how they are used, and 

17 how to file a complaint with the State sur18 vey and certification program and the 

19 State long-term care ombudsman program. 

20 ‘‘(vi) Summary information on the 

21 number, type, severity, and outcome of 

22 substantiated complaints. 

23 ‘‘(vii) The number of adjudicated in24 stances of criminal violations by employees 

25 of a nursing facility— 
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1 ‘‘(I) that were committed inside 

2 the facility; 

3 ‘‘(II) with respect to such in4 stances of violations or crimes com5 mitted inside of the facility that were 

6 the violations or crimes of abuse, ne7 glect, and exploitation, criminal sexual 

8 abuse, or other violations or crimes 

9 that resulted in serious bodily injury; 

10 and 

11 ‘‘(viii) The number of civil monetary 

12 penalties levied against the facility, em13 ployees, contractors, and other agents. 

14 ‘‘(ix) Any other information that the 

15 Secretary determines appropriate. 

16 The facility shall not make available under 

17 clause (iv) identifying information on complain18 ants or residents. 

19 ‘‘(B) DEADLINE FOR PROVISION OF INFOR20 MATION.— 

21 ‘‘(i) IN GENERAL.—Except as pro22 vided in clause (ii), the Secretary shall en23 sure that the information described in sub24 paragraph (A) is included on such website 

25 (or a successor website) not later than 1 
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1 year after the date of the enactment of this 

2 subsection. 

3 ‘‘(ii) EXCEPTION.—The Secretary 

4 shall ensure that the information described 

5 in subparagraph (A)(i) and (A)(iii) is in6 cluded on such website (or a successor 

7 website) not later than 1 year after the 

8 dates on which the data are submitted to 

9 the Secretary pursuant to section 

10 1124(c)(4) and subsection (b)(8)(C), re11 spectively. 

12 ‘‘(2) REVIEW AND MODIFICATION OF

13 WEBSITE.— 

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

15 establish a process— 

16 ‘‘(i) to review the accuracy, clarity of 

17 presentation, timeliness, and comprehen18 siveness of information reported on such 

19 website as of the day before the date of the 

20 enactment of this subsection; and 

21 ‘‘(ii) not later than 1 year after the 

22 date of the enactment of this subsection, to 

23 modify or revamp such website in accord24 ance with the review conducted under 

25 clause (i). 
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1 ‘‘(B) CONSULTATION.—In conducting the 

2 review under subparagraph (A)(i), the Sec3 retary shall consult with— 

4 ‘‘(i) State long-term care ombudsman 

5 programs; 

6 ‘‘(ii) consumer advocacy groups; 

7 ‘‘(iii) provider stakeholder groups; and 

8 ‘‘(iv) any other representatives of pro9 grams or groups the Secretary determines 

10 appropriate.’’. 

11 (2) TIMELINESS OF SUBMISSION OF SURVEY

12 AND CERTIFICATION INFORMATION.— 

13 (A) IN GENERAL.—Section 1819(g)(5) of 

14 the Social Security Act (42 U.S.C. 1395i– 

15 3(g)(5)) is amended by adding at the end the 

16 following new subparagraph: 

17 ‘‘(E) SUBMISSION OF SURVEY AND CER18 TIFICATION INFORMATION TO THE SEC19 RETARY.—In order to improve the timeliness of 

20 information made available to the public under 

21 subparagraph (A) and provided on the Nursing 

22 Home Compare Medicare website under sub23 section (i), each State shall submit information 

24 respecting any survey or certification rec25 ommendation made respecting a skilled nursing 
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1 facility (including any enforcement actions 

2 taken by the State or any Federal enforcement 

3 action recommended by the State) to the Sec4 retary not later than the date on which the 

5 State sends such information to the facility. 

6 The Secretary shall use the information sub7 mitted under the preceding sentence to update 

8 the information provided on the Nursing Home 

9 Compare Medicare website as expeditiously as 

10 practicable but not less frequently than quar11 terly.’’. 

12 (B) EFFECTIVE DATE.—The amendment 

13 made by this paragraph shall take effect 1 year 

14 after the date of the enactment of this Act. 

15 (3) SPECIAL FOCUS FACILITY PROGRAM.—Sec16 tion 1819(f) of such Act is amended by adding at 

17 the end the following new paragraph: 

18 ‘‘(8) SPECIAL FOCUS FACILITY PROGRAM.— 

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

20 conduct a special focus facility program for en21 forcement of requirements for skilled nursing 

22 facilities that the Secretary has identified as 

23 having a poor compliance history or that sub24 stantially failed to meet applicable requirements 

25 of this Act. 
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1 ‘‘(B) PERIODIC SURVEYS.—Under such 

2 program the Secretary shall conduct surveys of 

3 each facility in the program not less than once 

4 every 6 months.’’. 

5 (b) NURSING FACILITIES.— 

6 (1) IN GENERAL.—Section 1919 of the Social 

7 Security Act (42 U.S.C. 1396r) is amended— 

8 (A) by redesignating subsection (i) as sub9 section (j); and 

10 (B) by inserting after subsection (h) the 

11 following new subsection: 

12 ‘‘(i) NURSING HOME COMPARE WEBSITE.— 

13 ‘‘(1) INCLUSION OF ADDITIONAL INFORMA14 TION.— 

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

16 ensure that the Department of Health and 

17 Human Services includes, as part of the infor18 mation provided for comparison of nursing 

19 homes on the official internet website of the 

20 Federal Government for Medicare beneficiaries 

21 (commonly referred to as the ‘Nursing Home 

22 Compare’ Medicare website) (or a successor 

23 website), the following information in a manner 

24 that is prominent, easily accessible, readily un-
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1 derstandable to consumers of long-term care 

2 services, and searchable: 

3 ‘‘(i) Information that is reported to 

4 the Secretary under section 1124(c)(4) 

5 ‘‘(ii) Information on the ‘Special 

6 Focus Facility program’ (or a successor 

7 program) established by the Centers for 

8 Medicare & Medicaid Services, according to 

9 procedures established by the Secretary. 

10 Such procedures shall provide for the in11 clusion of information with respect to, and 

12 the names and locations of, those facilities 

13 that, since the previous quarter— 

14 ‘‘(I) were newly enrolled in the 

15 program; 

16 ‘‘(II) are enrolled in the program 

17 and have failed to significantly im18 prove; 

19 ‘‘(III) are enrolled in the pro20 gram and have significantly improved; 

21 ‘‘(IV) have graduated from the 

22 program; and 

23 ‘‘(V) have closed voluntarily or 

24 no longer participate under this title. 
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1 ‘‘(iii) Staffing data for each facility 

2 (including resident census data and data 

3 on the hours of care provided per resident 

4 per day) based on data submitted under 

5 subsection (b)(8)(C)(ii), including informa6 tion on staffing turnover and tenure, in a 

7 format that is clearly understandable to 

8 consumers of long-term care services and 

9 allows such consumers to compare dif10 ferences in staffing between facilities and 

11 State and national averages for the facili12 ties. Such format shall include— 

13 ‘‘(I) concise explanations of how 

14 to interpret the data (such as plain 

15 English explanation of data reflecting 

16 ‘nursing home staff hours per resident 

17 day’); 

18 ‘‘(II) differences in types of staff 

19 (such as training associated with dif20 ferent categories of staff); 

21 ‘‘(III) the relationship between 

22 nurse staffing levels and quality of 

23 care; and 
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1 ‘‘(IV) an explanation that appro2 priate staffing levels vary based on 

3 patient case mix. 

4 ‘‘(iv) Links to State internet websites 

5 with information regarding State survey 

6 and certification programs, links to Form 

7 2567 State inspection reports (or a suc8 cessor form) on such websites, information 

9 to guide consumers in how to interpret and 

10 understand such reports, and the facility 

11 plan of correction or other response to 

12 such report. 

13 ‘‘(v) The standardized complaint form 

14 developed under subsection (f)(10), includ15 ing explanatory material on what com16 plaint forms are, how they are used, and 

17 how to file a complaint with the State sur18 vey and certification program and the 

19 State long-term care ombudsman program. 

20 ‘‘(vi) Summary information on the 

21 number, type, severity, and outcome of 

22 substantiated complaints. 

23 ‘‘(vii) The number of adjudicated in24 stances of criminal violations by employees 

25 of a nursing facility— 
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1 ‘‘(I) that were committed inside 

2 of the facility; and 

3 ‘‘(II) with respect to such in4 stances of violations or crimes com5 mitted inside of the facility that were 

6 the violations or crimes of abuse, ne7 glect, and exploitation, criminal sexual 

8 abuse, or other violations or crimes 

9 that resulted in serious bodily injury. 

10 ‘‘(viii) the number of civil monetary 

11 penalties levied against the facility, em12 ployees, contractors, and other agents. 

13 ‘‘(ix) Any other information that the 

14 Secretary determines appropriate. 

15 The facility shall not make available under 

16 clause (ii) identifying information about com17 plainants or residents. 

18 ‘‘(B) DEADLINE FOR PROVISION OF INFOR19 MATION.— 

20 ‘‘(i) IN GENERAL.—Except as pro21 vided in clause (ii), the Secretary shall en22 sure that the information described in sub23 paragraph (A) is included on such website 

24 (or a successor website) not later than 1 
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1 year after the date of the enactment of this 

2 subsection. 

3 ‘‘(ii) EXCEPTION.—The Secretary 

4 shall ensure that the information described 

5 in subparagraph (A)(i) and (A)(iii) is in6 cluded on such website (or a successor 

7 website) not later than 1 year after the 

8 dates on which the data are submitted to 

9 the Secretary pursuant to section 

10 1124(c)(4) and subsection (b)(8)(C), re11 spectively. 

12 ‘‘(2) REVIEW AND MODIFICATION OF

13 WEBSITE.— 

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

15 establish a process— 

16 ‘‘(i) to review the accuracy, clarity of 

17 presentation, timeliness, and comprehen18 siveness of information reported on such 

19 website as of the day before the date of the 

20 enactment of this subsection; and 

21 ‘‘(ii) not later than 1 year after the 

22 date of the enactment of this subsection, to 

23 modify or revamp such website in accord24 ance with the review conducted under 

25 clause (i). 
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1 ‘‘(B) CONSULTATION.—In conducting the 

2 review under subparagraph (A)(i), the Sec3 retary shall consult with— 

4 ‘‘(i) State long-term care ombudsman 

5 programs; 

6 ‘‘(ii) consumer advocacy groups; 

7 ‘‘(iii) provider stakeholder groups; 

8 ‘‘(iv) skilled nursing facility employees 

9 and their representatives; and 

10 ‘‘(v) any other representatives of pro11 grams or groups the Secretary determines 

12 appropriate.’’. 

13 (2) TIMELINESS OF SUBMISSION OF SURVEY

14 AND CERTIFICATION INFORMATION.— 

15 (A) IN GENERAL.—Section 1919(g)(5) of 

16 the Social Security Act (42 U.S.C. 1396r(g)(5)) 

17 is amended by adding at the end the following 

18 new subparagraph: 

19 ‘‘(E) SUBMISSION OF SURVEY AND CER20 TIFICATION INFORMATION TO THE SEC21 RETARY.—In order to improve the timeliness of 

22 information made available to the public under 

23 subparagraph (A) and provided on the Nursing 

24 Home Compare Medicare website under sub25 section (i), each State shall submit information 
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1 respecting any survey or certification rec2 ommendation made respecting a nursing facility 

3 (including any enforcement actions taken by the 

4 State or any Federal enforcement action rec5 ommended by the State) to the Secretary not 

6 later than the date on which the State sends 

7 such information to the facility. The Secretary 

8 shall use the information submitted under the 

9 preceding sentence to update the information 

10 provided on the Nursing Home Compare Medi11 care website as expeditiously as practicable but 

12 not less frequently than quarterly.’’. 

13 (B) EFFECTIVE DATE.—The amendment 

14 made by this paragraph shall take effect 1 year 

15 after the date of the enactment of this Act. 

16 (3) SPECIAL FOCUS FACILITY PROGRAM.—Sec17 tion 1919(f) of such Act is amended by adding at 

18 the end of the following new paragraph: 

19 ‘‘(10) SPECIAL FOCUS FACILITY PROGRAM.— 

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

21 conduct a special focus facility program for en22 forcement of requirements for nursing facilities 

23 that the Secretary has identified as having a 

24 poor compliance history or that substantially 
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1 failed to meet applicable requirements of this 

2 Act. 

3 ‘‘(B) PERIODIC SURVEYS.—Under such 

4 program the Secretary shall conduct surveys of 

5 each facility in the program not less often than 

6 once every 6 months.’’. 

7 (c) AVAILABILITY OF REPORTS ON SURVEYS, CER8 TIFICATIONS, AND COMPLAINT INVESTIGATIONS.— 

9 (1) SKILLED NURSING FACILITIES.—Section 

10 1819(d)(1) of the Social Security Act (42 U.S.C. 

11 1395i–3(d)(1)), as amended by sections 1411 and 

12 1412, is amended by adding at the end the following 

13 new subparagraph: 

14 ‘‘(D) AVAILABILITY OF SURVEY, CERTIFI15 CATION, AND COMPLAINT INVESTIGATION RE16 PORTS.—A skilled nursing facility must— 

17 ‘‘(i) have reports with respect to any 

18 surveys, certifications, and complaint in19 vestigations made respecting the facility 

20 during the 3 preceding years available for 

21 any individual to review upon request; and 

22 ‘‘(ii) post notice of the availability of 

23 such reports in areas of the facility that 

24 are prominent and accessible to the public. 
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1 The facility shall not make available under 

2 clause (i) identifying information about com3 plainants or residents.’’. 

4 (2) NURSING FACILITIES.—Section 1919(d)(1) 

5 of the Social Security Act (42 U.S.C. 1396r(d)(1)), 

6 as amended by sections 1411 and 1412, is amended 

7 by adding at the end the following new subpara8 graph: 

9 ‘‘(D) AVAILABILITY OF SURVEY, CERTIFI10 CATION, AND COMPLAINT INVESTIGATION RE11 PORTS.—A nursing facility must— 

12 ‘‘(i) have reports with respect to any 

13 surveys, certifications, and complaint in14 vestigations made respecting the facility 

15 during the 3 preceding years available for 

16 any individual to review upon request; and 

17 ‘‘(ii) post notice of the availability of 

18 such reports in areas of the facility that 

19 are prominent and accessible to the public. 

20 The facility shall not make available under 

21 clause (i) identifying information about com22 plainants or residents.’’. 

23 (3) EFFECTIVE DATE.—The amendments made 

24 by this subsection shall take effect 1 year after the 

25 date of the enactment of this Act. 
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1 (d) GUIDANCE TO STATES ON FORM 2567 STATE IN2 SPECTION REPORTS AND COMPLAINT INVESTIGATION RE3 PORTS.— 

4 (1) GUIDANCE.—The Secretary of Health and 

5 Human Services (in this subtitle referred to as the 

6 ‘‘Secretary’’) shall provide guidance to States on 

7 how States can establish electronic links to Form 

8 2567 State inspection reports (or a successor form), 

9 complaint investigation reports, and a facility’s plan 

10 of correction or other response to such Form 2567 

11 State inspection reports (or a successor form) on the 

12 Internet website of the State that provides informa13 tion on skilled nursing facilities and nursing facili14 ties and the Secretary shall, if possible, include such 

15 information on Nursing Home Compare. 

16 (2) REQUIREMENT.—Section 1902(a)(9) of the 

17 Social Security Act (42 U.S.C. 1396a(a)(9)) is 

18 amended— 

19 (A) by striking ‘‘and’’ at the end of sub20 paragraph (B); 

21 (B) by striking the semicolon at the end of 

22 subparagraph (C) and inserting ‘‘, and’’; and 

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

24 subparagraph: 
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1 ‘‘(D) that the State maintain a consumer2 oriented website providing useful information to 

3 consumers regarding all skilled nursing facili4 ties and all nursing facilities in the State, in5 cluding for each facility, Form 2567 State in6 spection reports (or a successor form), com7 plaint investigation reports, the facility’s plan of 

8 correction, and such other information that the 

9 State or the Secretary considers useful in as10 sisting the public to assess the quality of long 

11 term care options and the quality of care pro12 vided by individual facilities;’’. 

13 (3) DEFINITIONS.—In this subsection: 

14 (A) NURSING FACILITY.—The term ‘‘nurs15 ing facility’’ has the meaning given such term 

16 in section 1919(a) of the Social Security Act 

17 (42 U.S.C. 1396r(a)). 

18 (B) SECRETARY.—The term ‘‘Secretary’’ 

19 means the Secretary of Health and Human 

20 Services. 

21 (C) SKILLED NURSING FACILITY.—The 

22 term ‘‘skilled nursing facility’’ has the meaning 

23 given such term in section 1819(a) of the Social 

24 Security Act (42 U.S.C. 1395i–3(a)). 
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1 SEC. 1414. REPORTING OF EXPENDITURES. 

2 Section 1888 of the Social Security Act (42 U.S.C. 

3 1395yy) is amended by adding at the end the following 

4 new subsection: 

5 ‘‘(f) REPORTING OF DIRECT CARE EXPENDI6 TURES.— 

7 ‘‘(1) IN GENERAL.—For cost reports submitted 

8 under this title for cost reporting periods beginning 

9 on or after the date that is no more than two years 

10 after the redesign of the report specified in subpara11 graph (2), skilled nursing facilities shall— 

12 ‘‘(A) separately report expenditures for 

13 wages and benefits for direct care staff (break14 ing out (at a minimum) registered nurses, li15 censed professional nurses, certified nurse as16 sistants, and other medical and therapy staff); 

17 and 

18 ‘‘(B) take into account agency and con19 tract staff in a manner to be determined by the 

20 Administrator. 

21 ‘‘(2) MODIFICATION OF FORM.—The Secretary, 

22 in consultation with private sector accountants expe23 rienced with skilled nursing facility cost reports, 

24 shall redesign such reports to meet the requirement 

25 of paragraph (1) not later than 2 years after the 

26 date of the enactment of this subsection. 
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1 ‘‘(3) CATEGORIZATION BY FUNCTIONAL AC2 COUNTS.—Beginning with cost reports submitted 

3 under paragraph (1), the Secretary, working in con4 sultation with the Medicare Payment Advisory Com5 mission, the Inspector General of the Department of 

6 Health and Human Services, and other expert par7 ties the Secretary determines appropriate, shall cat8 egorize the expenditures listed on cost reports, as 

9 modified under paragraph (1), submitted by skilled 

10 nursing facilities, regardless of any source of pay11 ment for such expenditures, for each skilled nursing 

12 facility into the following functional accounts on an 

13 annual basis: 

14 ‘‘(A) Spending on direct care services (in15 cluding nursing, therapy, and medical services). 

16 ‘‘(B) Spending on indirect care (including 

17 housekeeping and dietary services). 

18 ‘‘(C) Capital assets (including building and 

19 land costs). 

20 ‘‘(D) Administrative services costs. 

21 ‘‘(4) AVAILABILITY OF INFORMATION SUB22 MITTED.—The Secretary shall establish procedures 

23 to make information on expenditures submitted 

24 under this subsection readily available to interested 

25 parties upon request, subject to such requirements 
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1 as the Secretary may specify under the procedures 

2 established under this paragraph.’’. 

3 SEC. 1415. STANDARDIZED COMPLAINT FORM. 

4 (a) SKILLED NURSING FACILITIES.— 

5 (1) DEVELOPMENT BY THE SECRETARY.—Sec6 tion 1819(f) of the Social Security Act (42 U.S.C. 

7 1395i–3(f)), as amended by section 1413(a)(3), is 

8 amended by adding at the end the following new 

9 paragraph: 

10 ‘‘(9) STANDARDIZED COMPLAINT FORM.—The 

11 Secretary shall develop a standardized complaint 

12 form for use by a resident (or a person acting on the 

13 resident’s behalf) in filing a complaint with a State 

14 survey and certification agency and a State long15 term care ombudsman program with respect to a 

16 skilled nursing facility.’’. 

17 (2) STATE REQUIREMENTS.—Section 1819(e) 

18 of the Social Security Act (42 U.S.C. 1395i–3(e)) is 

19 amended by adding at the end the following new 

20 paragraph: 

21 ‘‘(6) COMPLAINT PROCESSES AND WHISTLE22 BLOWER PROTECTION.— 

23 ‘‘(A) COMPLAINT FORMS.—The State must 

24 make the standardized complaint form devel-
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1 oped under subsection (f)(9) available upon re2 quest to— 

3 ‘‘(i) a resident of a skilled nursing fa4 cility; 

5 ‘‘(ii) any person acting on the resi6 dent’s behalf; and 

7 ‘‘(iii) any person who works at a 

8 skilled nursing facility or is a representa9 tive of such a worker. 

10 ‘‘(B) COMPLAINT RESOLUTION PROCESS.— 

11 The State must establish a complaint resolution 

12 process in order to ensure that a resident, the 

13 legal representative of a resident of a skilled 

14 nursing facility, or other responsible party is 

15 not retaliated against if the resident, legal rep16 resentative, or responsible party has com17 plained, in good faith, about the quality of care 

18 or other issues relating to the skilled nursing 

19 facility, that the legal representative of a resi20 dent of a skilled nursing facility or other re21 sponsible party is not denied access to such 

22 resident or otherwise retaliated against if such 

23 representative party has complained, in good 

24 faith, about the quality of care provided by the 

25 facility or other issues relating to the facility, 
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1 and that a person who works at a skilled nurs2 ing facility is not retaliated against if the work3 er has complained, in good faith, about quality 

4 of care or services or an issue relating to the 

5 quality of care or services provided at the facil6 ity, whether the resident, legal representative, 

7 other responsible party, or worker used the 

8 form developed under subsection (f)(9) or some 

9 other method for submitting the complaint. 

10 Such complaint resolution process shall in11 clude— 

12 ‘‘(i) procedures to assure accurate 

13 tracking of complaints received, including 

14 notification to the complainant that a com15 plaint has been received; 

16 ‘‘(ii) procedures to determine the like17 ly severity of a complaint and for the in18 vestigation of the complaint; 

19 ‘‘(iii) deadlines for responding to a 

20 complaint and for notifying the complain21 ant of the outcome of the investigation; 

22 and 

23 ‘‘(iv) procedures to ensure that the 

24 identity of the complainant will be kept 

25 confidential. 
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1 ‘‘(C) WHISTLEBLOWER PROTECTION.— 

2 ‘‘(i) PROHIBITION AGAINST RETALIA3 TION.—No person who works at a skilled 

4 nursing facility may be penalized, discrimi5 nated, or retaliated against with respect to 

6 any aspect of employment, including dis7 charge, promotion, compensation, terms, 

8 conditions, or privileges of employment, or 

9 have a contract for services terminated, be10 cause the person (or anyone acting at the 

11 person’s request) complained, in good 

12 faith, about the quality of care or services 

13 provided by a skilled nursing facility or 

14 about other issues relating to quality of 

15 care or services, whether using the form 

16 developed under subsection (f)(9) or some 

17 other method for submitting the complaint. 

18 ‘‘(ii) RETALIATORY REPORTING.—A 

19 skilled nursing facility may not file a com20 plaint or a report against a person who 

21 works (or has worked at the facility) with 

22 the appropriate State professional discipli23 nary agency because the person (or anyone 

24 acting at the person’s request) complained 

25 in good faith, as described in clause (i). 
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1 ‘‘(iii) RELIEF.—Any person aggrieved 

2 by a violation of clause (i) or clause (ii) 

3 may, in a civil action, obtain all appro4 priate relief, including reinstatement, reim5 bursement of lost wages, compensation, 

6 and benefits, and exemplary damages 

7 where warranted, and such other relief as 

8 the court deems appropriate, as well as 

9 costs of suit and reasonable attorney and 

10 expert witness fees. 

11 ‘‘(iv) RIGHTS NOT WAIVABLE.—The 

12 rights protected by this paragraph may not 

13 be diminished by contract or other agree14 ment, and nothing in this paragraph shall 

15 be construed to diminish any greater or 

16 additional protection provided by Federal 

17 or State law or by contract or other agree18 ment. 

19 ‘‘(v) REQUIREMENT TO POST NOTICE

20 OF EMPLOYEE RIGHTS.—Each skilled 

21 nursing facility shall post conspicuously in 

22 an appropriate location a sign (in a form 

23 specified by the Secretary) specifying the 

24 rights of persons under this paragraph and 

25 including a statement that an employee 
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1 may file a complaint with the Secretary 

2 against a skilled nursing facility that vio3 lates the provisions of this paragraph and 

4 information with respect to the manner of 

5 filing such a complaint. 

6 ‘‘(D) RULE OF CONSTRUCTION.—Nothing 

7 in this paragraph shall be construed as pre8 venting a resident of a skilled nursing facility 

9 (or a person acting on the resident’s behalf) 

10 from submitting a complaint in a manner or 

11 format other than by using the standardized 

12 complaint form developed under subsection 

13 (f)(9) (including submitting a complaint orally). 

14 ‘‘(E) GOOD FAITH DEFINED.—For pur15 poses of this paragraph, an individual shall be 

16 deemed to be acting in good faith with respect 

17 to the filing of a complaint if the individual rea18 sonably believes— 

19 ‘‘(i) the information reported or dis20 closed in the complaint is true; and 

21 ‘‘(ii) the violation of this title has oc22 curred or may occur in relation to such in23 formation.’’. 

24 (b) NURSING FACILITIES.— 
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1 (1) DEVELOPMENT BY THE SECRETARY.—Sec2 tion 1919(f) of the Social Security Act (42 U.S.C. 

3 1395i–3(f)), as amended by section 1413(b), is 

4 amended by adding at the end the following new 

5 paragraph: 

6 ‘‘(11) STANDARDIZED COMPLAINT FORM.—The 

7 Secretary shall develop a standardized complaint 

8 form for use by a resident (or a person acting on the 

9 resident’s behalf) in filing a complaint with a State 

10 survey and certification agency and a State long11 term care ombudsman program with respect to a 

12 nursing facility.’’. 

13 (2) STATE REQUIREMENTS.—Section 1919(e) 

14 of the Social Security Act (42 U.S.C. 1395i–3(e)) is 

15 amended by adding at the end the following new 

16 paragraph: 

17 ‘‘(8) COMPLAINT PROCESSES AND WHISTLE18 BLOWER PROTECTION.— 

19 ‘‘(A) COMPLAINT FORMS.—The State must 

20 make the standardized complaint form devel21 oped under subsection (f)(11) available upon re22 quest to— 

23 ‘‘(i) a resident of a nursing facility; 

24 ‘‘(ii) any person acting on the resi25 dent’s behalf; and 
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•HR 3962 EH

1 ‘‘(iii) any person who works at a nurs2 ing facility or a representative of such a 

3 worker. 

4 ‘‘(B) COMPLAINT RESOLUTION PROCESS.— 

5 The State must establish a complaint resolution 

6 process in order to ensure that a resident, the 

7 legal representative of a resident of a nursing 

8 facility, or other responsible party is not retali9 ated against if the resident, legal representa10 tive, or responsible party has complained, in 

11 good faith, about the quality of care or other 

12 issues relating to the nursing facility, that the 

13 legal representative of a resident of a nursing 

14 facility or other responsible party is not denied 

15 access to such resident or otherwise retaliated 

16 against if such representative party has com17 plained, in good faith, about the quality of care 

18 provided by the facility or other issues relating 

19 to the facility, and that a person who works at 

20 a nursing facility is not retaliated against if the 

21 worker has complained, in good faith, about 

22 quality of care or services or an issue relating 

23 to the quality of care or services provided at the 

24 facility, whether the resident, legal representa25 tive, other responsible party, or worker used the 
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•HR 3962 EH

1 form developed under subsection (f)(11) or 

2 some other method for submitting the com3 plaint. Such complaint resolution process shall 

4 include— 

5 ‘‘(i) procedures to assure accurate 

6 tracking of complaints received, including 

7 notification to the complainant that a com8 plaint has been received; 

9 ‘‘(ii) procedures to determine the like10 ly severity of a complaint and for the in11 vestigation of the complaint; 

12 ‘‘(iii) deadlines for responding to a 

13 complaint and for notifying the complain14 ant of the outcome of the investigation; 

15 and 

16 ‘‘(iv) procedures to ensure that the 

17 identity of the complainant will be kept 

18 confidential. 

19 ‘‘(C) WHISTLEBLOWER PROTECTION.— 

20 ‘‘(i) PROHIBITION AGAINST RETALIA21 TION.—No person who works at a nursing 

22 facility may be penalized, discriminated, or 

23 retaliated against with respect to any as24 pect of employment, including discharge, 

25 promotion, compensation, terms, condi-
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•HR 3962 EH

1 tions, or privileges of employment, or have 

2 a contract for services terminated, because 

3 the person (or anyone acting at the per4 son’s request) complained, in good faith, 

5 about the quality of care or services pro6 vided by a nursing facility or about other 

7 issues relating to quality of care or serv8 ices, whether using the form developed 

9 under subsection (f)(11) or some other 

10 method for submitting the complaint. 

11 ‘‘(ii) RETALIATORY REPORTING.—A 

12 nursing facility may not file a complaint or 

13 a report against a person who works (or 

14 has worked at the facility with the appro15 priate State professional disciplinary agen16 cy because the person (or anyone acting at 

17 the person’s request) complained in good 

18 faith, as described in clause (i). 

19 ‘‘(iii) RELIEF.—Any person aggrieved 

20 by a violation of clause (i) or clause (ii) 

21 may, in a civil action, obtain all appro22 priate relief, including reinstatement, reim23 bursement of lost wages, compensation, 

24 and benefits, and exemplary damages 

25 where warranted, and such other relief as 
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•HR 3962 EH

1 the court deems appropriate, as well as 

2 costs of suit and reasonable attorney and 

3 expert witness fees. 

4 ‘‘(iv) RIGHTS NOT WAIVABLE.—The 

5 rights protected by this paragraph may not 

6 be diminished by contract or other agree7 ment, and nothing in this paragraph shall 

8 be construed to diminish any greater or 

9 additional protection provided by Federal 

10 or State law or by contract or other agree11 ment. 

12 ‘‘(v) REQUIREMENT TO POST NOTICE

13 OF EMPLOYEE RIGHTS.—Each nursing fa14 cility shall post conspicuously in an appro15 priate location a sign (in a form specified 

16 by the Secretary) specifying the rights of 

17 persons under this paragraph and includ18 ing a statement that an employee may file 

19 a complaint with the Secretary against a 

20 nursing facility that violates the provisions 

21 of this paragraph and information with re22 spect to the manner of filing such a com23 plaint. 

24 ‘‘(D) RULE OF CONSTRUCTION.—Nothing 

25 in this paragraph shall be construed as pre-
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1 venting a resident of a nursing facility (or a 

2 person acting on the resident’s behalf) from 

3 submitting a complaint in a manner or format 

4 other than by using the standardized complaint 

5 form developed under subsection (f)(11) (in6 cluding submitting a complaint orally). 

7 ‘‘(E) GOOD FAITH DEFINED.—For pur8 poses of this paragraph, an individual shall be 

9 deemed to be acting in good faith with respect 

10 to the filing of a complaint if the individual rea11 sonably believes— 

12 ‘‘(i) the information reported or dis13 closed in the complaint is true; and 

14 ‘‘(ii) the violation of this title has oc15 curred or may occur in relation to such in16 formation.’’. 

17 (c) EFFECTIVE DATE.—The amendments made by 

18 this section shall take effect 1 year after the date of the 

19 enactment of this Act. 

20 SEC. 1416. ENSURING STAFFING ACCOUNTABILITY. 

21 (a) SKILLED NURSING FACILITIES.—Section 

22 1819(b)(8) of the Social Security Act (42 U.S.C. 1395i– 

23 3(b)(8)) is amended by adding at the end the following 

24 new subparagraph: 
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•HR 3962 EH

1 ‘‘(C) SUBMISSION OF STAFFING INFORMA2 TION BASED ON PAYROLL DATA IN A UNIFORM

3 FORMAT.—On and after the first day of the 

4 first calendar quarter beginning after the date 

5 that is 2 years after the date of enactment of 

6 this subparagraph, and after consulting with 

7 State long-term care ombudsman programs, 

8 consumer advocacy groups, provider stakeholder 

9 groups, employees and their representatives, 

10 and other parties the Secretary deems appro11 priate, the Secretary shall require a skilled 

12 nursing facility to electronically submit to the 

13 Secretary direct care staffing information (in14 cluding information with respect to agency and 

15 contract staff) based on payroll and other 

16 verifiable and auditable data in a uniform for17 mat (according to specifications established by 

18 the Secretary in consultation with such pro19 grams, groups, and parties). Such specifications 

20 shall require that the information submitted 

21 under the preceding sentence— 

22 ‘‘(i) specify the category of work a 

23 certified employee performs (such as 

24 whether the employee is a registered nurse, 

25 licensed practical nurse, licensed vocational 
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•HR 3962 EH

1 nurse, certified nursing assistant, thera2 pist, or other medical personnel); 

3 ‘‘(ii) include resident census data and 

4 information on resident case mix; 

5 ‘‘(iii) include a regular reporting 

6 schedule; and 

7 ‘‘(iv) include information on employee 

8 turnover and tenure and on the hours of 

9 care provided by each category of certified 

10 employees referenced in clause (i) per resi11 dent per day. 

12 Nothing in this subparagraph shall be con13 strued as preventing the Secretary from requir14 ing submission of such information with respect 

15 to specific categories, such as nursing staff, be16 fore other categories of certified employees. In17 formation under this subparagraph with respect 

18 to agency and contract staff shall be kept sepa19 rate from information on employee staffing.’’. 

20 (b) NURSING FACILITIES.—Section 1919(b)(8) of the 

21 Social Security Act (42 U.S.C. 1396r(b)(8)) is amended 

22 by adding at the end the following new subparagraph: 

23 ‘‘(C) SUBMISSION OF STAFFING INFORMA24 TION BASED ON PAYROLL DATA IN A UNIFORM

25 FORMAT.—On and after the first day of the 
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•HR 3962 EH

1 first calendar quarter beginning after the date 

2 that is 2 years after the date of enactment of 

3 this subparagraph, and after consulting with 

4 State long-term care ombudsman programs, 

5 consumer advocacy groups, provider stakeholder 

6 groups, employees and their representatives, 

7 and other parties the Secretary deems appro8 priate, the Secretary shall require a nursing fa9 cility to electronically submit to the Secretary 

10 direct care staffing information (including in11 formation with respect to agency and contract 

12 staff) based on payroll and other verifiable and 

13 auditable data in a uniform format (according 

14 to specifications established by the Secretary in 

15 consultation with such programs, groups, and 

16 parties). Such specifications shall require that 

17 the information submitted under the preceding 

18 sentence— 

19 ‘‘(i) specify the category of work a 

20 certified employee performs (such as 

21 whether the employee is a registered nurse, 

22 licensed practical nurse, licensed vocational 

23 nurse, certified nursing assistant, thera24 pist, or other medical personnel); 
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•HR 3962 EH

1 ‘‘(ii) include resident census data and 

2 information on resident case mix; 

3 ‘‘(iii) include a regular reporting 

4 schedule; and 

5 ‘‘(iv) include information on employee 

6 turnover and tenure and on the hours of 

7 care provided by each category of certified 

8 employees referenced in clause (i) per resi9 dent per day. 

10 Nothing in this subparagraph shall be con11 strued as preventing the Secretary from requir12 ing submission of such information with respect 

13 to specific categories, such as nursing staff, be14 fore other categories of certified employees. In15 formation under this subparagraph with respect 

16 to agency and contract staff shall be kept sepa17 rate from information on employee staffing.’’. 

18 SEC. 1417. NATIONWIDE PROGRAM FOR NATIONAL AND 

19 STATE BACKGROUND CHECKS ON DIRECT PA20 TIENT ACCESS EMPLOYEES OF LONG-TERM 

21 CARE FACILITIES AND PROVIDERS. 

22 (a) IN GENERAL.—The Secretary of Health and 

23 Human Services (in this section referred to as the ‘‘Sec24 retary’’), shall establish a program to identify efficient, ef25 fective, and economical procedures for long term care fa-
835 

•HR 3962 EH

1 cilities or providers to conduct background checks on pro2 spective direct patient access employees on a nationwide 

3 basis (in this subsection, such program shall be referred 

4 to as the ‘‘nationwide program’’). The Secretary shall 

5 carry out the nationwide program under similar terms and 

6 conditions as the pilot program under section 307 of the 

7 Medicare Prescription Drug, Improvement, and Mod8 ernization Act of 2003 (Public Law 108–173; 117 Stat. 

9 2257), including the prohibition on hiring abusive workers 

10 and the authorization of the imposition of penalties by a 

11 participating State under subsections (b)(3)(A) and 

12 (b)(6), respectively, of such section 307. The program 

13 under this subsection shall contain the following modifica14 tions to such pilot program: 

15 (1) AGREEMENTS.— 

16 (A) NEWLY PARTICIPATING STATES.—The 

17 Secretary shall enter into agreements with each 

18 State— 

19 (i) that the Secretary has not entered 

20 into an agreement with under subsection 

21 (c)(1) of such section 307; 

22 (ii) that agrees to conduct background 

23 checks under the nationwide program on a 

24 Statewide basis; and 
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•HR 3962 EH

1 (iii) that submits an application to the 

2 Secretary containing such information and 

3 at such time as the Secretary may specify. 

4 Under such an agreement a State may 

5 agree to cover and reimburse each long6 term care facility or provider for all costs 

7 attributable to conducting background 

8 checks and screening described in this sub9 section that were not otherwise required to 

10 be conducted by such long-term care facil11 ity or provider before the enactment of this 

12 subsection, except that Federal funding 

13 with respect to such reimbursement shall 

14 be limited to the amount made available to 

15 the State from funds under subsection 

16 (b)(1). 

17 (B) CERTAIN PREVIOUSLY PARTICIPATING

18 STATES.—The Secretary shall enter into agree19 ments with each State— 

20 (i) that the Secretary has entered into 

21 an agreement with under such subsection 

22 (c)(1); 

23 (ii) that agrees to conduct background 

24 checks under the nationwide program on a 

25 Statewide basis; and 
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•HR 3962 EH

1 (iii) that submits an application to the 

2 Secretary containing such information and 

3 at such time as the Secretary may specify. 

4 Under such an agreement a State may 

5 agree to cover and reimburse each long6 term care facility or provider for all costs 

7 attributable to conducting background 

8 checks and screening described in this sub9 section that were not otherwise required to 

10 be conducted by such long-term care facil11 ity or provider before the enactment of this 

12 subsection, except that Federal funding 

13 with respect to such reimbursement shall 

14 be limited to the amount made available to 

15 the State from funds under subsection 

16 (b)(1). 

17 (2) NONAPPLICATION OF SELECTION CRI18 TERIA.—The selection criteria required under sub19 section (c)(3)(B) of such section 307 shall not apply. 

20 (3) REQUIRED FINGERPRINT CHECK AS PART

21 OF CRIMINAL BACKGROUND CHECK.—The proce22 dures established under subsection (b)(1) of such 

23 section 307 shall— 

24 (A) require that the long-term care facility 

25 or provider (or the designated agent of the 
838 

•HR 3962 EH

1 long-term care facility or provider) obtain State 

2 and national criminal or other background 

3 checks on the prospective employee through 

4 such means as the Secretary determines appro5 priate that utilize a search of State-based abuse 

6 and neglect registries and databases, including 

7 the abuse and neglect registries of another 

8 State in the case where a prospective employee 

9 previously resided in that State, State criminal 

10 history records, the records of any proceedings 

11 in the State that may contain disqualifying in12 formation about prospective employees (such as 

13 proceedings conducted by State professional li14 censing and disciplinary boards and State Med15 icaid Fraud Control Units), and Federal crimi16 nal history records, including a fingerprint 

17 check using the Integrated Automated Finger18 print Identification System of the Federal Bu19 reau of Investigation; and 

20 (B) require States to describe and test 

21 methods that reduce duplicative fingerprinting, 

22 including providing for the development of ‘‘rap 

23 back’’ capability by the State such that, if a di24 rect patient access employee of a long-term care 

25 facility or provider is convicted of a crime fol-
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•HR 3962 EH

1 lowing the initial criminal history background 

2 check conducted with respect to such employee, 

3 and the employee’s fingerprints match the 

4 prints on file with the State law enforcement 

5 department, the department will immediately 

6 inform the State and the State will immediately 

7 inform the long-term care facility or provider 

8 which employs the direct patient access em9 ployee of such conviction. 

10 (4) STATE REQUIREMENTS.—An agreement en11 tered into under paragraph (1) shall require that a 

12 participating State— 

13 (A) be responsible for monitoring compli14 ance with the requirements of the nationwide 

15 program; 

16 (B) have procedures in place to— 

17 (i) conduct screening and criminal or 

18 other background checks under the nation19 wide program in accordance with the re20 quirements of this section; 

21 (ii) monitor compliance by long-term 

22 care facilities and providers with the proce23 dures and requirements of the nationwide 

24 program; 
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•HR 3962 EH

1 (iii) as appropriate, provide for a pro2 visional period of employment by a long3 term care facility or provider of a direct 

4 patient access employee, not to exceed 60 

5 days, pending completion of the required 

6 criminal history background check and, in 

7 the case where the employee has appealed 

8 the results of such background check, 

9 pending completion of the appeals process, 

10 during which the employee shall be subject 

11 to direct on-site supervision (in accordance 

12 with procedures established by the State to 

13 ensure that a long-term care facility or 

14 provider furnishes such direct on-site su15 pervision); 

16 (iv) provide an independent process by 

17 which a provisional employee or an em18 ployee may appeal or dispute the accuracy 

19 of the information obtained in a back20 ground check performed under the nation21 wide program, including the specification 

22 of criteria for appeals for direct patient ac23 cess employees found to have disqualifying 

24 information which shall include consider25 ation of the passage of time, extenuating 
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•HR 3962 EH

1 circumstances, demonstration of rehabilita2 tion, and relevancy of the particular dis3 qualifying information with respect to the 

4 current employment of the individual; 

5 (v) provide for the designation of a 

6 single State agency as responsible for— 

7 (I) overseeing the coordination of 

8 any State and national criminal his9 tory background checks requested by 

10 a long-term care facility or provider 

11 (or the designated agent of the long12 term care facility or provider) utilizing 

13 a search of State and Federal crimi14 nal history records, including a finger15 print check of such records; 

16 (II) overseeing the design of ap17 propriate privacy and security safe18 guards for use in the review of the re19 sults of any State or national criminal 

20 history background checks conducted 

21 regarding a prospective direct patient 

22 access employee to determine whether 

23 the employee has any conviction for a 

24 relevant crime; 
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•HR 3962 EH

1 (III) immediately reporting to 

2 the long-term care facility or provider 

3 that requested the criminal history 

4 background check the results of such 

5 review; and 

6 (IV) in the case of an employee 

7 with a conviction for a relevant crime 

8 that is subject to reporting under sec9 tion 1128E of the Social Security Act 

10 (42 U.S.C. 1320a–7e), reporting the 

11 existence of such conviction to the 

12 database established under that sec13 tion; 

14 (vi) determine which individuals are 

15 direct patient access employees (as defined 

16 in paragraph (6)(B)) for purposes of the 

17 nationwide program; 

18 (vii) as appropriate, specify offenses, 

19 including convictions for violent crimes, for 

20 purposes of the nationwide program; and 

21 (viii) describe and test methods that 

22 reduce duplicative fingerprinting, including 

23 providing for the development of ‘‘rap 

24 back’’ capability such that, if a direct pa25 tient access employee of a long-term care 
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1 facility or provider is convicted of a crime 

2 following the initial criminal history back3 ground check conducted with respect to 

4 such employee, and the employee’s finger5 prints match the prints on file with the 

6 State law enforcement department— 

7 (I) the department will imme8 diately inform the State agency des9 ignated under clause (v) and such 

10 agency will immediately inform the fa11 cility or provider which employs the 

12 direct patient access employee of such 

13 conviction; and 

14 (II) the State will provide, or will 

15 require the facility to provide, to the 

16 employee a copy of the results of the 

17 criminal history background check 

18 conducted with respect to the em19 ployee at no charge in the case where 

20 the individual requests such a copy. 

21 Background checks and screenings under 

22 this subsection shall be valid for a period 

23 of no longer than 2 years, as determined 

24 by the State and approved by the Sec25 retary. 
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1 (5) PAYMENTS.— 

2 (A) NEWLY PARTICIPATING STATES.— 

3 (i) IN GENERAL.—As part of the ap4 plication submitted by a State under para5 graph (1)(A)(iii), the State shall guar6 antee, with respect to the costs to be in7 curred by the State in carrying out the na8 tionwide program, that the State will make 

9 available (directly or through donations 

10 from public or private entities) a particular 

11 amount of non-Federal contributions, as a 

12 condition of receiving the Federal match 

13 under clause (ii). 

14 (ii) FEDERAL MATCH.—The payment 

15 amount to each State that the Secretary 

16 enters into an agreement with under para17 graph (1)(A) shall be 3 times the amount 

18 that the State guarantees to make avail19 able under clause (i). 

20 (B) PREVIOUSLY PARTICIPATING

21 STATES.— 

22 (i) IN GENERAL.—As part of the ap23 plication submitted by a State under para24 graph (1)(B)(iii), the State shall guar25 antee, with respect to the costs to be in-
845 

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1 curred by the State in carrying out the na2 tionwide program, that the State will make 

3 available (directly or through donations 

4 from public or private entities) a particular 

5 amount of non-Federal contributions, as a 

6 condition of receiving the Federal match 

7 under clause (ii). 

8 (ii) FEDERAL MATCH.—The payment 

9 amount to each State that the Secretary 

10 enters into an agreement with under para11 graph (1)(B) shall be 3 times the amount 

12 that the State guarantees to make avail13 able under clause (i). 

14 (6) DEFINITIONS.—Under the nationwide pro15 gram: 

16 (A) LONG-TERM CARE FACILITY OR PRO17 VIDER.—The term ‘‘long-term care facility or 

18 provider’’ means the following facilities or pro19 viders which receive payment for services under 

20 title XVIII or XIX of the Social Security Act: 

21 (i) A skilled nursing facility (as de22 fined in section 1819(a) of the Social Secu23 rity Act (42 U.S.C. 1395i–3(a))). 
846 

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1 (ii) A nursing facility (as defined in 

2 section 1919(a) of such Act (42 U.S.C. 

3 1396r(a))). 

4 (iii) A home health agency. 

5 (iv) A provider of hospice care (as de6 fined in section 1861(dd)(1) of such Act 

7 (42 U.S.C. 1395x(dd)(1))). 

8 (v) A long-term care hospital (as de9 scribed in section 1886(d)(1)(B)(iv) of 

10 such Act (42 U.S.C. 

11 1395ww(d)(1)(B)(iv))). 

12 (vi) A provider of personal care serv13 ices. 

14 (vii) A provider of adult day care. 

15 (viii) A residential care provider that 

16 arranges for, or directly provides, long17 term care services, including an assisted 

18 living facility that provides a nursing home 

19 level of care conveyed by State licensure or 

20 State definition. 

21 (ix) An intermediate care facility for 

22 the mentally retarded (as defined in sec23 tion 1905(d) of such Act (42 U.S.C. 

24 1396d(d))). 
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1 (x) Any other facility or provider of 

2 long-term care services under such titles as 

3 the participating State determines appro4 priate. 

5 (B) DIRECT PATIENT ACCESS EM6 PLOYEE.—The term ‘‘direct patient access em7 ployee’’ means any individual who has access to 

8 a patient or resident of a long-term care facility 

9 or provider through employment or through a 

10 contract with such facility or provider and has 

11 duties that involve (or may involve) one-on-one 

12 contact with a patient or resident of the facility 

13 or provider, as determined by the State for pur14 poses of the nationwide program. Such term 

15 does not include a volunteer unless the volun16 teer has duties that are equivalent to the duties 

17 of a direct patient access employee and those 

18 duties involve (or may involve) one-on-one con19 tact with a patient or resident of the long-term 

20 care facility or provider. 

21 (7) EVALUATION AND REPORT.— 

22 (A) EVALUATION.—The Inspector General 

23 of the Department of Health and Human Serv24 ices shall conduct an evaluation of the nation25 wide program. Such evaluation shall include— 
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1 (i) a review of the various procedures 

2 implemented by participating States for 

3 long-term care facilities or providers, in4 cluding staffing agencies, to conduct back5 ground checks of direct patient access em6 ployees and identify the most efficient, ef7 fective, and economical procedures for con8 ducting such background checks; 

9 (ii) an assessment of the costs of con10 ducting such background checks (including 

11 start-up and administrative costs); 

12 (iii) a determination of the extent to 

13 which conducting such background checks 

14 leads to any unintended consequences, in15 cluding a reduction in the available work16 force for such facilities or providers; 

17 (iv) an assessment of the impact of 

18 the program on reducing the number of in19 cidents of neglect, abuse, and misappro20 priation of resident property to the extent 

21 practicable; and 

22 (v) an evaluation of other aspects of 

23 the program, as determined appropriate by 

24 the Secretary. 
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1 (B) REPORT.—Not later than 180 days 

2 after the completion of the nationwide program, 

3 the Inspector General of the Department of 

4 Health and Human Services shall submit a re5 port to Congress containing the results of the 

6 evaluation conducted under subparagraph (A). 

7 (b) FUNDING.— 

8 (1) NOTIFICATION.—The Secretary of Health 

9 and Human Services shall notify the Secretary of 

10 the Treasury of the amount necessary to carry out 

11 the nationwide program under this section, including 

12 costs for the Department of Health and Human 

13 Services to administer and evaluate the program, for 

14 the period of fiscal years 2010 through 2012, except 

15 that in no case shall such amount exceed 

16 $160,000,000. 

17 (2) TRANSFER OF FUNDS.—Out of any funds 

18 in the Treasury not otherwise appropriated, the Sec19 retary of the Treasury shall provide for the transfer 

20 to the Secretary of Health and Human Services of 

21 the amount specified as necessary to carry out the 

22 nationwide program under paragraph (1). Such 

23 amount shall remain available until expended. 
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1 PART 2—TARGETING ENFORCEMENT 

2 SEC. 1421. CIVIL MONEY PENALTIES. 

3 (a) SKILLED NURSING FACILITIES.— 

4 (1) IN GENERAL.—Section 1819(h)(2)(B)(ii) of 

5 the Social Security Act (42 U.S.C. 1395i– 

6 3(h)(2)(B)(ii)) is amended to read as follows: 

7 ‘‘(ii) AUTHORITY WITH RESPECT TO

8 CIVIL MONEY PENALTIES.— 

9 ‘‘(I) AMOUNT.—The Secretary 

10 may impose a civil money penalty in 

11 the applicable per instance or per day 

12 amount (as defined in subclause (II) 

13 and (III)) for each day or instance, 

14 respectively, of noncompliance (as de15 termined appropriate by the Sec16 retary). 

17 ‘‘(II) APPLICABLE PER INSTANCE

18 AMOUNT.—In this clause, the term 

19 ‘applicable per instance amount’ 

20 means— 

21 ‘‘(aa) in the case where the 

22 deficiency is found to be a direct 

23 proximate cause of death of a 

24 resident of the facility, an 

25 amount not to exceed $100,000. 
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1 ‘‘(bb) in each case of a defi2 ciency where the facility is cited 

3 for actual harm or immediate 

4 jeopardy, an amount not less 

5 than $3,050 and not more than 

6 $25,000; and 

7 ‘‘(cc) in each case of any 

8 other deficiency, an amount not 

9 less than $250 and not to exceed 

10 $3050. 

11 ‘‘(III) APPLICABLE PER DAY

12 AMOUNT.—In this clause, the term 

13 ‘applicable per day amount’ means— 

14 ‘‘(aa) in each case of a defi15 ciency where the facility is cited 

16 for actual harm or immediate 

17 jeopardy, an amount not less 

18 than $3,050 and not more than 

19 $25,000; and 

20 ‘‘(bb) in each case of any 

21 other deficiency, an amount not 

22 less than $250 and not to exceed 

23 $3,050. 

24 ‘‘(IV) REDUCTION OF CIVIL

25 MONEY PENALTIES IN CERTAIN CIR-
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1 CUMSTANCES.—Subject to subclauses 

2 (V) and (VI), in the case where a fa3 cility self-reports and promptly cor4 rects a deficiency for which a penalty 

5 was imposed under this clause not 

6 later than 10 calendar days after the 

7 date of such imposition, the Secretary 

8 may reduce the amount of the penalty 

9 imposed by not more than 50 percent. 

10 ‘‘(V) PROHIBITION ON REDUC11 TION FOR CERTAIN DEFICIENCIES.— 

12 ‘‘(aa) REPEAT DEFI13 CIENCIES.—The Secretary may 

14 not reduce under subclause (IV) 

15 the amount of a penalty if the 

16 deficiency is a repeat deficiency. 

17 ‘‘(bb) CERTAIN OTHER DE18 FICIENCIES.—The Secretary may 

19 not reduce under subclause (IV) 

20 the amount of a penalty if the 

21 penalty is imposed for a defi22 ciency described in subclause 

23 (II)(aa) or (III)(aa) and the ac24 tual harm or widespread harm 

25 immediately jeopardizes the 
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1 health or safety of a resident or 

2 residents of the facility, or if the 

3 penalty is imposed for a defi4 ciency described in subclause 

5 (II)(bb). 

6 ‘‘(VI) LIMITATION ON AGGRE7 GATE REDUCTIONS.—The aggregate 

8 reduction in a penalty under sub9 clause (IV) may not exceed 35 percent 

10 on the basis of self-reporting, on the 

11 basis of a waiver of an appeal (as pro12 vided for under regulations under sec13 tion 488.436 of title 42, Code of Fed14 eral Regulations), or on the basis of 

15 both. 

16 ‘‘(VII) COLLECTION OF CIVIL

17 MONEY PENALTIES.—In the case of a 

18 civil money penalty imposed under 

19 this clause, the Secretary— 

20 ‘‘(aa) subject to item (cc), 

21 shall, not later than 30 days 

22 after the date of imposition of 

23 the penalty, provide the oppor24 tunity for the facility to partici25 pate in an independent informal 
854 

•HR 3962 EH

1 dispute resolution process, estab2 lished by the State survey agen3 cy, which generates a written 

4 record prior to the collection of 

5 such penalty, but such oppor6 tunity shall not affect the respon7 sibility of the State survey agen8 cy for making final recommenda9 tions for such penalties; 

10 ‘‘(bb) in the case where the 

11 penalty is imposed for each day 

12 of noncompliance, shall not im13 pose a penalty for any day during 

14 the period beginning on the ini15 tial day of the imposition of the 

16 penalty and ending on the day on 

17 which the informal dispute reso18 lution process under item (aa) is 

19 completed; 

20 ‘‘(cc) may provide for the 

21 collection of such civil money 

22 penalty and the placement of 

23 such amounts collected in an es24 crow account under the direction 

25 of the Secretary on the earlier of 
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•HR 3962 EH

1 the date on which the informal 

2 dispute resolution process under 

3 item (aa) is completed or the 

4 date that is 90 days after the 

5 date of the imposition of the pen6 alty; 

7 ‘‘(dd) may provide that such 

8 amounts collected are kept in 

9 such account pending the resolu10 tion of any subsequent appeals; 

11 ‘‘(ee) in the case where the 

12 facility successfully appeals the 

13 penalty, may provide for the re14 turn of such amounts collected 

15 (plus interest) to the facility; and 

16 ‘‘(ff) in the case where all 

17 such appeals are unsuccessful, 

18 may provide that some portion of 

19 such amounts collected may be 

20 used to support activities that 

21 benefit residents, including as22 sistance to support and protect 

23 residents of a facility that closes 

24 (voluntarily or involuntarily) or is 

25 decertified (including offsetting 
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•HR 3962 EH

1 costs of relocating residents to 

2 home and community-based set3 tings or another facility), projects 

4 that support resident and family 

5 councils and other consumer in6 volvement in assuring quality 

7 care in facilities, and facility im8 provement initiatives approved by 

9 the Secretary (including joint 

10 training of facility staff and sur11 veyors, technical assistance for 

12 facilities under quality assurance 

13 programs, the appointment of 

14 temporary management, and 

15 other activities approved by the 

16 Secretary). 

17 ‘‘(VIII) PROCEDURE.—The pro18 visions of section 1128A (other than 

19 subsections (a) and (b) and except to 

20 the extent that such provisions require 

21 a hearing prior to the imposition of a 

22 civil money penalty) shall apply to a 

23 civil money penalty under this clause 

24 in the same manner as such provi-
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•HR 3962 EH

1 sions apply to a penalty or proceeding 

2 under section 1128A(a).’’. 

3 (2) CONFORMING AMENDMENT.—The second 

4 sentence of section 1819(h)(5) of the Social Security 

5 Act (42 U.S.C. 1395i–3(h)(5)) is amended by insert6 ing ‘‘(ii),’’after ‘‘(i),’’. 

7 (b) NURSING FACILITIES.— 

8 (1) PENALTIES IMPOSED BY THE STATE.— 

9 (A) IN GENERAL.—Section 1919(h)(2) of 

10 the Social Security Act (42 U.S.C. 1396r(h)(2)) 

11 is amended— 

12 (i) in subparagraph (A)(ii), by strik13 ing the first sentence and inserting the fol14 lowing: ‘‘A civil money penalty in accord15 ance with subparagraph (G).’’; and 

16 (ii) by adding at the end the following 

17 new subparagraph: 

18 ‘‘(G) CIVIL MONEY PENALTIES.— 

19 ‘‘(i) IN GENERAL.—The State may 

20 impose a civil money penalty under sub21 paragraph (A)(ii) in the applicable per in22 stance or per day amount (as defined in 

23 subclauses (II) and (III)) for each day or 

24 instance, respectively, of noncompliance (as 

25 determined appropriate by the Secretary). 
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•HR 3962 EH

1 ‘‘(ii) APPLICABLE PER INSTANCE

2 AMOUNT.—In this subparagraph, the term 

3 ‘applicable per instance amount’ means— 

4 ‘‘(I) in the case where the defi5 ciency is found to be a direct proxi6 mate cause of death of a resident of 

7 the facility, an amount not to exceed 

8 $100,000. 

9 ‘‘(II) in each case of a deficiency 

10 where the facility is cited for actual 

11 harm or immediate jeopardy, an 

12 amount not less than $3,050 and not 

13 more than $25,000; and 

14 ‘‘(III) in each case of any other 

15 deficiency, an amount not less than 

16 $250 and not to exceed $3,050. 

17 ‘‘(iii) APPLICABLE PER DAY

18 AMOUNT.—In this subparagraph, the term 

19 ‘applicable per day amount’ means— 

20 ‘‘(I) in each case of a deficiency 

21 where the facility is cited for actual 

22 harm or immediate jeopardy, an 

23 amount not less than $3,050 and not 

24 more than $25,000; and 
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1 ‘‘(II) in each case of any other 

2 deficiency, an amount not less than 

3 $250 and not to exceed $3,050. 

4 ‘‘(iv) REDUCTION OF CIVIL MONEY

5 PENALTIES IN CERTAIN CIR6 CUMSTANCES.—Subject to clauses (v) and 

7 (vi), in the case where a facility self-re8 ports and promptly corrects a deficiency 

9 for which a penalty was imposed under 

10 subparagraph (A)(ii) not later than 10 cal11 endar days after the date of such imposi12 tion, the State may reduce the amount of 

13 the penalty imposed by not more than 50 

14 percent. 

15 ‘‘(v) PROHIBITION ON REDUCTION

16 FOR CERTAIN DEFICIENCIES.— 

17 ‘‘(I) REPEAT DEFICIENCIES.— 

18 The State may not reduce under 

19 clause (iv) the amount of a penalty if 

20 the State had reduced a penalty im21 posed on the facility in the preceding 

22 year under such clause with respect to 

23 a repeat deficiency. 

24 ‘‘(II) CERTAIN OTHER DEFI25 CIENCIES.—The State may not reduce 
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•HR 3962 EH

1 under clause (iv) the amount of a pen2 alty if the penalty is imposed for a de3 ficiency described in clause (ii)(II) or 

4 (iii)(I) and the actual harm or wide5 spread harm that immediately jeop6 ardizes the health or safety of a resi7 dent or residents of the facility, or if 

8 the penalty is imposed for a deficiency 

9 described in clause (ii)(I). 

10 ‘‘(III) LIMITATION ON AGGRE11 GATE REDUCTIONS.—The aggregate 

12 reduction in a penalty under clause 

13 (iv) may not exceed 35 percent on the 

14 basis of self-reporting, on the basis of 

15 a waiver of an appeal (as provided for 

16 under regulations under section 

17 488.436 of title 42, Code of Federal 

18 Regulations), or on the basis of both. 

19 ‘‘(vi) COLLECTION OF CIVIL MONEY

20 PENALTIES.—In the case of a civil money 

21 penalty imposed under subparagraph 

22 (A)(ii), the State— 

23 ‘‘(I) subject to subclause (III), 

24 shall, not later than 30 days after the 

25 date of imposition of the penalty, pro-
861 

•HR 3962 EH

1 vide the opportunity for the facility to 

2 participate in an independent informal 

3 dispute resolution process, established 

4 by the State survey agency, which 

5 generates a written record prior to the 

6 collection of such penalty, but such 

7 opportunity shall not affect the re8 sponsibility of the State survey agency 

9 for making final recommendations for 

10 such penalties; 

11 ‘‘(II) in the case where the pen12 alty is imposed for each day of non13 compliance, shall not impose a penalty 

14 for any day during the period begin15 ning on the initial day of the imposi16 tion of the penalty and ending on the 

17 day on which the informal dispute res18 olution process under subclause (I) is 

19 completed; 

20 ‘‘(III) may provide for the collec21 tion of such civil money penalty and 

22 the placement of such amounts col23 lected in an escrow account under the 

24 direction of the State on the earlier of 

25 the date on which the informal dis-
862 

•HR 3962 EH

1 pute resolution process under sub2 clause (I) is completed or the date 

3 that is 90 days after the date of the 

4 imposition of the penalty; 

5 ‘‘(IV) may provide that such 

6 amounts collected are kept in such ac7 count pending the resolution of any 

8 subsequent appeals; 

9 ‘‘(V) in the case where the facil10 ity successfully appeals the penalty, 

11 may provide for the return of such 

12 amounts collected (plus interest) to 

13 the facility; and 

14 ‘‘(VI) in the case where all such 

15 appeals are unsuccessful, may provide 

16 that such funds collected shall be used 

17 for the purposes described in the sec18 ond sentence of subparagraph 

19 (A)(ii).’’. 

20 (B) CONFORMING AMENDMENT.—The sec21 ond sentence of section 1919(h)(2)(A)(ii) of the 

22 Social Security Act (42 U.S.C. 

23 1396r(h)(2)(A)(ii)) is amended by inserting be24 fore the period at the end the following: ‘‘, and 

25 some portion of such funds may be used to sup-
863 

•HR 3962 EH

1 port activities that benefit residents, including 

2 assistance to support and protect residents of a 

3 facility that closes (voluntarily or involuntarily) 

4 or is decertified (including offsetting costs of re5 locating residents to home and community6 based settings or another facility), projects that 

7 support resident and family councils and other 

8 consumer involvement in assuring quality care 

9 in facilities, and facility improvement initiatives 

10 approved by the Secretary (including joint 

11 training of facility staff and surveyors, pro12 viding technical assistance to facilities under 

13 quality assurance programs, the appointment of 

14 temporary management, and other activities ap15 proved by the Secretary)’’. 

16 (2) PENALTIES IMPOSED BY THE SEC17 RETARY.— 

18 (A) IN GENERAL.—Section 

19 1919(h)(3)(C)(ii) of the Social Security Act (42 

20 U.S.C. 1396r(h)(3)(C)) is amended to read as 

21 follows: 

22 ‘‘(ii) AUTHORITY WITH RESPECT TO

23 CIVIL MONEY PENALTIES.— 

24 ‘‘(I) AMOUNT.—Subject to sub25 clause (II), the Secretary may impose 
864 

•HR 3962 EH

1 a civil money penalty in an amount 

2 not to exceed $10,000 for each day or 

3 each instance of noncompliance (as 

4 determined appropriate by the Sec5 retary). 

6 ‘‘(II) REDUCTION OF CIVIL

7 MONEY PENALTIES IN CERTAIN CIR8 CUMSTANCES.—Subject to subclause 

9 (III), in the case where a facility self10 reports and promptly corrects a defi11 ciency for which a penalty was im12 posed under this clause not later than 

13 10 calendar days after the date of 

14 such imposition, the Secretary may 

15 reduce the amount of the penalty im16 posed by not more than 50 percent. 

17 ‘‘(III) PROHIBITION ON REDUC18 TION FOR REPEAT DEFICIENCIES.— 

19 The Secretary may not reduce the 

20 amount of a penalty under subclause 

21 (II) if the Secretary had reduced a 

22 penalty imposed on the facility in the 

23 preceding year under such subclause 

24 with respect to a repeat deficiency. 
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•HR 3962 EH

1 ‘‘(IV) COLLECTION OF CIVIL

2 MONEY PENALTIES.—In the case of a 

3 civil money penalty imposed under 

4 this clause, the Secretary— 

5 ‘‘(aa) subject to item (bb), 

6 shall, not later than 30 days 

7 after the date of imposition of 

8 the penalty, provide the oppor9 tunity for the facility to partici10 pate in an independent informal 

11 dispute resolution process which 

12 generates a written record prior 

13 to the collection of such penalty; 

14 ‘‘(bb) in the case where the 

15 penalty is imposed for each day 

16 of noncompliance, shall not im17 pose a penalty for any day during 

18 the period beginning on the ini19 tial day of the imposition of the 

20 penalty and ending on the day on 

21 which the informal dispute reso22 lution process under item (aa) is 

23 completed; 

24 ‘‘(cc) may provide for the 

25 collection of such civil money 
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•HR 3962 EH

1 penalty and the placement of 

2 such amounts collected in an es3 crow account under the direction 

4 of the Secretary on the earlier of 

5 the date on which the informal 

6 dispute resolution process under 

7 item (aa) is completed or the 

8 date that is 90 days after the 

9 date of the imposition of the pen10 alty; 

11 ‘‘(dd) may provide that such 

12 amounts collected are kept in 

13 such account pending the resolu14 tion of any subsequent appeals; 

15 ‘‘(ee) in the case where the 

16 facility successfully appeals the 

17 penalty, may provide for the re18 turn of such amounts collected 

19 (plus interest) to the facility; and 

20 ‘‘(ff) in the case where all 

21 such appeals are unsuccessful, 

22 may provide that some portion of 

23 such amounts collected may be 

24 used to support activities that 

25 benefit residents, including as-
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•HR 3962 EH

1 sistance to support and protect 

2 residents of a facility that closes 

3 (voluntarily or involuntarily) or is 

4 decertified (including offsetting 

5 costs of relocating residents to 

6 home and community-based set7 tings or another facility), projects 

8 that support resident and family 

9 councils and other consumer in10 volvement in assuring quality 

11 care in facilities, and facility im12 provement initiatives approved by 

13 the Secretary (including joint 

14 training of facility staff and sur15 veyors, technical assistance for 

16 facilities under quality assurance 

17 programs, the appointment of 

18 temporary management, and 

19 other activities approved by the 

20 Secretary). 

21 ‘‘(V) PROCEDURE.—The provi22 sions of section 1128A (other than 

23 subsections (a) and (b) and except to 

24 the extent that such provisions require 

25 a hearing prior to the imposition of a 
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•HR 3962 EH

1 civil money penalty) shall apply to a 

2 civil money penalty under this clause 

3 in the same manner as such provi4 sions apply to a penalty or proceeding 

5 under section 1128A(a).’’. 

6 (B) CONFORMING AMENDMENT.—Section 

7 1919(h)(8) of the Social Security Act (42 

8 U.S.C. 1396r(h)(5)(8)) is amended by inserting 

9 ‘‘and in paragraph (3)(C)(ii)’’ after ‘‘paragraph 

10 (2)(A)’’. 

11 (c) EFFECTIVE DATE.—The amendments made by 

12 this section shall take effect 1 year after the date of the 

13 enactment of this Act. 

14 SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PRO15 GRAM. 

16 (a) ESTABLISHMENT.— 

17 (1) IN GENERAL.—The Secretary, in consulta18 tion with the Inspector General of the Department 

19 of Health and Human Services, shall establish a 

20 pilot program (in this section referred to as the 

21 ‘‘pilot program’’) to develop, test, and implement use 

22 of an independent monitor to oversee interstate and 

23 large intrastate chains of skilled nursing facilities 

24 and nursing facilities. 
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•HR 3962 EH

1 (2) SELECTION.—The Secretary shall select 

2 chains of skilled nursing facilities and nursing facili3 ties described in paragraph (1) to participate in the 

4 pilot program from among those chains that submit 

5 an application to the Secretary at such time, in such 

6 manner, and containing such information as the Sec7 retary may require. 

8 (3) DURATION.—The Secretary shall conduct 

9 the pilot program for a 2-year period. 

10 (4) IMPLEMENTATION.—The Secretary shall 

11 implement the pilot program not later than one year 

12 after the date of the enactment of this Act. 

13 (b) REQUIREMENTS.—The Secretary shall evaluate 

14 chains selected to participate in the pilot program based 

15 on criteria selected by the Secretary, including where evi16 dence suggests that one or more facilities of the chain are 

17 experiencing serious safety and quality of care problems. 

18 Such criteria may include the evaluation of a chain that 

19 includes one or more facilities participating in the ‘‘Special 

20 Focus Facility’’ program (or a successor program) or one 

21 or more facilities with a record of repeated serious safety 

22 and quality of care deficiencies. 

23 (c) RESPONSIBILITIES OF THE INDEPENDENT MON24 ITOR.—An independent monitor that enters into a con-
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•HR 3962 EH

1 tract with the Secretary to participate in the conduct of 

2 such program shall— 

3 (1) conduct periodic reviews and prepare root4 cause quality and deficiency analyses of a chain to 

5 assess if facilities of the chain are in compliance 

6 with State and Federal laws and regulations applica7 ble to the facilities; 

8 (2) undertake sustained oversight of the chain, 

9 whether publicly or privately held, to involve the 

10 owners of the chain and the principal business part11 ners of such owners in facilitating compliance by fa12 cilities of the chain with State and Federal laws and 

13 regulations applicable to the facilities; 

14 (3) analyze the management structure, distribu15 tion of expenditures, and nurse staffing levels of fa16 cilities of the chain in relation to resident census, 

17 staff turnover rates, and tenure; 

18 (4) report findings and recommendations with 

19 respect to such reviews, analyses, and oversight to 

20 the chain and facilities of the chain, to the Secretary 

21 and to relevant States; and 

22 (5) publish the results of such reviews, anal23 yses, and oversight. 

24 (d) IMPLEMENTATION OF RECOMMENDATIONS.— 
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•HR 3962 EH

1 (1) RECEIPT OF FINDING BY CHAIN.—Not later 

2 than 10 days after receipt of a finding of an inde3 pendent monitor under subsection (c)(4), a chain 

4 participating in the pilot program shall submit to 

5 the independent monitor a report— 

6 (A) outlining corrective actions the chain 

7 will take to implement the recommendations in 

8 such report; or 

9 (B) indicating that the chain will not im10 plement such recommendations and why it will 

11 not do so. 

12 (2) RECEIPT OF REPORT BY INDEPENDENT

13 MONITOR.—Not later than 10 days after the date of 

14 receipt of a report submitted by a chain under para15 graph (1), an independent monitor shall finalize its 

16 recommendations and submit a report to the chain 

17 and facilities of the chain, the Secretary, and the 

18 State (or States) involved, as appropriate, containing 

19 such final recommendations. 

20 (e) COST OF APPOINTMENT.—A chain shall be re21 sponsible for a portion of the costs associated with the 

22 appointment of independent monitors under the pilot pro23 gram. The chain shall pay such portion to the Secretary 

24 (in an amount and in accordance with procedures estab25 lished by the Secretary). 
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1 (f) WAIVER AUTHORITY.—The Secretary may waive 

2 such requirements of titles XVIII and XIX of the Social 

3 Security Act (42 U.S.C. 1395 et seq.; 1396 et seq.) as 

4 may be necessary for the purpose of carrying out the pilot 

5 program. 

6 (g) AUTHORIZATION OF APPROPRIATIONS.—There 

7 are authorized to be appropriated such sums as may be 

8 necessary to carry out this section. 

9 (h) DEFINITIONS.—In this section: 

10 (1) FACILITY.—The term ‘‘facility’’ means a 

11 skilled nursing facility or a nursing facility. 

12 (2) NURSING FACILITY.—The term ‘‘nursing 

13 facility’’ has the meaning given such term in section 

14 1919(a) of the Social Security Act (42 U.S.C. 

15 1396r(a)). 

16 (3) SECRETARY.—The term ‘‘Secretary’’ means 

17 the Secretary of Health and Human Services, acting 

18 through the Assistant Secretary for Planning and 

19 Evaluation. 

20 (4) SKILLED NURSING FACILITY.—The term 

21 ‘‘skilled nursing facility’’ has the meaning given such 

22 term in section 1819(a) of the Social Security Act 

23 (42 U.S.C. 1395(a)). 

24 (i) EVALUATION AND REPORT.— 
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1 (1) EVALUATION.—The Inspector General of 

2 the Department of Health and Human Services shall 

3 evaluate the pilot program. Such evaluation shall— 

4 (A) determine whether the independent 

5 monitor program should be established on a 

6 permanent basis; and 

7 (B) if the Inspector General determines 

8 that the independent monitor program should 

9 be established on a permanent basis, rec10 ommend appropriate procedures and mecha11 nisms for such establishment. 

12 (2) REPORT.—Not later than 180 days after 

13 the completion of the pilot program, the Inspector 

14 General shall submit to Congress and the Secretary 

15 a report containing the results of the evaluation con16 ducted under paragraph (1), together with rec17 ommendations for such legislation and administra18 tive action as the Inspector General determines ap19 propriate. 

20 SEC. 1423. NOTIFICATION OF FACILITY CLOSURE. 

21 (a) SKILLED NURSING FACILITIES.— 

22 (1) IN GENERAL.—Section 1819(c) of the So23 cial Security Act (42 U.S.C. 1395i–3(c)) is amended 

24 by adding at the end the following new paragraph: 

25 ‘‘(7) NOTIFICATION OF FACILITY CLOSURE.— 
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1 ‘‘(A) IN GENERAL.—Any individual who is 

2 the administrator of a skilled nursing facility 

3 must— 

4 ‘‘(i) submit to the Secretary, the State 

5 long-term care ombudsman, residents of 

6 the facility, and the legal representatives of 

7 such residents or other responsible parties, 

8 written notification of an impending clo9 sure— 

10 ‘‘(I) subject to subclause (II), not 

11 later than the date that is 60 days 

12 prior to the date of such closure; and 

13 ‘‘(II) in the case of a facility 

14 where the Secretary terminates the fa15 cility’s participation under this title, 

16 not later than the date that the Sec17 retary determines appropriate; 

18 ‘‘(ii) ensure that the facility does not 

19 admit any new residents on or after the 

20 date on which such written notification is 

21 submitted; and 

22 ‘‘(iii) include in the notice a plan for 

23 the transfer and adequate relocation of the 

24 residents of the facility by a specified date 

25 prior to closure that has been approved by 
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1 the State, including assurances that the 

2 residents will be transferred to the most 

3 appropriate facility or other setting in 

4 terms of quality, services, and location, 

5 taking into consideration the needs and 

6 best interests of each resident. 

7 ‘‘(B) RELOCATION.— 

8 ‘‘(i) IN GENERAL.—The State shall 

9 ensure that, before a facility closes, all 

10 residents of the facility have been success11 fully relocated to another facility or an al12 ternative home and community-based set13 ting. 

14 ‘‘(ii) CONTINUATION OF PAYMENTS

15 UNTIL RESIDENTS RELOCATED.—The Sec16 retary may, as the Secretary determines 

17 appropriate, continue to make payments 

18 under this title with respect to residents of 

19 a facility that has submitted a notification 

20 under subparagraph (A) during the period 

21 beginning on the date such notification is 

22 submitted and ending on the date on which 

23 the resident is successfully relocated.’’. 
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1 (2) CONFORMING AMENDMENTS.—Section 

2 1819(h)(4) of the Social Security Act (42 U.S.C. 

3 1395i–3(h)(4)) is amended— 

4 (A) in the first sentence, by striking ‘‘the 

5 Secretary shall terminate’’ and inserting ‘‘the 

6 Secretary, subject to subsection (c)(7), shall 

7 terminate’’; and 

8 (B) in the second sentence, by striking 

9 ‘‘subsection (c)(2)’’ and inserting ‘‘paragraphs 

10 (2) and (7) of subsection (c)’’. 

11 (b) NURSING FACILITIES.— 

12 (1) IN GENERAL.—Section 1919(c) of the So13 cial Security Act (42 U.S.C. 1396r(c)) is amended 

14 by adding at the end the following new paragraph: 

15 ‘‘(9) NOTIFICATION OF FACILITY CLOSURE.— 

16 ‘‘(A) IN GENERAL.—Any individual who is 

17 an administrator of a nursing facility must— 

18 ‘‘(i) submit to the Secretary, the State 

19 long-term care ombudsman, residents of 

20 the facility, and the legal representatives of 

21 such residents or other responsible parties, 

22 written notification of an impending clo23 sure— 
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1 ‘‘(I) subject to subclause (II), not 

2 later than the date that is 60 days 

3 prior to the date of such closure; and 

4 ‘‘(II) in the case of a facility 

5 where the Secretary terminates the fa6 cility’s participation under this title, 

7 not later than the date that the Sec8 retary determines appropriate; 

9 ‘‘(ii) ensure that the facility does not 

10 admit any new residents on or after the 

11 date on which such written notification is 

12 submitted; and 

13 ‘‘(iii) include in the notice a plan for 

14 the transfer and adequate relocation of the 

15 residents of the facility by a specified date 

16 prior to closure that has been approved by 

17 the State, including assurances that the 

18 residents will be transferred to the most 

19 appropriate facility or other setting in 

20 terms of quality, services, and location, 

21 taking into consideration the needs and 

22 best interests of each resident. 

23 ‘‘(B) RELOCATION.— 

24 ‘‘(i) IN GENERAL.—The State shall 

25 ensure that, before a facility closes, all 
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1 residents of the facility have been success2 fully relocated to another facility or an al3 ternative home and community-based set4 ting. 

5 ‘‘(ii) CONTINUATION OF PAYMENTS

6 UNTIL RESIDENTS RELOCATED.—The Sec7 retary may, as the Secretary determines 

8 appropriate, continue to make payments 

9 under this title with respect to residents of 

10 a facility that has submitted a notification 

11 under subparagraph (A) during the period 

12 beginning on the date such notification is 

13 submitted and ending on the date on which 

14 the resident is successfully relocated.’’. 

15 (c) EFFECTIVE DATE.—The amendments made by 

16 this section shall take effect 1 year after the date of the 

17 enactment of this Act. 

18 PART 3—IMPROVING STAFF TRAINING 

19 SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING. 

20 (a) SKILLED NURSING FACILITIES.—Section 

21 1819(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 

22 1395i–3(f)(2)(A)(i)(I)) is amended by inserting ‘‘(includ23 ing, in the case of initial training and, if the Secretary 

24 determines appropriate, in the case of ongoing training, 
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1 dementia management training and resident abuse preven2 tion training)’’ after ‘‘curriculum’’. 

3 (b) NURSING FACILITIES.—Section 

4 1919(f)(2)(A)(i)(I) of the Social Security Act (42 U.S.C. 

5 1396r(f)(2)(A)(i)(I)) is amended by inserting ‘‘(including, 

6 in the case of initial training and, if the Secretary deter7 mines appropriate, in the case of ongoing training, demen8 tia management training and resident abuse prevention 

9 training)’’ after ‘‘curriculum’’. 

10 (c) EFFECTIVE DATE.—The amendments made by 

11 this section shall take effect 1 year after the date of the 

12 enactment of this Act. 

13 SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED 

14 FOR CERTIFIED NURSE AIDES AND SUPER15 VISORY STAFF. 

16 (a) STUDY.— 

17 (1) IN GENERAL.—The Secretary shall conduct 

18 a study on the content of training for certified nurse 

19 aides and supervisory staff of skilled nursing facili20 ties and nursing facilities. The study shall include an 

21 analysis of the following: 

22 (A) Whether the number of initial training 

23 hours for certified nurse aides required under 

24 sections 1819(f)(2)(A)(i)(II) and 

25 1919(f)(2)(A)(i)(II) of the Social Security Act 
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1 (42 U.S.C. 1395i–3(f)(2)(A)(i)(II); 

2 1396r(f)(2)(A)(i)(II)) should be increased from 

3 75 and, if so, what the required number of ini4 tial training hours should be, including any rec5 ommendations for the content of such training 

6 (including training related to dementia). 

7 (B) Whether requirements for ongoing 

8 training under such sections 

9 1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) 

10 should be increased from 12 hours per year, in11 cluding any recommendations for the content of 

12 such training. 

13 (2) CONSULTATION.—In conducting the anal14 ysis under paragraph (1)(A), the Secretary shall 

15 consult with States that, as of the date of the enact16 ment of this Act, require more than 75 hours of 

17 training for certified nurse aides. 

18 (3) DEFINITIONS.—In this section: 

19 (A) NURSING FACILITY.—The term ‘‘nurs20 ing facility’’ has the meaning given such term 

21 in section 1919(a) of the Social Security Act 

22 (42 U.S.C. 1396r(a)). 

23 (B) SECRETARY.—The term ‘‘Secretary’’ 

24 means the Secretary of Health and Human 
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1 Services, acting through the Assistant Secretary 

2 for Planning and Evaluation. 

3 (C) SKILLED NURSING FACILITY.—The 

4 term ‘‘skilled nursing facility’’ has the meaning 

5 given such term in section 1819(a) of the Social 

6 Security Act (42 U.S.C. 1395(a)). 

7 (b) REPORT.—Not later than 2 years after the date 

8 of the enactment of this Act, the Secretary shall submit 

9 to Congress a report containing the results of the study 

10 conducted under subsection (a), together with rec11 ommendations for such legislation and administrative ac12 tion as the Secretary determines appropriate. 

13 SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERV14 ICES OF A SKILLED NURSING FACILITY OR 

15 NURSING FACILITY. 

16 (a) MEDICARE.—Section 1819(b)(4)(A) of the Social 

17 Security Act (42 U.S.C. 1395i–3(b)(4)(A)) is amended by 

18 adding at the end the following: ‘‘With respect to meeting 

19 the staffing requirement imposed by the Secretary to carry 

20 out clause (iv), the full-time director of food services of 

21 the facility, if not a qualified dietitian (as defined in sec22 tion 483.35(a)(2) of title 42, Code of Federal Regulations, 

23 as in effect as of the date of the enactment of this sen24 tence), shall be a Certified Dietary Manager meeting the 

25 requirements of the Certifying Board for Dietary Man-
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1 agers, or a Dietetic Technician, Registered meeting the 

2 requirements of the Commission on Dietetic Registration 

3 or have equivalent military, academic, or other qualifica4 tions (as specified by the Secretary).’’. 

5 (b) MEDICAID.—Section 1919(b)(4)(A) of the Social 

6 Security Act (42 U.S.C. 1396r(b)(4)(A)) is amended by 

7 adding at the end the following: ‘‘With respect to meeting 

8 the staffing requirement imposed by the Secretary to carry 

9 out clause (iv), the full-time director of food services of 

10 the facility, if not a qualified dietitian (as defined in sec11 tion 483.35(a)(2) of title 42, Code of Federal Regulations, 

12 as in effect as of the date of the enactment of this sen13 tence), shall be a Certified Dietary Manager meeting the 

14 requirements of the Certifying Board for Dietary Man15 agers, or a Dietetic Technician, Registered meeting the 

16 requirements of the Commission on Dietetic Registration 

17 or have equivalent military, academic, or other qualifica18 tions (as specified by the Secretary).’’. 

19 (c) EFFECTIVE DATE.—The amendments made by 

20 this section shall take effect on the date that is 180 days 

21 after the date of enactment of this Act. 
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1 Subtitle C—Quality Measurements 

2 SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR 

3 QUALITY IMPROVEMENT. 

4 Title XI of the Social Security Act, as amended by 

5 section 1401(a), is further amended by adding at the end 

6 the following new part: 

7 ‘‘PART E—QUALITY IMPROVEMENT

8 ‘‘ESTABLISHMENT OF NATIONAL PRIORITIES FOR

9 PERFORMANCE IMPROVEMENT

10 ‘‘SEC. 1191. (a) ESTABLISHMENT OF NATIONAL PRI11 ORITIES BY THE SECRETARY.—The Secretary shall estab12 lish and periodically update, not less frequently than tri13 ennially, national priorities for performance improvement. 

14 ‘‘(b) RECOMMENDATIONS FOR NATIONAL PRIOR15 ITIES.—In establishing and updating national priorities 

16 under subsection (a), the Secretary shall solicit and con17 sider recommendations from multiple outside stake18 holders. 

19 ‘‘(c) CONSIDERATIONS IN SETTING NATIONAL PRI20 ORITIES.—With respect to such priorities, the Secretary 

21 shall ensure that priority is given to areas in the delivery 

22 of health care services in the United States that— 

23 ‘‘(1) contribute to a large burden of disease, in24 cluding those that address the health care provided 
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1 to patients with prevalent, high-cost chronic dis2 eases; 

3 ‘‘(2) have the greatest potential to decrease 

4 morbidity and mortality in this country, including 

5 those that are designed to eliminate harm to pa6 tients; 

7 ‘‘(3) have the greatest potential for improving 

8 the performance, affordability, and patient9 centeredness of health care, including those due to 

10 variations in care; 

11 ‘‘(4) address health disparities across groups 

12 and areas; and 

13 ‘‘(5) have the potential for rapid improvement 

14 due to existing evidence, standards of care or other 

15 reasons. 

16 ‘‘(d) DEFINITIONS.—In this part: 

17 ‘‘(1) CONSENSUS-BASED ENTITY.—The term 

18 ‘consensus-based entity’ means an entity with a con19 tract with the Secretary under section 1890. 

20 ‘‘(2) QUALITY MEASURE.—The term ‘quality 

21 measure’ means a national consensus standard for 

22 measuring the performance and improvement of pop23 ulation health, or of institutional providers of serv24 ices, physicians, and other health care practitioners 

25 in the delivery of health care services. 
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1 ‘‘(e) FUNDING.— 

2 ‘‘(1) IN GENERAL.—The Secretary shall provide 

3 for the transfer, from the Federal Hospital Insur4 ance Trust Fund under section 1817 and the Fed5 eral Supplementary Medical Insurance Trust Fund 

6 under section 1841 (in such proportion as the Sec7 retary determines appropriate), of $2,000,000, for 

8 the activities under this section for each of the fiscal 

9 years 2010 through 2014. 

10 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— 

11 For purposes of carrying out the provisions of this 

12 section, in addition to funds otherwise available, out 

13 of any funds in the Treasury not otherwise appro14 priated, there are appropriated to the Secretary of 

15 Health and Human Services $2,000,000 for each of 

16 the fiscal years 2010 through 2014.’’. 

17 SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; 

18 GAO EVALUATION OF DATA COLLECTION 

19 PROCESS FOR QUALITY MEASUREMENT. 

20 Part E of title XI of the Social Security Act, as added 

21 by section 1441, is amended by adding at the end the fol22 lowing new sections: 

23 ‘‘SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES. 

24 ‘‘(a) AGREEMENTS WITH QUALIFIED ENTITIES.— 
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1 ‘‘(1) IN GENERAL.—The Secretary shall enter 

2 into agreements with qualified entities to develop 

3 quality measures for the delivery of health care serv4 ices in the United States. 

5 ‘‘(2) FORM OF AGREEMENTS.—The Secretary 

6 may carry out paragraph (1) by contract, grant, or 

7 otherwise. 

8 ‘‘(3) RECOMMENDATIONS OF CONSENSUS9 BASED ENTITY.—In carrying out this section, the 

10 Secretary shall— 

11 ‘‘(A) seek public input; and 

12 ‘‘(B) take into consideration recommenda13 tions of the consensus-based entity with a con14 tract with the Secretary under section 1890(a). 

15 ‘‘(b) DETERMINATION OF AREAS WHERE QUALITY

16 MEASURES ARE REQUIRED.—Consistent with the na17 tional priorities established under this part and with the 

18 programs administered by the Centers for Medicare & 

19 Medicaid Services and in consultation with other relevant 

20 Federal agencies, the Secretary shall determine areas in 

21 which quality measures for assessing health care services 

22 in the United States are needed. 

23 ‘‘(c) DEVELOPMENT OF QUALITY MEASURES.— 

24 ‘‘(1) PATIENT-CENTERED AND POPULATION25 BASED MEASURES.—In entering into agreements 
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1 under subsection (a), the Secretary shall give pri2 ority to the development of quality measures that 

3 allow the assessment of— 

4 ‘‘(A) health outcomes, presence of impair5 ment, and functional status of patients; 

6 ‘‘(B) the continuity and coordination of 

7 care and care transitions for patients across 

8 providers and health care settings, including 

9 end of life care; 

10 ‘‘(C) patient experience and patient en11 gagement; 

12 ‘‘(D) the safety, effectiveness, and timeli13 ness of care; 

14 ‘‘(E) health disparities including those as15 sociated with individual race, ethnicity, age, 

16 gender, place of residence or language; and 

17 ‘‘(F) the efficiency and resource use in the 

18 provision of care. 

19 ‘‘(2) USE OF FUNDS.—An entity that enters 

20 into an agreement under subsection (a) shall develop 

21 quality measures that— 

22 ‘‘(A) to the extent feasible, have the ability 

23 to be collected through the use of health infor24 mation technologies supporting better delivery 

25 of health care services; and 
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1 ‘‘(B) are available free of charge to users 

2 for the use of such measures. 

3 ‘‘(3) AVAILABILITY OF MEASURES.—The Sec4 retary shall make quality measures developed under 

5 this section available to the public. 

6 ‘‘(4) TESTING OF PROPOSED MEASURES.—The 

7 Secretary may use amounts made available under 

8 subsection (f) to fund the testing of proposed quality 

9 measures by qualified entities. Testing funded under 

10 this paragraph shall include testing of the feasibility 

11 and usability of proposed measures. 

12 ‘‘(5) UPDATING OF ENDORSED MEASURES.— 

13 The Secretary may use amounts made available 

14 under subsection (f) to fund the updating (and test15 ing, if applicable) by consensus-based entities of 

16 quality measures that have been previously endorsed 

17 by such an entity as new evidence is developed, in 

18 a manner consistent with section 1890(b)(3). 

19 ‘‘(d) QUALIFIED ENTITIES.—Before entering into 

20 agreements with a qualified entity, the Secretary shall en21 sure that the entity is a public, private, or academic insti22 tution with technical expertise in the area of health quality 

23 measurement. 

24 ‘‘(e) APPLICATION FOR GRANT.—A grant may be 

25 made under this section only if an application for the 
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1 grant is submitted to the Secretary and the application 

2 is in such form, is made in such manner, and contains 

3 such agreements, assurances, and information as the Sec4 retary determines to be necessary to carry out this section. 

5 ‘‘(f) FUNDING.— 

6 ‘‘(1) IN GENERAL.—The Secretary shall provide 

7 for the transfer, from the Federal Hospital Insur8 ance Trust Fund under section 1817 and the Fed9 eral Supplementary Medical Insurance Trust Fund 

10 under section 1841 (in such proportion as the Sec11 retary determines appropriate), of $25,000,000, to 

12 the Secretary for purposes of carrying out this sec13 tion for each of the fiscal years 2010 through 2014. 

14 ‘‘(2) AUTHORIZATION OF APPROPRIATIONS.— 

15 For purposes of carrying out the provisions of this 

16 section, in addition to funds otherwise available, out 

17 of any funds in the Treasury not otherwise appro18 priated, there are appropriated to the Secretary of 

19 Health and Human Services $25,000,000 for each 

20 of the fiscal years 2010 through 2014. 

21 ‘‘SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROC22 ESS FOR QUALITY MEASUREMENT. 

23 ‘‘(a) GAO EVALUATIONS.—The Comptroller General 

24 of the United States shall conduct periodic evaluations of 
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1 the implementation of the data collection processes for 

2 quality measures used by the Secretary. 

3 ‘‘(b) CONSIDERATIONS.—In carrying out the evalua4 tion under subsection (a), the Comptroller General shall 

5 determine— 

6 ‘‘(1) whether the system for the collection of 

7 data for quality measures provides for validation of 

8 data as relevant and scientifically credible; 

9 ‘‘(2) whether data collection efforts under the 

10 system use the most efficient and cost-effective 

11 means in a manner that minimizes administrative 

12 burden on persons required to collect data and that 

13 adequately protects the privacy of patients’ personal 

14 health information and provides data security; 

15 ‘‘(3) whether standards under the system pro16 vide for an appropriate opportunity for physicians 

17 and other clinicians and institutional providers of 

18 services to review and correct findings; and 

19 ‘‘(4) the extent to which quality measures are 

20 consistent with section 1192(c)(1) or result in direct 

21 or indirect costs to users of such measures. 

22 ‘‘(c) REPORT.—The Comptroller General shall sub23 mit reports to Congress and to the Secretary containing 

24 a description of the findings and conclusions of the results 

25 of each such evaluation.’’. 
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1 SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT 

2 INTO SELECTION OF QUALITY MEASURES. 

3 Section 1808 of the Social Security Act (42 U.S.C. 

4 1395b–9) is amended by adding at the end the following 

5 new subsection: 

6 ‘‘(d) MULTI-STAKEHOLDER PRE-RULEMAKING INPUT

7 INTO SELECTION OF QUALITY MEASURES.— 

8 ‘‘(1) LIST OF MEASURES.—Not later than De9 cember 1 before each year (beginning with 2011), 

10 the Secretary shall make public a list of measures 

11 being considered for selection for quality measure12 ment by the Secretary in rulemaking with respect to 

13 payment systems under this title beginning in the 

14 payment year beginning in such year and for pay15 ment systems beginning in the calendar year fol16 lowing such year, as the case may be. 

17 ‘‘(2) CONSULTATION ON SELECTION OF EN18 DORSED QUALITY MEASURES.—A consensus-based 

19 entity that has entered into a contract under section 

20 1890 shall, as part of such contract, convene multi21 stakeholder groups to provide recommendations on 

22 the selection of individual or composite quality meas23 ures, for use in reporting performance information 

24 to the public or for use in public health care pro25 grams. 
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1 ‘‘(3) MULTI-STAKEHOLDER INPUT.—Not later 

2 than February 1 of each year (beginning with 

3 2011), the consensus-based entity described in para4 graph (2) shall transmit to the Secretary the rec5 ommendations of multi-stakeholder groups provided 

6 under paragraph (2). Such recommendations shall 

7 be included in the transmissions the consensus-based 

8 entity makes to the Secretary under the contract 

9 provided for under section 1890. 

10 ‘‘(4) REQUIREMENT FOR TRANSPARENCY IN

11 PROCESS.— 

12 ‘‘(A) IN GENERAL.—In convening multi13 stakeholder groups under paragraph (2) with 

14 respect to the selection of quality measures, the 

15 consensus-based entity described in such para16 graph shall provide for an open and transparent 

17 process for the activities conducted pursuant to 

18 such convening. 

19 ‘‘(B) SELECTION OF ORGANIZATIONS PAR20 TICIPATING IN MULTI-STAKEHOLDER

21 GROUPS.—The process under paragraph (2) 

22 shall ensure that the selection of representatives 

23 of multi-stakeholder groups includes provision 

24 for public nominations for, and the opportunity 

25 for public comment on, such selection. 
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1 ‘‘(5) USE OF INPUT.—The respective proposed 

2 rule shall contain a summary of the recommenda3 tions made by the multi-stakeholder groups under 

4 paragraph (2), as well as other comments received 

5 regarding the proposed measures, and the extent to 

6 which such proposed rule follows such recommenda7 tions and the rationale for not following such rec8 ommendations. 

9 ‘‘(6) MULTI-STAKEHOLDER GROUPS.—For pur10 poses of this subsection, the term ‘multi-stakeholder 

11 groups’ means, with respect to a quality measure, a 

12 voluntary collaborative of organizations representing 

13 persons interested in or affected by the use of such 

14 quality measure, such as the following: 

15 ‘‘(A) Hospitals and other institutional pro16 viders. 

17 ‘‘(B) Physicians. 

18 ‘‘(C) Health care quality alliances. 

19 ‘‘(D) Nurses and other health care practi20 tioners. 

21 ‘‘(E) Health plans. 

22 ‘‘(F) Patient advocates and consumer 

23 groups. 

24 ‘‘(G) Employers. 
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1 ‘‘(H) Public and private purchasers of 

2 health care items and services. 

3 ‘‘(I) Labor organizations. 

4 ‘‘(J) Relevant departments or agencies of 

5 the United States. 

6 ‘‘(K) Biopharmaceutical companies and 

7 manufacturers of medical devices. 

8 ‘‘(L) Licensing, credentialing, and accred9 iting bodies. 

10 ‘‘(7) FUNDING.— 

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

12 provide for the transfer, from the Federal Hos13 pital Insurance Trust Fund under section 1817 

14 and the Federal Supplementary Medical Insur15 ance Trust Fund under section 1841 (in such 

16 proportion as the Secretary determines appro17 priate), of $1,000,000, to the Secretary for pur18 poses of carrying out this subsection for each of 

19 the fiscal years 2010 through 2014. 

20 ‘‘(B) AUTHORIZATION OF APPROPRIA21 TIONS.—For purposes of carrying out the provi22 sions of this subsection, in addition to funds 

23 otherwise available, out of any funds in the 

24 Treasury not otherwise appropriated, there are 

25 appropriated to the Secretary of Health and 
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1 Human Services $1,000,000 for each of the fis2 cal years 2010 through 2014.’’. 

3 SEC. 1444. APPLICATION OF QUALITY MEASURES. 

4 (a) INPATIENT HOSPITAL SERVICES.—Section 

5 1886(b)(3)(B) of such Act (42 U.S.C. 1395ww(b)(3)(B)) 

6 is amended by adding at the end the following new clause: 

7 ‘‘(x)(I) Subject to subclause (II), for purposes of re8 porting data on quality measures for inpatient hospital 

9 services furnished during fiscal year 2012 and each subse10 quent fiscal year, the quality measures specified under 

11 clause (viii) shall be measures selected by the Secretary 

12 from measures that have been endorsed by the entity with 

13 a contract with the Secretary under section 1890(a). 

14 ‘‘(II) In the case of a specified area or medical topic 

15 determined appropriate by the Secretary for which a fea16 sible and practical quality measure has not been endorsed 

17 by the entity with a contract under section 1890(a), the 

18 Secretary may specify a measure that is not so endorsed 

19 as long as due consideration is given to measures that 

20 have been endorsed or adopted by a consensus organiza21 tion identified by the Secretary. The Secretary shall sub22 mit such a non-endorsed measure to the entity for consid23 eration for endorsement. If the entity considers but does 

24 not endorse such a measure and if the Secretary does not 

25 phase-out use of such measure, the Secretary shall include 
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1 the rationale for continued use of such a measure in rule2 making.’’. 

3 (b) OUTPATIENT HOSPITAL SERVICES.—Section 

4 1833(t)(17) of such Act (42 U.S.C. 1395l(t)(17)) is 

5 amended by adding at the end the following new subpara6 graph: 

7 ‘‘(F) USE OF ENDORSED QUALITY MEAS8 URES.—The provisions of clause (x) of section 

9 1886(b)(3)(C) shall apply to quality measures 

10 for covered OPD services under this paragraph 

11 in the same manner as such provisions apply to 

12 quality measures for inpatient hospital serv13 ices.’’. 

14 (c) PHYSICIANS’ SERVICES.—Section 

15 1848(k)(2)(C)(ii) of such Act (42 U.S.C. 1395w– 

16 4(k)(2)(C)(ii)) is amended by adding at the end the fol17 lowing: ‘‘The Secretary shall submit such a non-endorsed 

18 measure to the entity for consideration for endorsement. 

19 If the entity considers but does not endorse such a meas20 ure and if the Secretary does not phase-out use of such 

21 measure, the Secretary shall include the rationale for con22 tinued use of such a measure in rulemaking.’’. 

23 (d) RENAL DIALYSIS SERVICES.—Section 

24 1881(h)(2)(B)(ii) of such Act (42 U.S.C. 

25 1395rr(h)(2)(B)(ii)) is amended by adding at the end the 
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1 following: ‘‘The Secretary shall submit such a non-en2 dorsed measure to the entity for consideration for endorse3 ment. If the entity considers but does not endorse such 

4 a measure and if the Secretary does not phase-out use 

5 of such measure, the Secretary shall include the rationale 

6 for continued use of such a measure in rulemaking.’’. 

7 (e) ENDORSEMENT OF STANDARDS.—Section 

8 1890(b)(2) of the Social Security Act (42 U.S.C. 

9 1395aaa(b)(2)) is amended by adding after and below sub10 paragraph (B) the following: 

11 ‘‘If the entity does not endorse a measure, such enti12 ty shall explain the reasons and provide suggestions 

13 about changes to such measure that might make it 

14 a potentially endorsable measure.’’. 

15 (f) EFFECTIVE DATE.—Except as otherwise pro16 vided, the amendments made by this section shall apply 

17 to quality measures applied for payment years beginning 

18 with 2012 or fiscal year 2012, as the case may be. 

19 SEC. 1445. CONSENSUS-BASED ENTITY FUNDING. 

20 Section 1890(d) of the Social Security Act (42 U.S.C. 

21 1395aaa(d)) is amended by striking ‘‘for each of fiscal 

22 years 2009 through 2012’’ and inserting ‘‘for fiscal year 

23 2009, and $12,000,000 for each of the fiscal years 2010 

24 through 2012’’. 
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1 SEC. 1446. QUALITY INDICATORS FOR CARE OF PEOPLE 

2 WITH ALZHEIMER’S DISEASE. 

3 (a) QUALITY INDICATORS.—The Secretary of Health 

4 and Human Services shall develop quality indicators for 

5 the provision of medical services to people with Alz6 heimer’s disease and other dementias and a plan for im7 plementing the indicators to measure the quality of care 

8 provided for people with these conditions by physicians, 

9 hospitals, and other appropriate providers of services and 

10 suppliers. 

11 (b) REPORT.—The Secretary shall submit a report to 

12 the Committees on Energy and Commerce and Ways and 

13 Means of the United States House of Representatives and 

14 to the Committees on Finance and Health, Education, 

15 Labor, and Pensions of the United States Senate not later 

16 than 24 months after the date of the enactment of this 

17 Act setting forth the status of their efforts to implement 

18 the requirements of subsection (a). 
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1 Subtitle D—Physician Payments 

2 Sunshine Provision 

3 SEC. 1451. REPORTS ON FINANCIAL RELATIONSHIPS BE4 TWEEN MANUFACTURERS AND DISTRIBU5 TORS OF COVERED DRUGS, DEVICES, 

6 BIOLOGICALS, OR MEDICAL SUPPLIES 

7 UNDER MEDICARE, MEDICAID, OR CHIP AND 

8 PHYSICIANS AND OTHER HEALTH CARE ENTI9 TIES AND BETWEEN PHYSICIANS AND OTHER 

10 HEALTH CARE ENTITIES. 

11 (a) IN GENERAL.—Part A of title XI of the Social 

12 Security Act (42 U.S.C. 1301 et seq.), as amended by sec13 tion 1631(a), is further amended by inserting after section 

14 1128G the following new section: 

15 ‘‘SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS’ FINAN16 CIAL RELATIONSHIPS WITH MANUFACTUR17 ERS AND DISTRIBUTORS OF COVERED 

18 DRUGS, DEVICES, BIOLOGICALS, OR MEDICAL 

19 SUPPLIES UNDER MEDICARE, MEDICAID, OR 

20 CHIP AND WITH ENTITIES THAT BILL FOR 

21 SERVICES UNDER MEDICARE. 

22 ‘‘(a) REPORTING OF PAYMENTS OR OTHER TRANS23 FERS OF VALUE.— 

24 ‘‘(1) IN GENERAL.—Except as provided in this 

25 subsection, not later than March 31, 2011, and an-
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1 nually thereafter, each applicable manufacturer or 

2 distributor that provides a payment or other transfer 

3 of value to a covered recipient, or to an entity or in4 dividual at the request of or designated on behalf of 

5 a covered recipient, shall submit to the Secretary, in 

6 such electronic form as the Secretary shall require, 

7 the following information with respect to the pre8 ceding calendar year: 

9 ‘‘(A) With respect to the covered recipient, 

10 the recipient’s name, business address, physi11 cian specialty, and national provider identifier. 

12 ‘‘(B) With respect to the payment or other 

13 transfer of value, other than a drug sample— 

14 ‘‘(i) its value and date; 

15 ‘‘(ii) the name of the related drug, de16 vice, or supply, if available, to the level of 

17 specificity available; and 

18 ‘‘(iii) a description of its form, indi19 cated (as appropriate for all that apply) 

20 as— 

21 ‘‘(I) cash or a cash equivalent; 

22 ‘‘(II) in-kind items or services; 

23 ‘‘(III) stock, a stock option, or 

24 any other ownership interest, divi-
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1 dend, profit, or other return on invest2 ment; or 

3 ‘‘(IV) any other form (as defined 

4 by the Secretary). 

5 ‘‘(C) With respect to a drug sample, the 

6 name, number, date, and dosage units of the 

7 sample. 

8 ‘‘(2) AGGREGATE REPORTING.—Information 

9 submitted by an applicable manufacturer or dis10 tributor under paragraph (1) shall include the ag11 gregate amount of all payments or other transfers of 

12 value provided by the manufacturer or distributor to 

13 covered recipients (and to entities or individuals at 

14 the request of or designated on behalf of a covered 

15 recipient) during the year involved, including all pay16 ments and transfers of value regardless of whether 

17 such payments or transfer of value were individually 

18 disclosed. 

19 ‘‘(3) SPECIAL RULE FOR CERTAIN PAYMENTS

20 OR OTHER TRANSFERS OF VALUE.—In the case 

21 where an applicable manufacturer or distributor pro22 vides a payment or other transfer of value to an en23 tity or individual at the request of or designated on 

24 behalf of a covered recipient, the manufacturer or 

25 distributor shall disclose that payment or other 
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1 transfer of value under the name of the covered re2 cipient. 

3 ‘‘(4) DELAYED REPORTING FOR PAYMENTS

4 MADE PURSUANT TO PRODUCT DEVELOPMENT

5 AGREEMENTS.—In the case of a payment or other 

6 transfer of value made to a covered recipient by an 

7 applicable manufacturer or distributor pursuant to a 

8 product development agreement for services fur9 nished in connection with the development of a new 

10 drug, device, biological, or medical supply, the appli11 cable manufacturer or distributor may report the 

12 value and recipient of such payment or other trans13 fer of value in the first reporting period under this 

14 subsection in the next reporting deadline after the 

15 earlier of the following: 

16 ‘‘(A) The date of the approval or clearance 

17 of the covered drug, device, biological, or med18 ical supply by the Food and Drug Administra19 tion. 

20 ‘‘(B) Two calendar years after the date 

21 such payment or other transfer of value was 

22 made. 

23 ‘‘(5) DELAYED REPORTING FOR PAYMENTS

24 MADE PURSUANT TO CLINICAL INVESTIGATIONS.—In 

25 the case of a payment or other transfer of value 
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1 made to a covered recipient by an applicable manu2 facturer or distributor in connection with a clinical 

3 investigation regarding a new drug, device, biologi4 cal, or medical supply, the applicable manufacturer 

5 or distributor may report as required under this sec6 tion in the next reporting period under this sub7 section after the earlier of the following: 

8 ‘‘(A) The date that the clinical investiga9 tion is registered on the website maintained by 

10 the National Institutes of Health pursuant to 

11 section 671 of the Food and Drug Administra12 tion Amendments Act of 2007. 

13 ‘‘(B) Two calendar years after the date 

14 such payment or other transfer of value was 

15 made. 

16 ‘‘(6) CONFIDENTIALITY.—Information de17 scribed in paragraph (4) or (5) shall be considered 

18 confidential and shall not be subject to disclosure 

19 under section 552 of title 5, United States Code, or 

20 any other similar Federal, State, or local law, until 

21 or after the date on which the information is made 

22 available to the public under such paragraph. 

23 ‘‘(7) PHYSICIANS IN SELF-INSURED HEALTH

24 PLANS.—Nothing in this subsection shall be con25 strued to require the disclosure of a payment or 
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1 other transfer of value to a physician by a self-in2 sured health plan. 

3 ‘‘(b) REPORTING OF OWNERSHIP INTEREST BY PHY4 SICIANS.— 

5 ‘‘(1) HOSPITALS AND OTHER ENTITIES THAT

6 BILL MEDICARE.—Not later than March 31 of each 

7 year (beginning with 2011), each hospital or other 

8 health care entity (not including a Medicare Advan9 tage organization) that bills the Secretary under 

10 part A or part B of title XVIII for services shall re11 port on the ownership shares (other than ownership 

12 shares described in section 1877(c)) of each physi13 cian who, directly or indirectly, owns an interest in 

14 the entity. 

15 ‘‘(2) ADDITIONAL PHYSICIAN OWNERSHIP.— 

16 Not later than March 31 of each year (beginning 

17 with 2011), in addition to the requirement under 

18 subsection (a)(1), any applicable manufacturer, ap19 plicable group purchasing organization, or applicable 

20 distributor shall submit to the Secretary, in such 

21 electronic form as the Secretary shall require, the 

22 following information regarding any ownership or in23 vestment interest (other than an ownership or in24 vestment interest in a publicly traded security and 

25 mutual fund, as described in section 1877(c)) held 
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1 by a physician (or an immediate family member of 

2 such physician (as defined for purposes of section 

3 1877(a))) in the applicable manufacturer, applicable 

4 group purchasing organization or applicable dis5 tributor during the preceding year: 

6 ‘‘(A) The dollar amount invested by each 

7 physician holding such an ownership or invest8 ment interest. 

9 ‘‘(B) The value and terms of each such 

10 ownership or investment interest. 

11 ‘‘(C) Any payment or other transfer of 

12 value provided to a physician holding such an 

13 ownership or investment interest (or to an enti14 ty or individual at the request of or designated 

15 on behalf of a physician holding such an owner16 ship or investment interest), including the infor17 mation described in clauses (i) through (iii) of 

18 paragraph (a)(1)(B), and information described 

19 in subsection (f)(8)(A) and (f)(8)(B). 

20 ‘‘(D) Any other information regarding the 

21 ownership or investment interest the Secretary 

22 determines appropriate. 

23 ‘‘(3) DEFINITIONS.—In this subsection: 
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1 ‘‘(A) PHYSICIAN.—The term ‘physician’ in2 cludes a physician’s immediate family members 

3 (as defined for purposes of section 1877(a)). 

4 ‘‘(B) APPLICABLE GROUP PURCHASING OR5 GANIZATION.—The term ‘applicable group pur6 chasing organization’ means any organization 

7 or other entity (as defined by the Secretary) 

8 that purchases, arranges for, or negotiates the 

9 purchase of a covered drug, device, biological, 

10 or medical supply. 

11 ‘‘(4) STUDY OF PRACTICE PATTERNS IN AD12 VANCED DIAGNOSTIC IMAGING AND RADIATION ON13 COLOGY SERVICES.—The Comptroller General of the 

14 United States shall conduct a study to evaluate the 

15 extent of use of physician self-referral arrangements 

16 and the effects of such arrangements on the cost of 

17 providing advanced diagnostic imaging and radiation 

18 oncology services to Medicare beneficiaries under 

19 title XVIII. The study shall be completed and sub20 mitted to Congress not later than July 1, 2011. 

21 ‘‘(c) PUBLIC AVAILABILITY.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall estab23 lish procedures to ensure that, not later than Sep24 tember 30, 2011, and on June 30 of each year be25 ginning thereafter, the information submitted under 
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1 subsections (a) and (b), other than information re2 gard drug samples, with respect to the preceding 

3 calendar year is made available through an Internet 

4 website that— 

5 ‘‘(A) is searchable and is in a format that 

6 is clear and understandable; 

7 ‘‘(B) contains information that is pre8 sented by the name of the applicable manufac9 turer or distributor, the name of the covered re10 cipient, the business address of the covered re11 cipient, the specialty (if applicable) of the cov12 ered recipient, the value of the payment or 

13 other transfer of value, the date on which the 

14 payment or other transfer of value was provided 

15 to the covered recipient, the form of the pay16 ment or other transfer of value, indicated (as 

17 appropriate) under subsection (a)(1)(B)(ii), the 

18 nature of the payment or other transfer of 

19 value, indicated (as appropriate) under sub20 section (a)(1)(B)(iii), and the name of the cov21 ered drug, device, biological, or medical supply, 

22 as applicable; 

23 ‘‘(C) contains information that is able to 

24 be easily aggregated and downloaded; 
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1 ‘‘(D) contains a description of any enforce2 ment actions taken to carry out this section, in3 cluding any penalties imposed under subsection 

4 (d), during the preceding year; 

5 ‘‘(E) contains background information on 

6 industry-physician relationships; 

7 ‘‘(F) in the case of information submitted 

8 with respect to a payment or other transfer of 

9 value described in subsection (a)(5), lists such 

10 information separately from the other informa11 tion submitted under subsection (a) and des12 ignates such separately listed information as 

13 funding for clinical research; 

14 ‘‘(G) contains any other information the 

15 Secretary determines would be helpful to the 

16 average consumer; and 

17 ‘‘(H) provides the covered recipient an op18 portunity to submit corrections to the informa19 tion made available to the public with respect to 

20 the covered recipient. 

21 ‘‘(2) ACCURACY OF REPORTING.—The accuracy 

22 of the information that is submitted under sub23 sections (a) and (b) and made available under para24 graph (1) shall be the responsibility of the reporting 

25 entity reporting under subsection (a) or (b), as ap-
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1 plicable. The Secretary shall establish procedures to 

2 ensure that the covered recipient is provided with an 

3 opportunity to submit corrections to the applicable 

4 reporting entity with regard to information made 

5 public with respect to the covered recipient and, 

6 under such procedures, the corrections shall be 

7 transmitted to the Secretary. 

8 ‘‘(3) SPECIAL RULE FOR DRUG SAMPLES.—In9 formation relating to drug samples provided under 

10 subsection (a) shall not be made available to the 

11 public by the Secretary but may be made available 

12 outside the Department of Health and Human Serv13 ices by the Secretary for research or legitimate busi14 ness purposes pursuant to data use agreements. 

15 ‘‘(4) SPECIAL RULE FOR NATIONAL PROVIDER

16 IDENTIFIERS.—Information relating to national pro17 vider identifiers provided under subsection (a) shall 

18 not be made available to the public by the Secretary 

19 but may be made available outside the Department 

20 of Health and Human Services by the Secretary for 

21 research or legitimate business purposes pursuant to 

22 data use agreements. 

23 ‘‘(d) PENALTIES FOR NONCOMPLIANCE.— 

24 ‘‘(1) FAILURE TO REPORT.— 
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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), except as provided in paragraph (2), 

3 any reporting entity that fails to submit infor4 mation required under subsection (a) or (b), as 

5 applicable, in a timely manner in accordance 

6 with regulations promulgated to carry out such 

7 applicable subsection shall be subject to a civil 

8 money penalty of not less than $1,000, but not 

9 more than $10,000, for each payment or other 

10 transfer of value or ownership or investment in11 terest not reported as required under such sub12 section. Such penalty shall be imposed and col13 lected in the same manner as civil money pen14 alties under subsection (a) of section 1128A are 

15 imposed and collected under that section. 

16 ‘‘(B) LIMITATION.—The total amount of 

17 civil money penalties imposed under subpara18 graph (A), with respect to each annual submis19 sion of information under subsection (a) by a 

20 reporting entity, shall not exceed $150,000. 

21 ‘‘(2) KNOWING FAILURE TO REPORT.— 

22 ‘‘(A) IN GENERAL.—Subject to subpara23 graph (B), any reporting entity that knowingly 

24 fails to submit information required under sub25 section (a) or (b), as applicable, in a timely 
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1 manner in accordance with regulations promul2 gated to carry out such applicable subsection, 

3 shall be subject to a civil money penalty of not 

4 less than $10,000, but not more than 

5 $100,000, for each payment or other transfer of 

6 value or ownership or investment interest not 

7 reported as required under such subsection. 

8 Such penalty shall be imposed and collected in 

9 the same manner as civil money penalties under 

10 subsection (a) of section 1128A are imposed 

11 and collected under that section. 

12 ‘‘(B) LIMITATION.—The total amount of 

13 civil money penalties imposed under subpara14 graph (A) with respect to each annual submis15 sion of information under subsection (a) or (b) 

16 by an applicable reporting entity shall not ex17 ceed $1,000,000, or, if greater, 0.1 percentage 

18 of the total annual revenues of the reporting en19 tity. 

20 ‘‘(3) USE OF FUNDS.—Funds collected by the 

21 Secretary as a result of the imposition of a civil 

22 money penalty under this subsection shall be used to 

23 carry out this section. 

24 ‘‘(4) ENFORCEMENT THROUGH STATE ATTOR25 NEYS GENERAL.—The attorney general of a State, 
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1 after providing notice to the Secretary of an intent 

2 to proceed under this paragraph in a specific case 

3 and providing the Secretary with an opportunity to 

4 bring an action under this subsection and the Sec5 retary declining such opportunity, may proceed 

6 under this subsection against an applicable manufac7 turer or distributor in the State. 

8 ‘‘(e) ANNUAL REPORT TO CONGRESS.—Not later 

9 than April 1 of each year beginning with 2011, the Sec10 retary shall submit to Congress a report that includes the 

11 following: 

12 ‘‘(1) The information submitted under this sec13 tion during the preceding year, aggregated for each 

14 applicable reporting entity that submitted such in15 formation during such year. 

16 ‘‘(2) A description of any enforcement actions 

17 taken to carry out this section, including any pen18 alties imposed under subsection (d), during the pre19 ceding year. 

20 ‘‘(f) DEFINITIONS.—In this section: 

21 ‘‘(1) APPLICABLE DISTRIBUTOR.—The term 

22 ‘applicable distributor’ means— 

23 ‘‘(A) any entity, other than an applicable 

24 group purchasing organization, that buys and 

25 resells, or receives a commission or other simi-
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1 lar form of payment, from another seller, for 

2 selling or arranging for the sale of a covered 

3 drug, device, biological, or medical supply; or 

4 ‘‘(B) any entity under common ownership 

5 with such an entity described in subparagraph 

6 (A) and which provides assistance or support to 

7 such entity so described with respect to the pro8 duction, preparation, propagation, 

9 compounding, conversion, processing, mar10 keting, or distribution of a covered drug, device, 

11 biological, or medical supply. 

12 Such term does not include a wholesale pharma13 ceutical distributor. 

14 ‘‘(2) APPLICABLE MANUFACTURER.—The term 

15 ‘applicable manufacturer’ means any entity which is 

16 engaged in the production, preparation, propagation, 

17 compounding, conversion, processing, marketing, or 

18 manufacturer-direct distribution of a covered drug, 

19 device, biological, or medical supply (or any entity 

20 under common ownership with such entity and which 

21 provides assistance or support to such entity with re22 spect to the production, preparation, propagation, 

23 compounding, conversion, processing, marketing, or 

24 distribution or a covered drug, device, biological, or 

25 medical supply). For purposes of this section only, 
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1 such term does not include a retail pharmacy li2 censed under State law. 

3 ‘‘(3) CLINICAL INVESTIGATION.—The term 

4 ‘clinical investigation’ means any experiment involv5 ing one or more human subjects, or materials de6 rived from human subjects, in which a drug or de7 vice is administered, dispensed, or used. 

8 ‘‘(4) COVERED DRUG, DEVICE, BIOLOGICAL, OR

9 MEDICAL SUPPLY.—The term ‘covered’ means, with 

10 respect to a drug, device, biological, or medical sup11 ply, such a drug, device, biological, or medical supply 

12 for which payment is available under title XVIII or 

13 a State plan under title XIX or XXI (or a waiver 

14 of such a plan). 

15 ‘‘(5) COVERED RECIPIENT.—The term ‘covered 

16 recipient’ means the following: 

17 ‘‘(A) A physician. 

18 ‘‘(B) A physician group practice. 

19 ‘‘(C) Any other prescriber of a covered 

20 drug, device, biological, or medical supply. 

21 ‘‘(D) A pharmacy or pharmacist. 

22 ‘‘(E) A health insurance issuer, group 

23 health plan, or other entity offering a health 

24 benefits plan, including any employee of such 

25 an issuer, plan, or entity. 
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1 ‘‘(F) A pharmacy benefit manager, includ2 ing any employee of such a manager. 

3 ‘‘(G) A hospital. 

4 ‘‘(H) A medical school. 

5 ‘‘(I) A sponsor of a continuing medical 

6 education program. 

7 ‘‘(J) A patient advocacy or disease specific 

8 group. 

9 ‘‘(K) A organization of health care profes10 sionals. 

11 ‘‘(L) A biomedical researcher. 

12 ‘‘(M) A group purchasing organization. 

13 ‘‘(6) EMPLOYEE.—The term ‘employee’ has the 

14 meaning given such term in section 1877(h)(2). 

15 ‘‘(7) KNOWINGLY.—The term ‘knowingly’ has 

16 the meaning given such term in section 3729(b) of 

17 title 31, United States Code. 

18 ‘‘(8) PAYMENT OR OTHER TRANSFER OF

19 VALUE.— 

20 ‘‘(A) IN GENERAL.—The term ‘payment or 

21 other transfer of value’ means a transfer of 

22 anything of value for or of any of the following: 

23 ‘‘(i) Gift, food, or entertainment. 

24 ‘‘(ii) Travel or trip. 

25 ‘‘(iii) Honoraria. 
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1 ‘‘(iv) Research funding or grant. 

2 ‘‘(v) Education or conference funding. 

3 ‘‘(vi) Consulting fees. 

4 ‘‘(vii) Ownership or investment inter5 est and royalties or license fee. 

6 ‘‘(B) INCLUSIONS.—Subject to subpara7 graph (C), the term ‘payment or other transfer 

8 of value’ includes any compensation, gift, hono9 rarium, speaking fee, consulting fee, travel, 

10 services, dividend, profit distribution, stock or 

11 stock option grant, or any ownership or invest12 ment interest held by a physician in a manufac13 turer (excluding a dividend or other profit dis14 tribution from, or ownership or investment in15 terest in, a publicly traded security or mutual 

16 fund (as described in section 1877(c))). 

17 ‘‘(C) EXCLUSIONS.—The term ‘payment or 

18 other transfer of value’ does not include the fol19 lowing: 

20 ‘‘(i) Any payment or other transfer of 

21 value provided by an applicable manufac22 turer or distributor to a covered recipient 

23 where the amount transferred to, requested 

24 by, or designated on behalf of the covered 

25 recipient does not exceed $5. 
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1 ‘‘(ii) The loan of a covered device for 

2 a short-term trial period, not to exceed 90 

3 days, to permit evaluation of the covered 

4 device by the covered recipient. 

5 ‘‘(iii) Items or services provided under 

6 a contractual warranty, including the re7 placement of a covered device, where the 

8 terms of the warranty are set forth in the 

9 purchase or lease agreement for the cov10 ered device. 

11 ‘‘(iv) A transfer of anything of value 

12 to a covered recipient when the covered re13 cipient is a patient and not acting in the 

14 professional capacity of a covered recipient. 

15 ‘‘(v) In-kind items used for the provi16 sion of charity care. 

17 ‘‘(vi) A dividend or other profit dis18 tribution from, or ownership or investment 

19 interest in, a publicly traded security and 

20 mutual fund (as described in section 

21 1877(c)). 

22 ‘‘(vii) Compensation paid by an appli23 cable manufacturer or distributor to a cov24 ered recipient who is directly employed by 
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1 and works solely for such manufacturer or 

2 distributor. 

3 ‘‘(viii) Payments made to a covered 

4 recipient by an applicable manufacturer or 

5 by a health plan affiliated with an applica6 ble manufacturer for medical care provided 

7 to employees of such manufacturer or their 

8 dependents. 

9 ‘‘(ix) Any discount (including a re10 bate). 

11 ‘‘(x) Any payment or other transfer of 

12 value that is made to a covered recipient 

13 indirectly through an entity other than the 

14 applicable manufacturer in connection with 

15 an activity or service— 

16 ‘‘(I) in which the applicable man17 ufacturer is unaware of the identity of 

18 the covered recipient and is not using 

19 such activity or service to market its 

20 product to the covered recipient; and 

21 ‘‘(II) that is not designed to mar22 ket or promote the product to the cov23 ered recipient. 

24 ‘‘(xi) In the case of an applicable 

25 manufacturer who offers a self-insured 
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1 plan, payments for the provision of health 

2 care to employees under the plan. 

3 ‘‘(9) PHYSICIAN.—The term ‘physician’ has the 

4 meaning given that term in section 1861(r). For 

5 purposes of this section, such term does not include 

6 a physician who is an employee of the applicable 

7 manufacturer that is required to submit information 

8 under subsection (a). 

9 ‘‘(10) REPORTING ENTITY.—The term ‘report10 ing entity’ means— 

11 ‘‘(A) with respect to the reporting require12 ment under subsection (a), an applicable manu13 facturer or distributor of a covered drug, device, 

14 biological, or medical supply required to report 

15 under such subsection; and 

16 ‘‘(B) with respect to the reporting require17 ment under subsection (b), a hospital, other 

18 health care entity, applicable manufacturer, ap19 plicable distributor, or applicable group pur20 chasing organization required to report physi21 cian ownership under such subsection. 

22 ‘‘(g) ANNUAL REPORTS TO STATES.—Not later than 

23 April 1 of each year beginning with 2011, the Secretary 

24 shall submit to States a report that includes a summary 

25 of the information submitted under subsections (a), (b), 
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1 and (e) during the preceding year with respect to covered 

2 recipients or other hospitals and entities in the State. 

3 ‘‘(h) RELATION TO STATE LAWS.— 

4 ‘‘(1) IN GENERAL.—Effective on January 1, 

5 2011, subject to paragraph (2), the provisions of 

6 this section shall preempt any law or regulation of 

7 a State or of a political subdivision of a State that 

8 requires an applicable manufacturer and applicable 

9 distributor (as such terms are defined in subsection 

10 (f)) to disclose or report, in any format, the type of 

11 information (described in subsection (a)) regarding a 

12 payment or other transfer of value provided by the 

13 manufacturer to a covered recipient (as so defined). 

14 ‘‘(2) NO PREEMPTION OF ADDITIONAL RE15 QUIREMENTS.—Paragraph (1) shall not preempt any 

16 statute or regulation of a State or political subdivi17 sion of a State that requires any of the following: 

18 ‘‘(A) The disclosure or reporting of infor19 mation not of the type required to be disclosed 

20 or reported under this section. 

21 ‘‘(B) The disclosure or reporting, in any 

22 format, of information described in subsection 

23 (f)(8)(C), except in the case of information de24 scribed in clause (i) of subsection (f)(8)(C). 
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1 ‘‘(C) The disclosure or reporting, in any 

2 format, of the type of information by any per3 son or entity other than an applicable manufac4 turer (as so defined) or a covered recipient (as 

5 defined in subsection (f)). 

6 ‘‘(D) The disclosure or reporting, in any 

7 format, of the type of information required to 

8 be disclosed or reported under this section to a 

9 Federal, State, or local governmental agency for 

10 public health surveillance, investigation, or 

11 other public health purposes or health oversight 

12 purposes. 

13 Nothing in paragraph (1) shall be construed to limit 

14 the discovery or admissibility of information de15 scribed in this paragraph in a criminal, civil, or ad16 ministrative proceeding.’’. 

17 (b) AVAILABILITY OF INFORMATION FROM THE DIS18 CLOSURE OF FINANCIAL RELATIONSHIP REPORT

19 (DFRR).—The Secretary of Health and Human Services 

20 shall submit to Congress a report on the full results of 

21 the Disclosure of Physician Financial Relationships sur22 veys required pursuant to section 5006 of the Deficit Re23 duction Act of 2005. Such report shall be submitted to 

24 Congress not later than the date that is 6 months after 

25 the date such surveys are collected and shall be made pub-
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1 licly available on an Internet website of the Department 

2 of Health and Human Services. 

3 (c) GAO REPORT.—Not later than December 31, 

4 2012, the Comptroller General of the United States shall 

5 submit to Congress a report on section 1128H of the So6 cial Security Act, as added by subsection (a). Such report 

7 shall address the extent to which important transfers of 

8 value are being adequately reported under such section 

9 (including unreported transfers required by such section 

10 as well as transfers not required to be reported by such 

11 section), the impact on States of the Federal preemption 

12 provision under subsection (h) of such section, whether 

13 changes have occurred in the pattern of payments as a 

14 result of efforts to evade reporting requirements, a de15 scription of the financial relationships subject to delayed 

16 reporting under subsection (a) of such section, and any 

17 recommended improvements to the collection or the anal18 ysis of data reported under such section. 
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1 Subtitle E—Public Reporting on 

2 Health Care-Associated Infections 

3 SEC. 1461. REQUIREMENT FOR PUBLIC REPORTING BY 

4 HOSPITALS AND AMBULATORY SURGICAL 

5 CENTERS ON HEALTH CARE-ASSOCIATED IN6 FECTIONS. 

7 (a) IN GENERAL.—Title XI of the Social Security Act 

8 is amended by inserting after section 1138 the following 

9 section: 

10 ‘‘SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY 

11 HOSPITALS AND AMBULATORY SURGICAL 

12 CENTERS ON HEALTH CARE-ASSOCIATED IN13 FECTIONS. 

14 ‘‘(a) REPORTING REQUIREMENT.— 

15 ‘‘(1) IN GENERAL.—The Secretary shall provide 

16 that a hospital (as defined in subsection (g)) or am17 bulatory surgical center meeting the requirements of 

18 titles XVIII or XIX may participate in the programs 

19 established under such titles only if, in accordance 

20 with this section, the hospital or center reports such 

21 information on health care-associated infections that 

22 develop in the hospital or center (and such demo23 graphic information associated with such infections) 

24 as the Secretary specifies. 
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1 ‘‘(2) REPORTING PROTOCOLS.— Such informa2 tion shall be reported in accordance with reporting 

3 protocols established by the Secretary through the 

4 Director of the Centers for Disease Control and Pre5 vention (in this section referred to as the ‘CDC’) 

6 and to the National Healthcare Safety Network of 

7 the CDC or under such another reporting system of 

8 such Centers as determined appropriate by the Sec9 retary in consultation with such Director. 

10 ‘‘(3) COORDINATION WITH HIT.—The Sec11 retary, through the Director of the CDC and the Of12 fice of the National Coordinator for Health Informa13 tion Technology, shall ensure that the transmission 

14 of information under this subsection is coordinated 

15 with systems established under the HITECH Act, 

16 where appropriate. 

17 ‘‘(4) PROCEDURES TO ENSURE THE VALIDITY

18 OF INFORMATION.—The Secretary shall establish 

19 procedures regarding the validity of the information 

20 submitted under this subsection in order to ensure 

21 that such information is appropriately compared 

22 across hospitals and centers. Such procedures shall 

23 address failures to report as well as errors in report24 ing. 
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1 ‘‘(5) IMPLEMENTATION.—Not later than 1 year 

2 after the date of enactment of this section, the Sec3 retary, through the Director of CDC, shall promul4 gate regulations to carry out this section. 

5 ‘‘(b) PUBLIC POSTING OF INFORMATION.—The Sec6 retary shall promptly post, on the official public Internet 

7 site of the Department of Health and Human Services, 

8 the information reported under subsection (a). Such infor9 mation shall be set forth in a manner that allows for the 

10 comparison of information on health care-associated infec11 tions— 

12 ‘‘(1) among hospitals and ambulatory surgical 

13 centers; and 

14 ‘‘(2) by demographic information. 

15 ‘‘(c) ANNUAL REPORT TO CONGRESS.—On an annual 

16 basis the Secretary shall submit to the Congress a report 

17 that summarizes each of the following: 

18 ‘‘(1) The number and types of health care-asso19 ciated infections reported under subsection (a) in 

20 hospitals and ambulatory surgical centers during 

21 such year. 

22 ‘‘(2) Factors that contribute to the occurrence 

23 of such infections, including health care worker im24 munization rates. 
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1 ‘‘(3) Based on the most recent information 

2 available to the Secretary on the composition of the 

3 professional staff of hospitals and ambulatory sur4 gical centers, the number of certified infection con5 trol professionals on the staff of hospitals and ambu6 latory surgical centers. 

7 ‘‘(4) The total increases or decreases in health 

8 care costs that resulted from increases or decreases 

9 in the rates of occurrence of each such type of infec10 tion during such year. 

11 ‘‘(5) Recommendations, in coordination with the 

12 Center for Quality Improvement established under 

13 section 931 of the Public Health Service Act, for 

14 best practices to eliminate the rates of occurrence of 

15 each such type of infection in hospitals and ambula16 tory surgical centers. 

17 ‘‘(d) NON-PREEMPTION OF STATE LAWS.—Nothing 

18 in this section shall be construed as preempting or other19 wise affecting any provision of State law relating to the 

20 disclosure of information on health care-associated infec21 tions or patient safety procedures for a hospital or ambu22 latory surgical center. 

23 ‘‘(e) HEALTH CARE-ASSOCIATED INFECTION.—For 

24 purposes of this section: 
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1 ‘‘(1) IN GENERAL.—The term ‘health care-asso2 ciated infection’ means an infection that develops in 

3 a patient who has received care in any institutional 

4 setting where health care is delivered and is related 

5 to receiving health care. 

6 ‘‘(2) RELATED TO RECEIVING HEALTH CARE.— 

7 The term ‘related to receiving health care’, with re8 spect to an infection, means that the infection was 

9 not incubating or present at the time health care 

10 was provided. 

11 ‘‘(f) APPLICATION TO CRITICAL ACCESS HOS12 PITALS.—For purposes of this section, the term ‘hospital’ 

13 includes a critical access hospital, as defined in section 

14 1861(mm)(1).’’. 

15 (b) EFFECTIVE DATE.—With respect to section 

16 1138A of the Social Security Act (as inserted by sub17 section (a) of this section), the requirement under such 

18 section that hospitals and ambulatory surgical centers 

19 submit reports takes effect on such date (not later than 

20 2 years after the date of the enactment of this Act) as 

21 the Secretary of Health and Human Services shall specify. 

22 In order to meet such deadline, the Secretary may imple23 ment such section through guidance or other instructions. 

24 (c) GAO REPORT.—Not later than 18 months after 

25 the date of the enactment of this Act, the Comptroller 
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1 General of the United States shall submit to Congress a 

2 report on the program established under section 1138A 

3 of the Social Security Act, as inserted by subsection (a). 

4 Such report shall include an analysis of the appropriate5 ness of the types of information required for submission, 

6 compliance with reporting requirements, the success of the 

7 validity procedures established, and any conflict or overlap 

8 between the reporting required under such section and any 

9 other reporting systems mandated by either the States or 

10 the Federal Government. 

11 (d) REPORT ON ADDITIONAL DATA.—Not later than 

12 18 months after the date of the enactment of this Act, 

13 the Secretary of Health and Human Services shall submit 

14 to the Congress a report on the appropriateness of expand15 ing the requirements under such section to include addi16 tional information (such as health care worker immuniza17 tion rates), in order to improve health care quality and 

18 patient safety. 

19 TITLE V—MEDICARE GRADUATE 

20 MEDICAL EDUCATION 

21 SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSI22 TIONS. 

23 (a) IN GENERAL.—Section 1886(h) of the Social Se24 curity Act (42 U.S.C. 1395ww(h)) is amended— 
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1 (1) in paragraph (4)(F)(i), by striking ‘‘para2 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

3 (2) in paragraph (4)(H)(i), by striking ‘‘para4 graph (7)’’ and inserting ‘‘paragraphs (7) and (8)’’; 

5 (3) in paragraph (7)(E), by inserting ‘‘and 

6 paragraph (8)’’ after ‘‘this paragraph’’; and 

7 (4) by adding at the end the following new 

8 paragraph: 

9 ‘‘(8) ADDITIONAL REDISTRIBUTION OF UNUSED

10 RESIDENCY POSITIONS.— 

11 ‘‘(A) REDUCTIONS IN LIMIT BASED ON UN12 USED POSITIONS.— 

13 ‘‘(i) PROGRAMS SUBJECT TO REDUC14 TION.—If a hospital’s reference resident 

15 level (specified in clause (ii)) is less than 

16 the otherwise applicable resident limit (as 

17 defined in subparagraph (C)(ii)), effective 

18 for portions of cost reporting periods oc19 curring on or after July 1, 2011, the oth20 erwise applicable resident limit shall be re21 duced by 90 percent of the difference be22 tween such otherwise applicable resident 

23 limit and such reference resident level. 

24 ‘‘(ii) REFERENCE RESIDENT LEVEL.— 
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1 ‘‘(I) IN GENERAL.—Except as 

2 otherwise provided in a subsequent 

3 subclause, the reference resident level 

4 specified in this clause for a hospital 

5 is the highest resident level for any of 

6 the 3 most recent cost reporting peri7 ods (ending before the date of the en8 actment of this paragraph) of the hos9 pital for which a cost report has been 

10 settled (or, if not, submitted (subject 

11 to audit)), as determined by the Sec12 retary. 

13 ‘‘(II) USE OF MOST RECENT AC14 COUNTING PERIOD TO RECOGNIZE EX15 PANSION OF EXISTING PROGRAMS.—If 

16 a hospital submits a timely request to 

17 increase its resident level due to an 

18 expansion, or planned expansion, of 

19 an existing residency training pro20 gram that is not reflected on the most 

21 recent settled or submitted cost re22 port, after audit and subject to the 

23 discretion of the Secretary, subject to 

24 subclause (IV), the reference resident 

25 level for such hospital is the resident 
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1 level that includes the additional resi2 dents attributable to such expansion 

3 or establishment, as determined by 

4 the Secretary. The Secretary is au5 thorized to determine an alternative 

6 reference resident level for a hospital 

7 that submitted to the Secretary a 

8 timely request, before the start of the 

9 2009–2010 academic year, for an in10 crease in its reference resident level 

11 due to a planned expansion. 

12 ‘‘(III) SPECIAL PROVIDER

13 AGREEMENT.—In the case of a hos14 pital described in paragraph 

15 (4)(H)(v), the reference resident level 

16 specified in this clause is the limita17 tion applicable under subclause (I) of 

18 such paragraph. 

19 ‘‘(IV) PREVIOUS REDISTRIBU20 TION.—The reference resident level 

21 specified in this clause for a hospital 

22 shall be increased to the extent re23 quired to take into account an in24 crease in resident positions made 

25 available to the hospital under para-
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1 graph (7)(B) that are not otherwise 

2 taken into account under a previous 

3 subclause. 

4 ‘‘(iii) AFFILIATION.—The provisions 

5 of clause (i) shall be applied to hospitals 

6 which are members of the same affiliated 

7 group (as defined by the Secretary under 

8 paragraph (4)(H)(ii)) and to the extent the 

9 hospitals can demonstrate that they are 

10 filling any additional resident slots allo11 cated to other hospitals through an affili12 ation agreement, the Secretary shall adjust 

13 the determination of available slots accord14 ingly, or which the Secretary otherwise has 

15 permitted the resident positions (under 

16 section 402 of the Social Security Amend17 ments of 1967) to be aggregated for pur18 poses of applying the resident position lim19 itations under this subsection. 

20 ‘‘(B) REDISTRIBUTION.— 

21 ‘‘(i) IN GENERAL.—The Secretary 

22 shall increase the otherwise applicable resi23 dent limit for each qualifying hospital that 

24 submits an application under this subpara25 graph by such number as the Secretary 
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1 may approve for portions of cost reporting 

2 periods occurring on or after July 1, 2011. 

3 The estimated aggregate number of in4 creases in the otherwise applicable resident 

5 limit under this subparagraph may not ex6 ceed the Secretary’s estimate of the aggre7 gate reduction in such limits attributable 

8 to subparagraph (A). 

9 ‘‘(ii) REQUIREMENTS FOR QUALI10 FYING HOSPITALS.—A hospital is not a 

11 qualifying hospital for purposes of this 

12 paragraph unless the following require13 ments are met: 

14 ‘‘(I) MAINTENANCE OF PRIMARY

15 CARE RESIDENT LEVEL.—The hos16 pital maintains the number of primary 

17 care residents at a level that is not 

18 less than the base level of primary 

19 care residents increased by the num20 ber of additional primary care resi21 dent positions provided to the hospital 

22 under this subparagraph. For pur23 poses of this subparagraph, the ‘base 

24 level of primary care residents’ for a 

25 hospital is the level of such residents 
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1 as of a base period (specified by the 

2 Secretary), determined without regard 

3 to whether such positions were in ex4 cess of the otherwise applicable resi5 dent limit for such period but taking 

6 into account the application of sub7 clauses (II) and (III) of subparagraph 

8 (A)(ii). 

9 ‘‘(II) DEDICATED ASSIGNMENT

10 OF ADDITIONAL RESIDENT POSITIONS

11 TO PRIMARY CARE.—The hospital as12 signs all such additional resident posi13 tions for primary care residents. 

14 ‘‘(III) ACCREDITATION.—The 

15 hospital’s residency programs in pri16 mary care are fully accredited or, in 

17 the case of a residency training pro18 gram not in operation as of the base 

19 year, the hospital is actively applying 

20 for such accreditation for the program 

21 for such additional resident positions 

22 (as determined by the Secretary). 

23 ‘‘(iii) CONSIDERATIONS IN REDIS24 TRIBUTION.—In determining for which 

25 qualifying hospitals the increase in the oth-
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1 erwise applicable resident limit is provided 

2 under this subparagraph, the Secretary 

3 shall take into account the demonstrated 

4 likelihood of the hospital filling the posi5 tions within the first 3 cost reporting peri6 ods beginning on or after July 1, 2011, 

7 made available under this subparagraph, 

8 as determined by the Secretary. 

9 ‘‘(iv) PRIORITY FOR CERTAIN HOS10 PITALS.—In determining for which quali11 fying hospitals the increase in the other12 wise applicable resident limit is provided 

13 under this subparagraph, the Secretary 

14 shall distribute the increase to qualifying 

15 hospitals based on the following criteria: 

16 ‘‘(I) The Secretary shall give 

17 preference to hospitals that had a re18 duction in resident training positions 

19 under subparagraph (A). 

20 ‘‘(II) The Secretary shall give 

21 preference to hospitals with 3-year 

22 primary care residency training pro23 grams, such as family practice and 

24 general internal medicine. 
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1 ‘‘(III) The Secretary shall give 

2 preference to hospitals insofar as they 

3 have in effect formal arrangements 

4 (as determined by the Secretary) that 

5 place greater emphasis upon training 

6 in Federally qualified health centers, 

7 rural health clinics, and other nonpro8 vider settings, and to hospitals that 

9 receive additional payments under 

10 subsection (d)(5)(F) and emphasize 

11 training in an outpatient department. 

12 ‘‘(IV) The Secretary shall give 

13 preference to hospitals with a number 

14 of positions (as of July 1, 2009) in 

15 excess of the otherwise applicable resi16 dent limit for such period. 

17 ‘‘(V) The Secretary shall give 

18 preference to hospitals that place 

19 greater emphasis upon training in a 

20 health professional shortage area (des21 ignated under section 332 of the Pub22 lic Health Service Act) or a health 

23 professional needs area (designated 

24 under section 2211 of such Act). 
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1 ‘‘(VI) The Secretary shall give 

2 preference to hospitals in States that 

3 have low resident-to-population ratios 

4 (including a greater preference for 

5 those States with lower resident-to6 population ratios). 

7 ‘‘(v) LIMITATION.—In no case shall 

8 more than 20 full-time equivalent addi9 tional residency positions be made available 

10 under this subparagraph with respect to 

11 any hospital. 

12 ‘‘(vi) APPLICATION OF PER RESIDENT

13 AMOUNTS FOR PRIMARY CARE.—With re14 spect to additional residency positions in a 

15 hospital attributable to the increase pro16 vided under this subparagraph, the ap17 proved FTE resident amounts are deemed 

18 to be equal to the hospital per resident 

19 amounts for primary care and nonprimary 

20 care computed under paragraph (2)(D) for 

21 that hospital. 

22 ‘‘(vii) DISTRIBUTION.—The Secretary 

23 shall distribute the increase in resident 

24 training positions to qualifying hospitals 
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1 under this subparagraph not later than 

2 July 1, 2011. 

3 ‘‘(C) RESIDENT LEVEL AND LIMIT DE4 FINED.—In this paragraph: 

5 ‘‘(i) The term ‘resident level’ has the 

6 meaning given such term in paragraph 

7 (7)(C)(i). 

8 ‘‘(ii) The term ‘otherwise applicable 

9 resident limit’ means, with respect to a 

10 hospital, the limit otherwise applicable 

11 under subparagraphs (F)(i) and (H) of 

12 paragraph (4) on the resident level for the 

13 hospital determined without regard to this 

14 paragraph but taking into account para15 graph (7)(A). 

16 ‘‘(D) MAINTENANCE OF PRIMARY CARE

17 RESIDENT LEVEL.—In carrying out this para18 graph, the Secretary shall require hospitals that 

19 receive additional resident positions under sub20 paragraph (B)— 

21 ‘‘(i) to maintain records, and periodi22 cally report to the Secretary, on the num23 ber of primary care residents in its resi24 dency training programs; and 
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1 ‘‘(ii) as a condition of payment for a 

2 cost reporting period under this subsection 

3 for such positions, to maintain the level of 

4 such positions at not less than the sum 

5 of— 

6 ‘‘(I) the base level of primary 

7 care resident positions (as determined 

8 under subparagraph (B)(ii)(I)) before 

9 receiving such additional positions; 

10 and 

11 ‘‘(II) the number of such addi12 tional positions.’’. 

13 (b) IME.— 

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

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

16 1395ww(d)(5)(B)(v)), in the third sentence, is 

17 amended— 

18 (A) by striking ‘‘subsection (h)(7)’’ and in19 serting ‘‘subsections (h)(7) and (h)(8)’’; and 

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

21 ‘‘they apply’’. 

22 (2) CONFORMING PROVISION.—Section 

23 1886(d)(5)(B) of the Social Security Act (42 U.S.C. 

24 1395ww(d)(5)(B)) is amended by adding at the end 

25 the following clause: 
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1 ‘‘(x) For discharges occurring on or after July 1, 

2 2011, insofar as an additional payment amount under this 

3 subparagraph is attributable to resident positions distrib4 uted to a hospital under subsection (h)(8)(B), the indirect 

5 teaching adjustment factor shall be computed in the same 

6 manner as provided under clause (ii) with respect to such 

7 resident positions.’’. 

8 (c) CONFORMING AMENDMENT.—Section 422(b)(2) 

9 of the Medicare Prescription Drug, Improvement, and 

10 Modernization Act of 2003 (Public Law 108–173) is 

11 amended by striking ‘‘section 1886(h)(7)’’ and all that fol12 lows and inserting ‘‘paragraphs (7) and (8) of subsection 

13 (h) of section 1886 of the Social Security Act.’’. 

14 SEC. 1502. INCREASING TRAINING IN NONPROVIDER SET15 TINGS. 

16 (a) DIRECT GME.—Section 1886(h)(4)(E) of the So17 cial Security Act (42 U.S.C. 1395ww(h)) is amended— 

18 (1) by designating the first sentence as a clause 

19 (i) with the heading ‘‘IN GENERAL.—’’ and appro20 priate indentation; 

21 (2) by striking ‘‘shall be counted and that all 

22 the time’’ and inserting ‘‘shall be counted and 

23 that— 
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1 ‘‘(I) effective for cost reporting 

2 periods beginning before July 1, 2009, 

3 all the time’’; 

4 (3) in subclause (I), as inserted by paragraph 

5 (1), by striking the period at the end and inserting 

6 ‘‘; and’’; and 

7 (A) by inserting after subclause (I), as so 

8 inserted, the following: 

9 ‘‘(II) effective for cost reporting 

10 periods beginning on or after July 1, 

11 2009, all the time so spent by a resi12 dent shall be counted towards the de13 termination of full-time equivalency, 

14 without regard to the setting in which 

15 the activities are performed, if the 

16 hospital incurs the costs of the sti17 pends and fringe benefits of the resi18 dent during the time the resident 

19 spends in that setting. 

20 Any hospital claiming under this subpara21 graph for time spent in a nonprovider set22 ting shall maintain and make available to 

23 the Secretary records regarding the 

24 amount of such time and such amount in 

25 comparison with amounts of such time in 
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1 such base year as the Secretary shall speci2 fy.’’. 

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

4 Security Act (42 U.S.C. 1395ww(d)(5)(B)(iv)) is amend5 ed— 

6 (1) by striking ‘‘(iv) Effective for discharges oc7 curring on or after October 1, 1997’’ and inserting 

8 ‘‘(iv)(I) Effective for discharges occurring on or 

9 after October 1, 1997, and before July 1, 2009’’; 

10 and 

11 (2) by inserting after subclause (I), as inserted 

12 by paragraph (1), the following new subclause: 

13 ‘‘(II) Effective for discharges occurring on or 

14 after July 1, 2009, all the time spent by an intern 

15 or resident in patient care activities at an entity in 

16 a nonprovider setting shall be counted towards the 

17 determination of full-time equivalency if the hospital 

18 incurs the costs of the stipends and fringe benefits 

19 of the intern or resident during the time the intern 

20 or resident spends in that setting.’’. 

21 (c) OIG STUDY ON IMPACT ON TRAINING.—The In22 spector General of the Department of Health and Human 

23 Services shall analyze the data collected by the Secretary 

24 of Health and Human Services from the records made 

25 available to the Secretary under section 1886(h)(4)(E) of 
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1 the Social Security Act, as amended by subsection (a), in 

2 order to assess the extent to which there is an increase 

3 in time spent by medical residents in training in nonpro4 vider settings as a result of the amendments made by this 

5 section. Not later than 4 years after the date of the enact6 ment of this Act, the Inspector General shall submit a re7 port to Congress on such analysis and assessment. 

8 (d) DEMONSTRATION PROJECT FOR APPROVED

9 TEACHING HEALTH CENTERS.— 

10 (1) IN GENERAL.—The Secretary of Health and 

11 Human Services shall conduct a demonstration 

12 project under which an approved teaching health 

13 center (as defined in paragraph (3)) would be eligi14 ble for payment under subsections (h) and (k) of 

15 section 1886 of the Social Security Act (42 U.S.C. 

16 1395ww) of amounts for its own direct costs of 

17 graduate medical education activities for primary 

18 care residents, as well as for the direct costs of grad19 uate medical education activities of its contracting 

20 hospital for such residents, in a manner similar to 

21 the manner in which such payments would be made 

22 to a hospital if the hospital were to operate such a 

23 program. 

24 (2) CONDITIONS.—Under the demonstration 

25 project— 
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1 (A) an approved teaching health center 

2 shall contract with an accredited teaching hos3 pital to carry out the inpatient responsibilities 

4 of the primary care residency program of the 

5 hospital involved and is responsible for payment 

6 to the hospital for the hospital’s costs of the 

7 salary and fringe benefits for residents in the 

8 program; 

9 (B) the number of primary care residents 

10 of the center shall not count against the con11 tracting hospital’s resident limit; and 

12 (C) the contracting hospital shall agree not 

13 to diminish the number of residents in its pri14 mary care residency training program. 

15 (3) APPROVED TEACHING HEALTH CENTER DE16 FINED.—In this subsection, the term ‘‘approved 

17 teaching health center’’ means a nonprovider setting, 

18 such as a Federally qualified health center or rural 

19 health clinic (as defined in section 1861(aa) of the 

20 Social Security Act), that develops and operates an 

21 accredited primary care residency program for which 

22 funding would be available if it were operated by a 

23 hospital. 
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1 SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DI2 DACTIC AND SCHOLARLY ACTIVITIES AND 

3 OTHER ACTIVITIES. 

4 (a) DIRECT GME.—Section 1886(h) of the Social Se5 curity Act (42 U.S.C. 1395ww(h)) is amended— 

6 (1) in paragraph (4)(E), as amended by section 

7 1502(a)— 

8 (A) in clause (i), by striking ‘‘Such rules’’ 

9 and inserting ‘‘Subject to clause (ii), such 

10 rules’’; and 

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

12 clause: 

13 ‘‘(ii) TREATMENT OF CERTAIN NON14 PROVIDER AND DIDACTIC ACTIVITIES.— 

15 Such rules shall provide that all time spent 

16 by an intern or resident in an approved 

17 medical residency training program in a 

18 nonprovider setting that is primarily en19 gaged in furnishing patient care (as de20 fined in paragraph (5)(K)) in nonpatient 

21 care activities, such as didactic conferences 

22 and seminars, but not including research 

23 not associated with the treatment or diag24 nosis of a particular patient, as such time 

25 and activities are defined by the Secretary, 
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1 shall be counted toward the determination 

2 of full-time equivalency.’’; 

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

4 following new subparagraph: 

5 ‘‘(I) TREATMENT OF CERTAIN TIME IN AP6 PROVED MEDICAL RESIDENCY TRAINING PRO7 GRAMING.—In determining the hospital’s num8 ber of full-time equivalent residents for pur9 poses of this subsection, all the time that is 

10 spent by an intern or resident in an approved 

11 medical residency training program on vacation, 

12 sick leave, or other approved leave, as such time 

13 is defined by the Secretary, and that does not 

14 prolong the total time the resident is partici15 pating in the approved program beyond the nor16 mal duration of the program shall be counted 

17 toward the determination of full-time equiva18 lency.’’; and 

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

20 following new subparagraph: 

21 ‘‘(K) NONPROVIDER SETTING THAT IS PRI22 MARILY ENGAGED IN FURNISHING PATIENT

23 CARE.—The term ‘nonprovider setting that is 

24 primarily engaged in furnishing patient care’ 

25 means a nonprovider setting in which the pri-
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1 mary activity is the care and treatment of pa2 tients, as defined by the Secretary.’’. 

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

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

5 section 1501(b), is amended by adding at the end the fol6 lowing new clause: 

7 ‘‘(xi)(I) The provisions of subparagraph (I) of sub8 section (h)(4) shall apply under this subparagraph in the 

9 same manner as they apply under such subsection. 

10 ‘‘(II) In determining the hospital’s number of full11 time equivalent residents for purposes of this subpara12 graph, all the time spent by an intern or resident in an 

13 approved medical residency training program in non14 patient care activities, such as didactic conferences and 

15 seminars, as such time and activities are defined by the 

16 Secretary, that occurs in the hospital shall be counted to17 ward the determination of full-time equivalency if the hos18 pital— 

19 ‘‘(aa) is recognized as a subsection (d) hospital; 

20 ‘‘(bb) is recognized as a subsection (d) Puerto 

21 Rico hospital; 

22 ‘‘(cc) is reimbursed under a reimbursement sys23 tem authorized under section 1814(b)(3); or 

24 ‘‘(dd) is a provider-based hospital outpatient de25 partment. 
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1 ‘‘(III) In determining the hospital’s number of full2 time equivalent residents for purposes of this subpara3 graph, all the time spent by an intern or resident in an 

4 approved medical residency training program in research 

5 activities that are not associated with the treatment or di6 agnosis of a particular patient, as such time and activities 

7 are defined by the Secretary, shall not be counted toward 

8 the determination of full-time equivalency.’’. 

9 (c) EFFECTIVE DATES; APPLICATION.— 

10 (1) IN GENERAL.—Except as otherwise pro11 vided, the Secretary of Health and Human Services 

12 shall implement the amendments made by this sec13 tion in a manner so as to apply to cost reporting pe14 riods beginning on or after January 1, 1983. 

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

16 the Social Security Act, as added by subsection 

17 (a)(1)(B), shall apply to cost reporting periods be18 ginning on or after July 1, 2008. 

19 (3) IME.—Section 1886(d)(5)(B)(x)(III) of the 

20 Social Security Act, as added by subsection (b), shall 

21 apply to cost reporting periods beginning on or after 

22 October 1, 2001. Such section, as so added, shall 

23 not give rise to any inference on how the law in ef24 fect prior to such date should be interpreted. 
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1 (4) APPLICATION.—The amendments made by 

2 this section shall not be applied in a manner that re3 quires reopening of any settled hospital cost reports 

4 as to which there is not a jurisdictionally proper ap5 peal pending as of the date of the enactment of this 

6 Act on the issue of payment for indirect costs of 

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

8 the Social Security Act or for direct graduate med9 ical education costs under section 1886(h) of such 

10 Act. 

11 SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS 

12 FROM CLOSED HOSPITALS. 

13 (a) DIRECT GME.—Section 1886(h)(4)(H) of the So14 cial Security Act (42 U.S.C. Section 1395ww(h)(4)(H)) 

15 is amended by adding at the end the following new clause: 

16 ‘‘(vi) REDISTRIBUTION OF RESIDENCY

17 SLOTS AFTER A HOSPITAL CLOSES.— 

18 ‘‘(I) IN GENERAL.—The Sec19 retary shall, by regulation, establish a 

20 process consistent with subclauses (II) 

21 and (III) under which, in the case 

22 where a hospital (other than a hos23 pital described in clause (v)) with an 

24 approved medical residency program 

25 in a State closes on or after the date 
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1 that is 2 years before the date of the 

2 enactment of this clause, the Sec3 retary shall increase the otherwise ap4 plicable resident limit under this para5 graph for other hospitals in the State 

6 in accordance with this clause. 

7 ‘‘(II) PROCESS FOR HOSPITALS

8 IN CERTAIN AREAS.—In determining 

9 for which hospitals the increase in the 

10 otherwise applicable resident limit de11 scribed in subclause (I) is provided, 

12 the Secretary shall establish a process 

13 to provide for such increase to one or 

14 more hospitals located in the State. 

15 Such process shall take into consider16 ation the recommendations submitted 

17 to the Secretary by the senior health 

18 official (as designated by the chief ex19 ecutive officer of such State) if such 

20 recommendations are submitted not 

21 later than 180 days after the date of 

22 the hospital closure involved (or, in 

23 the case of a hospital that closed after 

24 the date that is 2 years before the 

25 date of the enactment of this clause, 
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1 180 days after such date of enact2 ment). 

3 ‘‘(III) LIMITATION.—The esti4 mated aggregate number of increases 

5 in the otherwise applicable resident 

6 limits for hospitals under this clause 

7 shall be equal to the estimated num8 ber of resident positions in the ap9 proved medical residency programs 

10 that closed on or after the date de11 scribed in subclause (I).’’. 

12 (b) NO EFFECT ON TEMPORARY FTE CAP ADJUST13 MENTS.—The amendments made by this section shall not 

14 effect any temporary adjustment to a hospital’s FTE cap 

15 under section 413.79(h) of title 42, Code of Federal Regu16 lations (as in effect on the date of enactment of this Act) 

17 and shall not affect the application of section 

18 1886(h)(4)(H)(v) of the Social Security Act. 

19 (c) CONFORMING AMENDMENTS.— 

20 (1) Section 422(b)(2) of the Medicare Prescrip21 tion Drug, Improvement, and Modernization Act of 

22 2003 (Public Law 108–173), as amended by section 

23 1501(c), is amended by striking ‘‘(7) and’’ and in24 serting ‘‘(4)(H)(vi), (7), and’’. 
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1 (2) Section 1886(h)(7)(E) of the Social Secu2 rity Act (42 U.S.C. 1395ww(h)(7)(E)) is amended 

3 by inserting ‘‘or under paragraph (4)(H)(vi)’’ after 

4 ‘‘under this paragraph’’. 

5 SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED 

6 MEDICAL RESIDENCY TRAINING. 

7 (a) SPECIFICATION OF GOALS FOR APPROVED MED8 ICAL RESIDENCY TRAINING PROGRAMS.—Section 

9 1886(h)(1) of the Social Security Act (42 U.S.C. 

10 1395ww(h)(1)) is amended— 

11 (1) by designating the matter beginning with 

12 ‘‘Notwithstanding’’ as a subparagraph (A) with the 

13 heading ‘‘IN GENERAL.—’’ and with appropriate in14 dentation; and 

15 (2) by adding at the end the following new sub16 paragraph: 

17 ‘‘(B) GOALS AND ACCOUNTABILITY FOR

18 APPROVED MEDICAL RESIDENCY TRAINING PRO19 GRAMS.—The goals of medical residency train20 ing programs are to foster a physician work21 force so that physicians are trained to be able 

22 to do the following: 

23 ‘‘(i) Work effectively in various health 

24 care delivery settings, such as nonprovider 

25 settings. 
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1 ‘‘(ii) Coordinate patient care within 

2 and across settings relevant to their spe3 cialties. 

4 ‘‘(iii) Understand the relevant cost 

5 and value of various diagnostic and treat6 ment options. 

7 ‘‘(iv) Work in inter-professional teams 

8 and multi-disciplinary team-based models 

9 in provider and nonprovider settings to en10 hance safety and improve quality of patient 

11 care. 

12 ‘‘(v) Be knowledgeable in methods of 

13 identifying systematic errors in health care 

14 delivery and in implementing systematic 

15 solutions in case of such errors, including 

16 experience and participation in continuous 

17 quality improvement projects to improve 

18 health outcomes of the population the phy19 sicians serve. 

20 ‘‘(vi) Be meaningful EHR users (as 

21 determined under section 1848(o)(2)) in 

22 the delivery of care and in improving the 

23 quality of the health of the community and 

24 the individuals that the hospital serves.’’. 
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1 (b) GAO STUDY ON EVALUATION OF TRAINING PRO2 GRAMS.— 

3 (1) IN GENERAL.—The Comptroller General of 

4 the United States shall conduct a study to evaluate 

5 the extent to which medical residency training pro6 grams— 

7 (A) are meeting the goals described in sec8 tion 1886(h)(1)(B) of the Social Security Act, 

9 as added by subsection (a), in a range of resi10 dency programs, including primary care and 

11 other specialties; and 

12 (B) have the appropriate faculty expertise 

13 to teach the topics required to achieve such 

14 goals. 

15 (2) REPORT.—Not later than 18 months after 

16 the date of the enactment of this Act, the Comp17 troller General shall submit to Congress a report on 

18 such study and shall include in such report rec19 ommendations as to how medical residency training 

20 programs could be further encouraged to meet such 

21 goals through means such as— 

22 (A) development of curriculum require23 ments; and 

24 (B) assessment of the accreditation proc25 esses of the Accreditation Council for Graduate 
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1 Medical Education and the American Osteo2 pathic Association and effectiveness of those 

3 processes in accrediting medical residency pro4 grams that meet the goals referred to in para5 graph (1)(A). 

6 TITLE VI—PROGRAM INTEGRITY 

7 Subtitle A—Increased Funding to 

8 Fight Waste, Fraud, and Abuse 

9 SEC. 1601. INCREASED FUNDING AND FLEXIBILITY TO 

10 FIGHT FRAUD AND ABUSE. 

11 (a) IN GENERAL.—Section 1817(k) of the Social Se12 curity Act (42 U.S.C. 1395i(k)) is amended— 

13 (1) by adding at the end the following new 

14 paragraph: 

15 ‘‘(7) ADDITIONAL FUNDING.—In addition to the 

16 funds otherwise appropriated to the Account from 

17 the Trust Fund under paragraphs (3) and (4) and 

18 for purposes described in paragraphs (3)(C) and 

19 (4)(A), there are hereby appropriated an additional 

20 $100,000,000 to such Account from such Trust 

21 Fund for each fiscal year beginning with 2011. The 

22 funds appropriated under this paragraph shall be al23 located in the same proportion as the total funding 

24 appropriated with respect to paragraphs (3)(A) and 

25 (4)(A) was allocated with respect to fiscal year 
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1 2010, and shall be available without further appro2 priation until expended.’’. 

3 (2) in paragraph (4)(A)— 

4 (A) by inserting ‘‘for activities described in 

5 paragraph (3)(C) and’’ after ‘‘necessary’’; and 

6 (B) by inserting ‘‘until expended’’ after 

7 ‘‘appropriation’’. 

8 (b) FLEXIBILITY IN PURSUING FRAUD AND

9 ABUSE.—Section 1893(a) of the Social Security Act (42 

10 U.S.C. 1395ddd(a)) is amended by inserting ‘‘, or other11 wise,’’ after ‘‘entities’’. 

12 Subtitle B—Enhanced Penalties for 

13 Fraud and Abuse 

14 SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS 

15 ON PROVIDER OR SUPPLIER ENROLLMENT 

16 APPLICATIONS. 

17 (a) IN GENERAL.—Section 1128A(a) of the Social 

18 Security Act (42 U.S.C. 1320a–7a(a)) is amended— 

19 (1) in paragraph (1)(D), by striking all that fol20 lows ‘‘in which the person was excluded’’ and insert21 ing ‘‘under Federal law from the Federal health care 

22 program under which the claim was made, or’’; 

23 (2) by striking ‘‘or’’ at the end of paragraph 

24 (6); 
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1 (3) in paragraph (7), by inserting at the end 

2 ‘‘or’’; 

3 (4) by inserting after paragraph (7) the fol4 lowing new paragraph: 

5 ‘‘(8) knowingly makes or causes to be made any 

6 false statement, omission, or misrepresentation of a 

7 material fact in any application, agreement, bid, or 

8 contract to participate or enroll as a provider of 

9 services or supplier under a Federal health care pro10 gram, including managed care organizations under 

11 title XIX, Medicare Advantage organizations under 

12 part C of title XVIII, prescription drug plan spon13 sors under part D of title XVIII, and entities that 

14 apply to participate as providers of services or sup15 pliers in such managed care organizations and such 

16 plans;’’; 

17 (5) in the matter following paragraph (8), as 

18 inserted by paragraph (4), by striking ‘‘or in cases 

19 under paragraph (7), $50,000 for each such act)’’ 

20 and inserting ‘‘in cases under paragraph (7), 

21 $50,000 for each such act, or in cases under para22 graph (8), $50,000 for each false statement, omis23 sion, or misrepresentation of a material fact)’’; and 

24 (6) in the second sentence, by striking ‘‘for a 

25 lawful purpose)’’ and inserting ‘‘for a lawful pur-
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1 pose, or in cases under paragraph (8), an assess2 ment of not more than 3 times the amount claimed 

3 as the result of the false statement, omission, or 

4 misrepresentation of material fact claimed by a pro5 vider of services or supplier whose application to 

6 participate contained such false statement, omission, 

7 or misrepresentation)’’. 

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

9 subsection (a) shall apply to acts committed on or after 

10 January 1, 2010. 

11 SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF 

12 FALSE STATEMENTS MATERIAL TO A FALSE 

13 CLAIM. 

14 (a) IN GENERAL.—Section 1128A(a) of the Social 

15 Security Act (42 U.S.C. 1320a–7a(a)), as amended by sec16 tion 1611, is further amended— 

17 (1) in paragraph (7), by striking ‘‘or’’ at the 

18 end; 

19 (2) in paragraph (8), by inserting ‘‘or’’ at the 

20 end; and 

21 (3) by inserting after paragraph (8), the fol22 lowing new paragraph: 

23 ‘‘(9) knowingly makes, uses, or causes to be 

24 made or used, a false record or statement material 

25 to a false or fraudulent claim for payment for items 
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1 and services furnished under a Federal health care 

2 program;’’; and 

3 (4) in the matter following paragraph (9), as 

4 inserted by paragraph (3)— 

5 (A) by striking ‘‘or in cases under para6 graph (8)’’ and inserting ‘‘in cases under para7 graph (8)’’; and 

8 (B) by striking ‘‘a material fact)’’ and in9 serting ‘‘a material fact, in cases under para10 graph (9), $50,000 for each false record or 

11 statement)’’. 

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

13 subsection (a) shall apply to acts committed on or after 

14 January 1, 2010. 

15 SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPEC16 TIONS. 

17 (a) IN GENERAL.—Section 1128A(a) of the Social 

18 Security Act (42 U.S.C. 1320a–7a(a)), as amended by sec19 tions 1611 and 1612, is further amended— 

20 (1) in paragraph (8), by striking ‘‘or’’ at the 

21 end; 

22 (2) in paragraph (9), by inserting ‘‘or’’ at the 

23 end; 

24 (3) by inserting after paragraph (9) the fol25 lowing new paragraph: 
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1 ‘‘(10) fails to grant timely access, upon reason2 able request (as defined by the Secretary in regula3 tions), to the Inspector General of the Department 

4 of Health and Human Services, for the purpose of 

5 audits, investigations, evaluations, or other statutory 

6 functions of the Inspector General of the Depart7 ment of Health and Human Services;’’; and 

8 (4) in the matter following paragraph (10), as 

9 inserted by paragraph (3), by inserting ‘‘, or in cases 

10 under paragraph (10), $15,000 for each day of the 

11 failure described in such paragraph’’ after ‘‘false 

12 record or statement’’. 

13 (b) ENSURING TIMELY INSPECTIONS RELATING TO

14 CONTRACTS WITH MA ORGANIZATIONS.—Section 

15 1857(d)(2) of such Act (42 U.S.C. 1395w–27(d)(2)) is 

16 amended— 

17 (1) in subparagraph (A), by inserting ‘‘timely’’ 

18 before ‘‘inspect’’; and 

19 (2) in subparagraph (B), by inserting ‘‘timely’’ 

20 before ‘‘audit and inspect’’. 

21 (c) EFFECTIVE DATE.—The amendments made by 

22 subsection (a) shall apply to violations committed on or 

23 after January 1, 2010. 
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1 SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS. 

2 (a) MEDICARE.—Part A of title XVIII of the Social 

3 Security Act is amended by inserting after section 1819 

4 the following new section: 

5 ‘‘SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE 

6 CARE. 

7 ‘‘(a) IN GENERAL.—If the Secretary determines on 

8 the basis of a survey or otherwise, that a hospice program 

9 that is certified for participation under this title has dem10 onstrated a substandard quality of care and failed to meet 

11 such other requirements as the Secretary may find nec12 essary in the interest of the health and safety of the indi13 viduals who are provided care and services by the agency 

14 or organization involved and determines— 

15 ‘‘(1) that the deficiencies involved immediately 

16 jeopardize the health and safety of the individuals to 

17 whom the program furnishes items and services, the 

18 Secretary shall take immediate action to remove the 

19 jeopardy and correct the deficiencies through the 

20 remedy specified in subsection (b)(2)(A)(iii) or ter21 minate the certification of the program, and may 

22 provide, in addition, for 1 or more of the other rem23 edies described in subsection (b)(2)(A); or 

24 ‘‘(2) that the deficiencies involved do not imme25 diately jeopardize the health and safety of the indi-
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1 viduals to whom the program furnishes items and 

2 services, the Secretary may— 

3 ‘‘(A) impose intermediate sanctions devel4 oped pursuant to subsection (b), in lieu of ter5 minating the certification of the program; and 

6 ‘‘(B) if, after such a period of intermediate 

7 sanctions, the program is still not in compliance 

8 with such requirements, the Secretary shall ter9 minate the certification of the program. 

10 If the Secretary determines that a hospice program 

11 that is certified for participation under this title is 

12 in compliance with such requirements but, as of a 

13 previous period, was not in compliance with such re14 quirements, the Secretary may provide for a civil 

15 money penalty under subsection (b)(2)(A)(i) for the 

16 days in which it finds that the program was not in 

17 compliance with such requirements. 

18 ‘‘(b) INTERMEDIATE SANCTIONS.— 

19 ‘‘(1) DEVELOPMENT AND IMPLEMENTATION.— 

20 The Secretary shall develop and implement, by not 

21 later than July 1, 2012— 

22 ‘‘(A) a range of intermediate sanctions to 

23 apply to hospice programs under the conditions 

24 described in subsection (a), and 
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1 ‘‘(B) appropriate procedures for appealing 

2 determinations relating to the imposition of 

3 such sanctions. 

4 ‘‘(2) SPECIFIED SANCTIONS.— 

5 ‘‘(A) IN GENERAL.—The intermediate 

6 sanctions developed under paragraph (1) may 

7 include— 

8 ‘‘(i) civil money penalties in an 

9 amount not to exceed $10,000 for each day 

10 of noncompliance or, in the case of a per 

11 instance penalty applied by the Secretary, 

12 not to exceed $25,000, 

13 ‘‘(ii) denial of all or part of the pay14 ments to which a hospice program would 

15 otherwise be entitled under this title with 

16 respect to items and services furnished by 

17 a hospice program on or after the date on 

18 which the Secretary determines that inter19 mediate sanctions should be imposed pur20 suant to subsection (a)(2), 

21 ‘‘(iii) the appointment of temporary 

22 management to oversee the operation of 

23 the hospice program and to protect and as24 sure the health and safety of the individ-
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1 uals under the care of the program while 

2 improvements are made, 

3 ‘‘(iv) corrective action plans, and 

4 ‘‘(v) in-service training for staff. 

5 The provisions of section 1128A (other than 

6 subsections (a) and (b)) shall apply to a civil 

7 money penalty under clause (i) in the same 

8 manner as such provisions apply to a penalty or 

9 proceeding under section 1128A(a). The tem10 porary management under clause (iii) shall not 

11 be terminated until the Secretary has deter12 mined that the program has the management 

13 capability to ensure continued compliance with 

14 all requirements referred to in that clause. 

15 ‘‘(B) CLARIFICATION.—The sanctions 

16 specified in subparagraph (A) are in addition to 

17 sanctions otherwise available under State or 

18 Federal law and shall not be construed as lim19 iting other remedies, including any remedy 

20 available to an individual at common law. 

21 ‘‘(C) COMMENCEMENT OF PAYMENT.—A 

22 denial of payment under subparagraph (A)(ii) 

23 shall terminate when the Secretary determines 

24 that the hospice program no longer dem25 onstrates a substandard quality of care and 
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1 meets such other requirements as the Secretary 

2 may find necessary in the interest of the health 

3 and safety of the individuals who are provided 

4 care and services by the agency or organization 

5 involved. 

6 ‘‘(3) SECRETARIAL AUTHORITY.—The Secretary 

7 shall develop and implement, by not later than July 

8 1, 2011, specific procedures with respect to the con9 ditions under which each of the intermediate sanc10 tions developed under paragraph (1) is to be applied, 

11 including the amount of any fines and the severity 

12 of each of these sanctions. Such procedures shall be 

13 designed so as to minimize the time between identi14 fication of deficiencies and imposition of these sanc15 tions and shall provide for the imposition of incre16 mentally more severe fines for repeated or uncor17 rected deficiencies.’’. 

18 (b) APPLICATION TO MEDICAID.—Section 1905(o) of 

19 the Social Security Act (42 U.S.C. 1396d(o)) is amended 

20 by adding at the end the following new paragraph: 

21 ‘‘(4) The provisions of section 1819A shall apply to 

22 a hospice program providing hospice care under this title 

23 in the same manner as such provisions apply to a hospice 

24 program providing hospice care under title XVIII.’’. 
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1 (c) APPLICATION TO CHIP.—Title XXI of the Social 

2 Security Act is amended by adding at the end the fol3 lowing new section: 

4 ‘‘SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE. 

5 ‘‘The provisions of section 1819A shall apply to a 

6 hospice program providing hospice care under this title in 

7 the same manner such provisions apply to a hospice pro8 gram providing hospice care under title XVIII.’’. 

9 SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EX10 CLUDED FROM PROGRAM PARTICIPATION. 

11 (a) IN GENERAL.—Section 1128A(a) of the Social 

12 Security Act (42 U.S.C. 1320a–7a(a)), as amended by the 

13 previous sections, is further amended— 

14 (1) by striking ‘‘or’’ at the end of paragraph 

15 (9); 

16 (2) by inserting ‘‘or’’ at the end of paragraph 

17 (10); 

18 (3) by inserting after paragraph (10) the fol19 lowing new paragraph: 

20 ‘‘(11) orders or prescribes an item or service, 

21 including without limitation home health care, diag22 nostic and clinical lab tests, prescription drugs, du23 rable medical equipment, ambulance services, phys24 ical or occupational therapy, or any other item or 

25 service, during a period when the person has been 
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1 excluded from participation in a Federal health care 

2 program, and the person knows or should know that 

3 a claim for such item or service will be presented to 

4 such a program;’’; and 

5 (4) in the matter following paragraph (11), as 

6 inserted by paragraph (2), by striking ‘‘$15,000 for 

7 each day of the failure described in such paragraph’’ 

8 and inserting ‘‘$15,000 for each day of the failure 

9 described in such paragraph, or in cases under para10 graph (11), $50,000 for each order or prescription 

11 for an item or service by an excluded individual’’. 

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

13 subsection (a) shall apply to violations committed on or 

14 after January 1, 2010. 

15 SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF 

16 FALSE INFORMATION BY MEDICARE ADVAN17 TAGE AND PART D PLANS. 

18 (a) IN GENERAL.—Section 1857(g)(2)(A) of the So19 cial Security Act (42 U.S.C. 1395w–27(g)(2)(A)) is 

20 amended by inserting ‘‘except with respect to a determina21 tion under subparagraph (E), an assessment of not more 

22 than 3 times the amount claimed by such plan or plan 

23 sponsor based upon the misrepresentation or falsified in24 formation involved,’’ after ‘‘for each such determination,’’. 
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1 (b) EFFECTIVE DATE.—The amendment made by 

2 subsection (a) shall apply to violations committed on or 

3 after January 1, 2010. 

4 SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVAN5 TAGE AND PART D MARKETING VIOLATIONS. 

6 (a) IN GENERAL.—Section 1857(g)(1) of the Social 

7 Security Act (42 U.S.C. 1395w–27(g)(1)), as amended by 

8 section 1221(b), is amended— 

9 (1) in subparagraph (G), by striking ‘‘or’’ at 

10 the end; 

11 (2) by inserting after subparagraph (H) the fol12 lowing new subparagraphs: 

13 ‘‘(I) except as provided under subpara14 graph (C) or (D) of section 1860D–1(b)(1), en15 rolls an individual in any plan under this part 

16 without the prior consent of the individual or 

17 the designee of the individual; 

18 ‘‘(J) transfers an individual enrolled under 

19 this part from one plan to another without the 

20 prior consent of the individual or the designee 

21 of the individual or solely for the purpose of 

22 earning a commission; 

23 ‘‘(K) fails to comply with marketing re24 strictions described in subsections (h) and (j) of 
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1 section 1851 or applicable implementing regula2 tions or guidance; or 

3 ‘‘(L) employs or contracts with any indi4 vidual or entity who engages in the conduct de5 scribed in subparagraphs (A) through (K) of 

6 this paragraph;’’; and 

7 (3) by adding at the end the following new sen8 tence: ‘‘The Secretary may provide, in addition to 

9 any other remedies authorized by law, for any of the 

10 remedies described in paragraph (2), if the Secretary 

11 determines that any employee or agent of such orga12 nization, or any provider or supplier who contracts 

13 with such organization, has engaged in any conduct 

14 described in subparagraphs (A) through (L) of this 

15 paragraph.’’ 

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

17 subsection (a) shall apply to violations committed on or 

18 after January 1, 2010. 

19 SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF 

20 PROGRAM AUDITS. 

21 (a) IN GENERAL.—Section 1128(b)(2) of the Social 

22 Security Act (42 U.S.C. 1320a–7(b)(2)) is amended— 

23 (1) in the heading, by inserting ‘‘OR AUDIT’’ 

24 after ‘‘INVESTIGATION’’; and 
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1 (2) by striking ‘‘investigation into’’ and all that 

2 follows through the period and inserting ‘‘investiga3 tion or audit related to—’’ 

4 ‘‘(i) any offense described in para5 graph (1) or in subsection (a); or 

6 ‘‘(ii) the use of funds received, directly 

7 or indirectly, from any Federal health care 

8 program (as defined in section 

9 1128B(f)).’’. 

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

11 subsection (a) shall apply to violations committed on or 

12 after January 1, 2010. 

13 SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND EN14 TITIES FROM PARTICIPATION IN MEDICARE 

15 AND STATE HEALTH CARE PROGRAMS. 

16 (a) IN GENERAL.—Section 1128(c) of the Social Se17 curity Act, as previously amended by this division, is fur18 ther amended— 

19 (1) in the heading, by striking ‘‘AND PERIOD’’ 

20 and inserting ‘‘PERIOD, AND EFFECT’’; and 

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

22 paragraph: 

23 ‘‘(4)(A) For purposes of this Act, subject to subpara24 graph (C), the effect of exclusion is that no payment may 

25 be made by any Federal health care program (as defined 
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1 in section 1128B(f)) with respect to any item or service 

2 furnished— 

3 ‘‘(i) by an excluded individual or entity; or 

4 ‘‘(ii) at the medical direction or on the prescrip5 tion of a physician or other authorized individual 

6 when the person submitting a claim for such item or 

7 service knew or had reason to know of the exclusion 

8 of such individual. 

9 ‘‘(B) For purposes of this section and sections 1128A 

10 and 1128B, subject to subparagraph (C), an item or serv11 ice has been furnished by an individual or entity if the 

12 individual or entity directly or indirectly provided, ordered, 

13 manufactured, distributed, prescribed, or otherwise sup14 plied the item or service regardless of how the item or 

15 service was paid for by a Federal health care program or 

16 to whom such payment was made. 

17 ‘‘(C)(i) Payment may be made under a Federal 

18 health care program for emergency items or services (not 

19 including items or services furnished in an emergency 

20 room of a hospital) furnished by an excluded individual 

21 or entity, or at the medical direction or on the prescription 

22 of an excluded physician or other authorized individual 

23 during the period of such individual’s exclusion. 

24 ‘‘(ii) In the case that an individual eligible for bene25 fits under title XVIII or XIX submits a claim for payment 
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1 for items or services furnished by an excluded individual 

2 or entity, and such individual eligible for such benefits did 

3 not know or have reason to know that such excluded indi4 vidual or entity was so excluded, then, notwithstanding 

5 such exclusion, payment shall be made for such items or 

6 services. In such case the Secretary shall notify such indi7 vidual eligible for such benefits of the exclusion of the indi8 vidual or entity furnishing the items or services. Payment 

9 shall not be made for items or services furnished by an 

10 excluded individual or entity to an individual eligible for 

11 such benefits after a reasonable time (as determined by 

12 the Secretary in regulations) after the Secretary has noti13 fied the individual eligible for such benefits of the exclu14 sion of the individual or entity furnishing the items or 

15 services. 

16 ‘‘(iii) In the case that a claim for payment for items 

17 or services furnished by an excluded individual or entity 

18 is submitted by an individual or entity other than an indi19 vidual eligible for benefits under title XVIII or XIX or 

20 the excluded individual or entity, and the Secretary deter21 mines that the individual or entity that submitted the 

22 claim took reasonable steps to learn of the exclusion and 

23 reasonably relied upon inaccurate or misleading informa24 tion from the relevant Federal health care program or its 

25 contractor, the Secretary may waive repayment of the 
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1 amount paid in violation of the exclusion to the individual 

2 or entity that submitted the claim for the items or services 

3 furnished by the excluded individual or entity. If a Federal 

4 health care program contractor provided inaccurate or 

5 misleading information that resulted in the waiver of an 

6 overpayment under this clause, the Secretary shall take 

7 appropriate action to recover the improperly paid amount 

8 from the contractor.’’. 

9 SEC. 1620. OIG AUTHORITY TO EXCLUDE FROM FEDERAL 

10 HEALTH CARE PROGRAMS OFFICERS AND 

11 OWNERS OF ENTITIES CONVICTED OF FRAUD. 

12 Section 1128(b)(15)(A) of the Social Security Act 

13 (42 U.S.C. 1320a–7(b)(15)(A)) is amended— 

14 (1) in clause (i)— 

15 (A) by striking ‘‘has’’ and inserting ‘‘had’’; 

16 and 

17 (B) by striking ‘‘sanctioned entity and who 

18 knows or should know (as defined in section 

19 1128A(i)(6)) of’’ and inserting ‘‘sanctioned en20 tity at the time of, and who knew or should 

21 have known (as defined in section 1128A(i)(6)) 

22 of,’’ ; and 

23 (2) in clause (ii)— 

24 (A) by striking ‘‘is an officer’’ and insert25 ing ‘‘was an officer’’; and 
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1 (B) by inserting before the period the fol2 lowing: ‘‘at the time of the action constituting 

3 the basis for the conviction or exclusion de4 scribed in subparagraph (B)’’. 

5 SEC. 1621. SELF-REFERRAL DISCLOSURE PROTOCOL. 

6 (a) DEVELOPMENT OF SELF-REFERRAL DISCLOSURE

7 PROTOCOL.— 

8 (1) IN GENERAL.—The Secretary of Health and 

9 Human Services, in cooperation with the Inspector 

10 General of the Department of Health and Human 

11 Services, shall establish, not later than 6 months 

12 after the date of the enactment of this Act, a pro13 tocol to enable health care providers of services and 

14 suppliers to disclose an actual or potential violation 

15 of section 1877 of the Social Security Act (42 

16 U.S.C. 1395nn) pursuant to a self-referral disclosure 

17 protocol (in this section referred to as an ‘‘SRDP’’). 

18 The SRDP shall include direction to health care pro19 viders of services and suppliers on— 

20 (A) a specific person, official, or office to 

21 whom such disclosures shall be made; and 

22 (B) instruction on the implication of the 

23 SRDP on corporate integrity agreements and 

24 corporate compliance agreements. 
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1 (2) PUBLICATION ON INTERNET WEBSITE OF

2 SRDP INFORMATION.—The Secretary shall post in3 formation on the public Internet website of the Cen4 ters for Medicare & Medicaid Services to inform rel5 evant stakeholders of how to disclose actual or po6 tential violations pursuant to an SRDP. 

7 (3) RELATION TO ADVISORY OPINIONS.—The 

8 SRDP shall be separate from the advisory opinion 

9 process set forth in regulations implementing section 

10 1877(g) of the Social Security Act. 

11 (b) REDUCTION IN AMOUNTS OWED.—The Secretary 

12 is authorized to reduce the amount due and owing for all 

13 violations under section 1877 of the Social Security Act 

14 to an amount less than that specified in subsection (g) 

15 of such section. In establishing such amount for a viola16 tion, the Secretary may consider the following factors: 

17 (1) The nature and extent of the improper or 

18 illegal practice. 

19 (2) The timeliness of such self-disclosure. 

20 (3) The cooperation in providing additional in21 formation related to the disclosure. 

22 (4) Such other factors as the Secretary con23 siders appropriate. 

24 (c) REPORT.—Not later than 18 months after the 

25 date on which the SRDP protocol is established under sub-
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1 section (a)(1), the Secretary shall submit to Congress a 

2 report on the implementation of this section. Such report 

3 shall include— 

4 (1) the number of health care providers of serv5 ices and suppliers making disclosures pursuant to an 

6 SRDP; 

7 (2) the amounts collected pursuant to the 

8 SRDP; 

9 (3) the types of violations reported under the 

10 SRDP; and 

11 (4) such other information as may be necessary 

12 to evaluate the impact of this section. 

13 (d) RELATION TO OTHER LAW AND REGULATION.— 

14 Nothing in this section shall affect the application of sec15 tion 1128G(c) of the Social Security Act, as added by sec16 tion 1641, except, in the case of a health care provider 

17 of services or supplier who is a person (as defined in para18 graph (4) of such section 1128G(c)) who discloses an over19 payment (as defined in such paragraph) to the Secretary 

20 of Health and Human Services pursuant to a SRDP es21 tablished under this section, the 60-day period described 

22 in paragraph (2) of such section 1128G(c) shall be ex23 tended with respect to the return of an overpayment to 

24 the extent necessary for the Secretary to determine pursu25 ant to the SRDP the amount due and owing. 
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1 Subtitle C—Enhanced Program 

2 and Provider Protections 

3 SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AU4 THORITY. 

5 (a) IN GENERAL.—Title XI of the Social Security Act 

6 (42 U.S.C. 1301 et seq.) is amended by inserting after 

7 section 1128F the following new section: 

8 ‘‘SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PRO9 TECTIONS IN THE MEDICARE, MEDICAID, AND 

10 CHIP PROGRAMS. 

11 ‘‘(a) CERTAIN AUTHORIZED SCREENING, ENHANCED

12 OVERSIGHT PERIODS, AND ENROLLMENT MORATORIA.— 

13 ‘‘(1) IN GENERAL.—For periods beginning after 

14 January 1, 2011, in the case that the Secretary de15 termines there is a significant risk of fraudulent ac16 tivity (as determined by the Secretary based on rel17 evant complaints, reports, referrals by law enforce18 ment or other sources, data analysis, trending infor19 mation, or claims submissions by providers of serv20 ices and suppliers) with respect to a category of pro21 vider of services or supplier of items or services, in22 cluding a category within a geographic area, under 

23 title XVIII, XIX, or XXI, the Secretary may impose 

24 any of the following requirements with respect to a 

25 provider of services or a supplier (whether such pro-
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1 vider or supplier is initially enrolling in the program 

2 or is renewing such enrollment): 

3 ‘‘(A) Screening under paragraph (2). 

4 ‘‘(B) Enhanced oversight periods under 

5 paragraph (3). 

6 ‘‘(C) Enrollment moratoria under para7 graph (4). 

8 In applying this subsection for purposes of title XIX 

9 and XXI the Secretary may require a State to carry 

10 out the provisions of this subsection as a require11 ment of the State plan under title XIX or the child 

12 health plan under title XXI. Actions taken and de13 terminations made under this subsection shall not be 

14 subject to review by a judicial tribunal. 

15 ‘‘(2) SCREENING.—For purposes of paragraph 

16 (1), the Secretary shall establish procedures under 

17 which screening is conducted with respect to pro18 viders of services and suppliers described in such 

19 paragraph. Such screening may include— 

20 ‘‘(A) licensing board checks; 

21 ‘‘(B) screening against the list of individ22 uals and entities excluded from the program 

23 under title XVIII, XIX, or XXI; 

24 ‘‘(C) the excluded provider list system; 

25 ‘‘(D) background checks; and 
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1 ‘‘(E) unannounced pre-enrollment or other 

2 site visits. 

3 ‘‘(3) ENHANCED OVERSIGHT PERIOD.—For 

4 purposes of paragraph (1), the Secretary shall estab5 lish procedures to provide for a period of not less 

6 than 30 days and not more than 365 days during 

7 which providers of services and suppliers described 

8 in such paragraph, as the Secretary determines ap9 propriate, would be subject to enhanced oversight, 

10 such as required or unannounced (or required and 

11 unannounced) site visits or inspections, prepayment 

12 review, enhanced review of claims, and such other 

13 actions as specified by the Secretary, under the pro14 grams under titles XVIII, XIX, and XXI. Under 

15 such procedures, the Secretary may extend such pe16 riod for more than 365 days if the Secretary deter17 mines that after the initial period such additional 

18 period of oversight is necessary. 

19 ‘‘(4) MORATORIUM ON ENROLLMENT OF PRO20 VIDERS AND SUPPLIERS.—For purposes of para21 graph (1), the Secretary, based upon a finding of a 

22 risk of serious ongoing fraud within a program 

23 under title XVIII, XIX, or XXI, may impose a mor24 atorium on the enrollment of providers of services 

25 and suppliers within a category of providers of serv-
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1 ices and suppliers (including a category within a spe2 cific geographic area) under such title. Such a mora3 torium may only be imposed if the Secretary makes 

4 a determination that the moratorium would not ad5 versely impact access of individuals to care under 

6 such program. 

7 ‘‘(5) 90-DAY PERIOD OF ENHANCED OVERSIGHT

8 FOR INITIAL CLAIMS OF DME SUPPLIERS.—For peri9 ods beginning after January 1, 2011, if the Sec10 retary determines under paragraph (1) that there is 

11 a significant risk of fraudulent activity among sup12 pliers of durable medical equipment, in the case of 

13 a supplier of durable medical equipment who is with14 in a category or geographic area under title XVIII 

15 identified pursuant to such determination and who is 

16 initially enrolling under such title, the Secretary 

17 shall, notwithstanding section 1842(c)(2), withhold 

18 payment under such title with respect to durable 

19 medical equipment furnished by such supplier during 

20 the 90-day period beginning on the date of the first 

21 submission of a claim under such title for durable 

22 medical equipment furnished by such supplier. 

23 ‘‘(6) CLARIFICATION.—Nothing in this sub24 section shall be interpreted to preclude or limit the 

25 ability of a State to engage in provider screening or 
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1 enhanced provider oversight activities beyond those 

2 required by the Secretary.’’. 

3 (b) CONFORMING AMENDMENTS.— 

4 (1) MEDICAID.—Section 1902(a) of the Social 

5 Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is 

6 amended— 

7 (A) in paragraph (23), by inserting before 

8 the semicolon at the end the following: ‘‘or by 

9 a person to whom or entity to which a morato10 rium under section 1128G(a)(4) is applied dur11 ing the period of such moratorium’’; 

12 (B) in paragraph (72); by striking at the 

13 end ‘‘and’’; 

14 (C) in paragraph (73), by striking the pe15 riod at the end and inserting ‘‘; and’’; and 

16 (D) by adding after paragraph (73) the 

17 following new paragraph: 

18 ‘‘(74) provide that the State will enforce any 

19 determination made by the Secretary under sub20 section (a) of section 1128G (relating to a signifi21 cant risk of fraudulent activity with respect to a cat22 egory of provider or supplier described in such sub23 section (a) through use of the appropriate proce24 dures described in such subsection (a)), and that the 
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1 State will carry out any activities as required by the 

2 Secretary for purposes of such subsection (a).’’. 

3 (2) CHIP.—Section 2102 of such Act (42 

4 U.S.C. 1397bb) is amended by adding at the end the 

5 following new subsection: 

6 ‘‘(d) PROGRAM INTEGRITY.—A State child health 

7 plan shall include a description of the procedures to be 

8 used by the State— 

9 ‘‘(1) to enforce any determination made by the 

10 Secretary under subsection (a) of section 1128G (re11 lating to a significant risk of fraudulent activity with 

12 respect to a category of provider or supplier de13 scribed in such subsection through use of the appro14 priate procedures described in such subsection); and 

15 ‘‘(2) to carry out any activities as required by 

16 the Secretary for purposes of such subsection.’’. 

17 (3) MEDICARE.—Section 1866(j) of such Act 

18 (42 U.S.C. 1395cc(j)) is amended by adding at the 

19 end the following new paragraph: 

20 ‘‘(3) PROGRAM INTEGRITY.—The provisions of 

21 section 1128G(a) apply to enrollments and renewals 

22 of enrollments of providers of services and suppliers 

23 under this title.’’. 
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1 SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP 

2 PROGRAM DISCLOSURE REQUIREMENTS RE3 LATING TO PREVIOUS AFFILIATIONS. 

4 (a) IN GENERAL.—Section 1128G of the Social Secu5 rity Act, as inserted by section 1631, is amended by add6 ing at the end the following new subsection: 

7 ‘‘(b) ENHANCED PROGRAM DISCLOSURE REQUIRE8 MENTS.— 

9 ‘‘(1) DISCLOSURE.—A provider of services or 

10 supplier who submits on or after July 1, 2011, an 

11 application for enrollment and renewing enrollment 

12 in a program under title XVIII, XIX, or XXI shall 

13 disclose (in a form and manner determined by the 

14 Secretary) any current affiliation or affiliation with15 in the previous 10-year period with a provider of 

16 services or supplier that has uncollected debt or with 

17 a person or entity that has been suspended or ex18 cluded under such program, subject to a payment 

19 suspension, or has had its billing privileges revoked. 

20 ‘‘(2) ENHANCED SAFEGUARDS.—If the Sec21 retary determines that such previous affiliation of 

22 such provider or supplier poses a risk of fraud, 

23 waste, or abuse, the Secretary may apply such en24 hanced safeguards as the Secretary determines nec25 essary to reduce such risk associated with such pro26 vider or supplier enrolling or participating in the 
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1 program under title XVIII, XIX, or XXI. Such safe2 guards may include enhanced oversight, such as en3 hanced screening of claims, required or unannounced 

4 (or required and unannounced) site visits or inspec5 tions, additional information reporting requirements, 

6 and conditioning such enrollment on the provision of 

7 a surety bond. 

8 ‘‘(3) AUTHORITY TO DENY PARTICIPATION.—If 

9 the Secretary determines that there has been at 

10 least one such affiliation and that such affiliation or 

11 affiliations, as applicable, of such provider or sup12 plier poses a serious risk of fraud, waste, or abuse, 

13 the Secretary may deny the application of such pro14 vider or supplier.’’. 

15 (b) CONFORMING AMENDMENTS.— 

16 (1) MEDICAID.—Paragraph (74) of section 

17 1902(a) of such Act (42 U.S.C. 1396a(a)), as added 

18 by section 1631(b)(1), is amended— 

19 (A) by inserting ‘‘or subsection (b) of such 

20 section (relating to disclosure requirements)’’ 

21 before ‘‘, and that the State’’; and 

22 (B) by inserting before the period the fol23 lowing: ‘‘and apply any enhanced safeguards, 

24 with respect to a provider or supplier described 
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1 in such subsection (b), as the Secretary deter2 mines necessary under such subsection (b)’’. 

3 (2) CHIP.—Subsection (d) of section 2102 of 

4 such Act (42 U.S.C. 1397bb), as added by section 

5 1631(b)(2), is amended— 

6 (A) in paragraph (1), by striking at the 

7 end ‘‘and’’; 

8 (B) in paragraph (2) by striking the period 

9 at the end and inserting ‘‘; and’’; and 

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

11 paragraph: 

12 ‘‘(3) to enforce any determination made by the 

13 Secretary under subsection (b) of section 1128G (re14 lating to disclosure requirements) and to apply any 

15 enhanced safeguards, with respect to a provider or 

16 supplier described in such subsection, as the Sec17 retary determines necessary under such subsection.’’. 

18 SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER 

19 FOR CERTAIN EVALUATION AND MANAGE20 MENT SERVICES. 

21 Section 1848 of the Social Security Act (42 U.S.C. 

22 1395w–4), as amended by section 4101 of the HITECH 

23 Act (Public Law 111–5), is amended by adding at the end 

24 the following new subsection: 
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1 ‘‘(p) PAYMENT MODIFIER FOR CERTAIN EVALUA2 TION AND MANAGEMENT SERVICES.—The Secretary shall 

3 establish a payment modifier under the fee schedule under 

4 this section for evaluation and management services (as 

5 specified in section 1842(b)(16)(B)(ii)) that result in the 

6 ordering of additional services (such as lab tests), the pre7 scription of drugs, the furnishing or ordering of durable 

8 medical equipment in order to enable better monitoring 

9 of claims for payment for such additional services under 

10 this title, or the ordering, furnishing, or prescribing of 

11 other items and services determined by the Secretary to 

12 pose a high risk of waste, fraud, and abuse. The Secretary 

13 may require providers of services or suppliers to report 

14 such modifier in claims submitted for payment.’’. 

15 SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER 

16 MEDICARE INTEGRITY PROGRAM. 

17 (a) IN GENERAL.—Section 1893(c) of the Social Se18 curity Act (42 U.S.C. 1395ddd(c)) is amended— 

19 (1) in paragraph (3), by striking at the end 

20 ‘‘and’’; 

21 (2) by redesignating paragraph (4) as para22 graph (5); and 

23 (3) by inserting after paragraph (3) the fol24 lowing new paragraph: 
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1 ‘‘(4) for the contract year beginning in 2011 

2 and each subsequent contract year, the entity pro3 vides assurances to the satisfaction of the Secretary 

4 that the entity will conduct periodic evaluations of 

5 the effectiveness of the activities carried out by such 

6 entity under the Program and will submit to the 

7 Secretary an annual report on such activities; and’’. 

8 (b) REFERENCE TO MEDICAID INTEGRITY PRO9 GRAM.—For a similar provision with respect to the Med10 icaid Integrity Program, see section 1752. 

11 SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO 

12 ADOPT PROGRAMS TO REDUCE WASTE, 

13 FRAUD, AND ABUSE. 

14 (a) IN GENERAL.—Section 1866(j) of the Social Se15 curity Act (42 U.S.C. 42 U.S.C. 1395cc(j)), as amended 

16 by section 1631(d)(3), is further amended by adding at 

17 the end the following new paragraph: 

18 ‘‘(4) COMPLIANCE PROGRAMS FOR PROVIDERS

19 OF SERVICES AND SUPPLIERS.— 

20 ‘‘(A) IN GENERAL.—The Secretary may 

21 not enroll (or renew the enrollment of) a pro22 vider of services or a supplier (other than a 

23 physician or a skilled nursing facility) under 

24 this title if such provider of services or supplier 

25 fails to, subject to subparagraph (E), establish 
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1 a compliance program that contains the core 

2 elements established under subparagraph (B) 

3 and certify in a manner determined by the Sec4 retary, that the provider or suppler has estab5 lished such a program. 

6 ‘‘(B) ESTABLISHMENT OF CORE ELE7 MENTS.—The Secretary, in consultation with 

8 the Inspector General of the Department of 

9 Health and Human Services, shall establish 

10 core elements for a compliance program under 

11 subparagraph (A). Such elements may include 

12 written policies, procedures, and standards of 

13 conduct, a designated compliance officer and a 

14 compliance committee; effective training and 

15 education pertaining to fraud, waste, and abuse 

16 for the organization’s employees, and contrac17 tors; a confidential or anonymous mechanism, 

18 such as a hotline, to receive compliance ques19 tions and reports of fraud, waste, or abuse; dis20 ciplinary guidelines for enforcement of stand21 ards; internal monitoring and auditing proce22 dures, including monitoring and auditing of 

23 contractors; procedures for ensuring prompt re24 sponses to detected offenses and development of 

25 corrective action initiatives, including responses 
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1 to potential offenses; and procedures to return 

2 all identified overpayments to the programs 

3 under this title, title XIX, and title XXI. 

4 ‘‘(C) TIMELINE FOR IMPLEMENTATION.— 

5 The Secretary shall determine a timeline for the 

6 establishment of the core elements under sub7 paragraph (B) and the date on which a pro8 vider of services and suppliers (other than phy9 sicians and skilled nursing facilities) shall be re10 quired to have established such a program for 

11 purposes of this subsection. 

12 ‘‘(D) PILOT PROGRAM.—The Secretary 

13 may conduct a pilot program on the application 

14 of this subsection with respect to a category of 

15 providers of services or suppliers (other than 

16 physicians and skilled nursing facilities) that 

17 the Secretary determines to be a category which 

18 is at high risk for waste, fraud, and abuse be19 fore implementing the requirements of this sub20 section to all providers of services and suppliers 

21 described in subparagraph (C). 

22 ‘‘(E) TREATMENT OF SKILLED NURSING

23 FACILITIES.—For the requirement for skilled 

24 nursing facilities to establish compliance and 

25 ethics programs see section 1819(d)(1)(C). 
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1 ‘‘(F) CONSTRUCTION.—Nothing in this 

2 subsection exempts a physician from partici3 pating in a compliance program established by 

4 a health care provider or other entity with 

5 which the physician is employed, under con6 tract, or affiliated if such compliance is re7 quired by such provider or entity.’’. 

8 (b) REFERENCE TO SIMILAR MEDICAID PROVI9 SION.—For a similar provision with respect to the Med10 icaid program under title XIX of the Social Security Act, 

11 see section 1753. 

12 SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDI13 CARE CLAIMS REDUCED TO NOT MORE THAN 

14 12 MONTHS. 

15 (a) PURPOSE.—In general, the 36-month period cur16 rently allowed for claims filing under parts A, B, C, and, 

17 D of title XVIII of the Social Security Act presents oppor18 tunities for fraud schemes in which processing patterns 

19 of the Centers for Medicare & Medicaid Services can be 

20 observed and exploited. Narrowing the window for claims 

21 processing will not overburden providers and will reduce 

22 fraud and abuse. 

23 (b) REDUCING MAXIMUM PERIOD FOR SUBMIS24 SION.— 
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1 (1) PART A.—Section 1814(a) of the Social Se2 curity Act (42 U.S.C. 1395f(a)) is amended— 

3 (A) in paragraph (1), by striking ‘‘period 

4 of 3 calendar years’’ and all that follows and in5 serting ‘‘period of 1 calendar year from which 

6 such services are furnished; and’’; and 

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

8 sentence: ‘‘In applying paragraph (1), the Sec9 retary may specify exceptions to the 1 calendar 

10 year period specified in such paragraph.’’. 

11 (2) PART B.—Section 1835(a) of such Act (42 

12 U.S.C. 1395n(a)) is amended— 

13 (A) in paragraph (1), by striking ‘‘period 

14 of 3 calendar years’’ and all that follows and in15 serting ‘‘period of 1 calendar year from which 

16 such services are furnished; and’’; and 

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

18 sentence: ‘‘In applying paragraph (1), the Sec19 retary may specify exceptions to the 1 calendar 

20 year period specified in such paragraph.’’. 

21 (3) PARTS C AND D.—Section 1857(d) of such 

22 Act is amended by adding at the end the following 

23 new paragraph: 

24 ‘‘(7) PERIOD FOR SUBMISSION OF CLAIMS.— 

25 The contract shall require an MA organization or 
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1 PDP sponsor to require any provider of services 

2 under contract with, in partnership with, or affili3 ated with such organization or sponsor to ensure 

4 that, with respect to items and services furnished by 

5 such provider to an enrollee of such organization, 

6 written request, signed by such enrollee, except in 

7 cases in which the Secretary finds it impracticable 

8 for the enrollee to do so, is filed for payment for 

9 such items and services in such form, in such man10 ner, and by such person or persons as the Secretary 

11 may by regulation prescribe, no later than the close 

12 of the 1 calendar year period after such items and 

13 services are furnished. In applying the previous sen14 tence, the Secretary may specify exceptions to the 1 

15 calendar year period specified.’’. 

16 (c) EFFECTIVE DATE.—The amendments made by 

17 subsection (b) shall be effective for items and services fur18 nished on or after January 1, 2011. 

19 SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL 

20 EQUIPMENT OR HOME HEALTH SERVICES RE21 QUIRED TO BE MEDICARE ENROLLED PHYSI22 CIANS OR ELIGIBLE PROFESSIONALS. 

23 (a) DME.—Section 1834(a)(11)(B) of the Social Se24 curity Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 

25 striking ‘‘physician’’ and inserting ‘‘physician enrolled 
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1 under section 1866(j) or other professional, as determined 

2 by the Secretary’’. 

3 (b) HOME HEALTH SERVICES.— 

4 (1) PART A.—Section 1814(a)(2) of such Act 

5 (42 U.S.C. 1395(a)(2)) is amended in the matter 

6 preceding subparagraph (A) by inserting ‘‘in the 

7 case of services described in subparagraph (C), a 

8 physician enrolled under section 1866(j) or other 

9 professional, as determined by the Secretary,’’ before 

10 ‘‘or, in the case of services’’. 

11 (2) PART B.—Section 1835(a)(2) of such Act 

12 (42 U.S.C. 1395n(a)(2)) is amended in the matter 

13 preceding subparagraph (A) by inserting ‘‘, or in the 

14 case of services described in subparagraph (A), a 

15 physician enrolled under section 1866(j) or other 

16 professional, as determined by the Secretary,’’ after 

17 ‘‘a physician’’. 

18 (c) DISCRETION TO EXPAND APPLICATION.—The 

19 Secretary may extend the requirement applied by the 

20 amendments made by subsections (a) and (b) to durable 

21 medical equipment and home health services (relating to 

22 requiring certifications and written orders to be made by 

23 enrolled physicians and health professions) to other cat24 egories of items or services under this title, including cov25 ered part D drugs as defined in section 1860D–2(e), if 
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1 the Secretary determines that such application would help 

2 to reduce the risk of waste, fraud, and abuse with respect 

3 to such other categories under title XVIII of the Social 

4 Security Act. 

5 (d) EFFECTIVE DATE.—The amendments made by 

6 this section shall apply to written orders and certifications 

7 made on or after July 1, 2010. 

8 SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE 

9 DOCUMENTATION ON REFERRALS TO PRO10 GRAMS AT HIGH RISK OF WASTE AND ABUSE. 

11 (a) PHYSICIANS AND OTHER SUPPLIERS.—Section 

12 1842(h) of the Social Security Act is further amended by 

13 adding at the end the following new paragraph: 

14 ‘‘(9) The Secretary may disenroll, for a period of not 

15 more than one year for each act, a physician or supplier 

16 under section 1866(j) if such physician or supplier fails 

17 to maintain and, upon request of the Secretary, provide 

18 access to documentation relating to written orders or re19 quests for payment for durable medical equipment, certifi20 cations for home health services, or referrals for other 

21 items or services written or ordered by such physician or 

22 supplier under this title, as specified by the Secretary.’’. 

23 (b) PROVIDERS OF SERVICES.—Section 1866(a)(1) 

24 of such Act (42 U.S.C. 1395cc), is amended— 
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1 (1) in subparagraph (U), by striking at the end 

2 ‘‘and’’; 

3 (2) in subparagraph (V), by striking the period 

4 at the end and adding ‘‘; and’’; and 

5 (3) by adding at the end the following new sub6 paragraph: 

7 ‘‘(W) maintain and, upon request of the 

8 Secretary, provide access to documentation re9 lating to written orders or requests for payment 

10 for durable medical equipment, certifications for 

11 home health services, or referrals for other 

12 items or services written or ordered by the pro13 vider under this title, as specified by the Sec14 retary.’’. 

15 (c) OIG PERMISSIVE EXCLUSION AUTHORITY.—Sec16 tion 1128(b)(11) of the Social Security Act (42 U.S.C. 

17 1320a–7(b)(11)) is amended by inserting ‘‘, ordering, re18 ferring for furnishing, or certifying the need for’’ after 

19 ‘‘furnishing’’. 

20 (d) EFFECTIVE DATE.—The amendments made by 

21 this section shall apply to orders, certifications, and refer22 rals made on or after January 1, 2010. 
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1 SEC. 1639. FACE-TO-FACE ENCOUNTER WITH PATIENT RE2 QUIRED BEFORE ELIGIBILITY CERTIFI3 CATIONS FOR HOME HEALTH SERVICES OR 

4 DURABLE MEDICAL EQUIPMENT. 

5 (a) CONDITION OF PAYMENT FOR HOME HEALTH

6 SERVICES.— 

7 (1) PART A.—Section 1814(a)(2)(C) of such 

8 Act is amended— 

9 (A) by striking ‘‘and such services’’ and in10 serting ‘‘such services’’; and 

11 (B) by inserting after ‘‘care of a physi12 cian’’ the following: ‘‘, and, in the case of a cer13 tification or recertification made by a physician 

14 after January 1, 2010, prior to making such 

15 certification the physician must document that 

16 the physician has had a face-to-face encounter 

17 (including through use of telehealth and other 

18 than with respect to encounters that are inci19 dent to services involved) with the individual 

20 during the 6-month period preceding such cer21 tification, or other reasonable timeframe as de22 termined by the Secretary’’. 

23 (2) PART B.—Section 1835(a)(2)(A) of the So24 cial Security Act is amended— 

25 (A) by striking ‘‘and’’ before ‘‘(iii)’’; and 
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1 (B) by inserting after ‘‘care of a physi2 cian’’ the following: ‘‘, and (iv) in the case of 

3 a certification or recertification after January 

4 1, 2010, prior to making such certification the 

5 physician must document that the physician has 

6 had a face-to-face encounter (including through 

7 use of telehealth and other than with respect to 

8 encounters that are incident to services in9 volved) with the individual during the 6-month 

10 period preceding such certification or recertifi11 cation, or other reasonable timeframe as deter12 mined by the Secretary’’. 

13 (b) CONDITION OF PAYMENT FOR DURABLE MED14 ICAL EQUIPMENT.—Section 1834(a)(11)(B) of the Social 

15 Security Act (42 U.S.C. 1395m(a)(11)(B)) is amended by 

16 adding before the period at the end the following: ‘‘and 

17 shall require that any written order required for payment 

18 under this subsection be written only pursuant to the eligi19 ble health care professional authorized to make such writ20 ten order documenting that such professional has had a 

21 face-to-face encounter (including through use of telehealth 

22 and other than with respect to encounters that are inci23 dent to services involved) with the individual involved dur24 ing the 6-month period preceding such written order, or 
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1 other reasonable timeframe as determined by the Sec2 retary’’. 

3 (c) APPLICATION TO OTHER AREAS UNDER MEDI4 CARE.—The Secretary may apply a face-to-face encounter 

5 requirement similar to the requirement described in the 

6 amendments made by subsections (a) and (b) to other 

7 items and services for which payment is provided under 

8 title XVIII of the Social Security Act based upon a finding 

9 that such a decision would reduce the risk of waste, fraud, 

10 or abuse. 

11 (d) APPLICATION TO MEDICAID AND CHIP.—The 

12 face-to-face encounter requirements described in the 

13 amendments made by subsections (a) and (b) and any ex14 panded application of similar requirements pursuant to 

15 subsection (c) shall apply with respect to a certification 

16 or recertification for home health services under title XIX 

17 or XXI of the Social Security Act, a written order for du18 rable medical equipment under such title, and any other 

19 applicable item or service identified pursuant to subsection 

20 (c) for which payment is made under such title, respec21 tively, in the same manner and to the same extent as such 

22 requirements apply in the case of such a certification or 

23 recertification, written order, or other applicable item or 

24 service so identified, respectively, under title XVIII of such 

25 Act. 
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1 SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AU2 THORITY TO PROGRAM EXCLUSION INVES3 TIGATIONS. 

4 (a) IN GENERAL.—Section 1128(f) of the Social Se5 curity Act (42 U.S.C. 1320a–7(f)) is amended by adding 

6 at the end the following new paragraph: 

7 ‘‘(4) The provisions of subsections (d) and (e) of sec8 tion 205 shall apply with respect to this section to the 

9 same extent as they are applicable with respect to title 

10 II. The Secretary may delegate the authority granted by 

11 section 205(d) (as made applicable to this section) to the 

12 Inspector General of the Department of Health and 

13 Human Services or the Administrator of the Centers for 

14 Medicare & Medicaid Services for purposes of any inves15 tigation under this section.’’. 

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

17 subsection (a) shall apply to investigations beginning on 

18 or after January 1, 2010. 

19 SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND 

20 MEDICAID OVERPAYMENTS. 

21 Section 1128G of the Social Security Act, as inserted 

22 by section 1631 and amended by section 1632, is further 

23 amended by adding at the end the following new sub24 section: 
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1 ‘‘(c) REPORTS ON AND REPAYMENT OF OVERPAY2 MENTS IDENTIFIED THROUGH INTERNAL AUDITS AND

3 REVIEWS.— 

4 ‘‘(1) REPORTING AND RETURNING OVERPAY5 MENTS.—If a person knows of an overpayment, the 

6 person must— 

7 ‘‘(A) report and return the overpayment to 

8 the Secretary, the State, an intermediary, a 

9 carrier, or a contractor, as appropriate, at the 

10 correct address, and 

11 ‘‘(B) notify the Secretary, the State, inter12 mediary, carrier, or contractor to whom the 

13 overpayment was returned in writing of the rea14 son for the overpayment. 

15 ‘‘(2) TIMING.—Subject to section 1620(d) of 

16 the Affordable Health Care for America Act, an 

17 overpayment must be reported and returned under 

18 paragraph (1)(A) by not later than the date that is 

19 60 days after the date the person knows of the over20 payment. 

21 Any known overpayment retained later than the ap22 plicable date specified in this paragraph creates an 

23 obligation as defined in section 3729(b)(3) of title 

24 31 of the United States Code. 
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1 ‘‘(3) CLARIFICATION.—Repayment of any over2 payments (or refunding by withholding of future 

3 payments) by a provider of services or supplier does 

4 not otherwise limit the provider or supplier’s poten5 tial liability for administrative obligations such as 

6 applicable interests, fines, and penalties or civil or 

7 criminal sanctions involving the same claim if it is 

8 determined later that the reason for the overpay9 ment was related to fraud or other intentional con10 duct by the provider or supplier or the employees or 

11 agents of such provider or supplier. 

12 ‘‘(4) DEFINITIONS.—In this subsection: 

13 ‘‘(A) KNOWS.—The term ‘knows’ has the 

14 meaning given the terms ‘knowing’ and ‘know15 ingly’ in section 3729(b) of title 31 of the 

16 United States Code. 

17 ‘‘(B) OVERPAYMENT.—The term ‘‘overpay18 ment’’ means any funds that a person receives 

19 or retains under title XVIII, XIX, or XXI to 

20 which the person, after applicable reconciliation 

21 (pursuant to the applicable existing process 

22 under the respective title), is not entitled under 

23 such title. 

24 ‘‘(C) PERSON.—The term ‘person’ means a 

25 provider of services, supplier, Medicaid man-
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1 aged care organization (as defined in section 

2 1903(m)(1)(A)), Medicare Advantage organiza3 tion (as defined in section 1859(a)(1)), or PDP 

4 sponsor (as defined in section 1860D– 

5 41(a)(13)), but excluding a beneficiary.’’. 

6 SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIV7 ERS FOR OIG EXCLUSIONS TO BENE8 FICIARIES OF ANY FEDERAL HEALTH CARE 

9 PROGRAM. 

10 Section 1128(c)(3)(B) of the Social Security Act (42 

11 U.S.C. 1320a–7(c)(3)(B)) is amended by striking ‘‘indi12 viduals entitled to benefits under part A of title XVIII 

13 or enrolled under part B of such title, or both’’ and insert14 ing ‘‘beneficiaries (as defined in section 1128A(i)(5)) of 

15 that program’’. 

16 SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL 

17 DIALYSIS FACILITIES. 

18 Section 1881(b) of the Social Security Act (42 U.S.C. 

19 1395rr(b)) is amended by adding at the end the following 

20 new paragraph: 

21 ‘‘(15) For purposes of evaluating or auditing pay22 ments made to renal dialysis facilities for items and serv23 ices under this section under paragraph (1), each such 

24 renal dialysis facility, upon the request of the Secretary, 

25 shall provide to the Secretary access to information relat-
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1 ing to any ownership or compensation arrangement be2 tween such facility and the medical director of such facility 

3 or between such facility and any physician.’’. 

4 SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER 

5 ALTERNATE PAYEES REQUIRED TO REG6 ISTER UNDER MEDICARE. 

7 (a) MEDICARE.—Section 1866(j)(1) of the Social Se8 curity Act (42 U.S.C. 1395cc(j)(1)) is amended by adding 

9 at the end the following new subparagraph: 

10 ‘‘(D) BILLING AGENTS AND CLEARING11 HOUSES REQUIRED TO BE REGISTERED UNDER

12 MEDICARE.—Any agent, clearinghouse, or other 

13 alternate payee that submits claims on behalf of 

14 a health care provider must be registered with 

15 the Secretary in a form and manner specified 

16 by the Secretary.’’. 

17 (b) MEDICAID.—For a similar provision with respect 

18 to the Medicaid program under title XIX of the Social Se19 curity Act, see section 1759. 

20 (c) EFFECTIVE DATE.—The amendment made by 

21 subsection (a) shall apply to claims submitted on or after 

22 January 1, 2012. 
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1 SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO 

2 FALSE CLAIMS ACT AMENDMENTS. 

3 Section 1128A of the Social Security Act, as amended 

4 by sections 1611, 1612, 1613, and 1615, is further 

5 amended— 

6 (1) in subsection (a)— 

7 (A) in paragraph (1), by striking ‘‘to an 

8 officer, employee, or agent of the United States, 

9 or of any department or agency thereof, or of 

10 any State agency (as defined in subsection 

11 (i)(1))’’; 

12 (B) in paragraph (4)— 

13 (i) in the matter preceding subpara14 graph (A), by striking ‘‘participating in a 

15 program under title XVIII or a State 

16 health care program’’ and inserting ‘‘par17 ticipating in a Federal health care program 

18 (as defined in section 1128B(f))’’; and 

19 (ii) in subparagraph (A), by striking 

20 ‘‘title XVIII or a State health care pro21 gram’’ and inserting ‘‘a Federal health 

22 care program (as defined in section 

23 1128B(f))’’; 

24 (C) by striking ‘‘or’’ at the end of para25 graph (10); 
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1 (D) by inserting after paragraph (11) the 

2 following new paragraphs: 

3 ‘‘(12) conspires to commit a violation of this 

4 section; or 

5 ‘‘(13) knowingly makes, uses, or causes to be 

6 made or used, a false record or statement material 

7 to an obligation to pay or transmit money or prop8 erty to a Federal health care program, or knowingly 

9 conceals or knowingly and improperly avoids or de10 creases an obligation to pay or transmit money or 

11 property to a Federal health care program;’’; and 

12 (E) in the matter following paragraph 

13 (13), as inserted by subparagraph (D)— 

14 (i) by striking ‘‘or’’ before ‘‘in cases 

15 under paragraph (11)’’; and 

16 (ii) by inserting ‘‘, in cases under 

17 paragraph (12), $50,000 for any violation 

18 described in this section committed in fur19 therance of the conspiracy involved; or in 

20 cases under paragraph (13), $50,000 for 

21 each false record or statement, or conceal22 ment, avoidance, or decrease’’ after ‘‘by an 

23 excluded individual’’; and 

24 (F) in the second sentence, by striking 

25 ‘‘such false statement, omission, or misrepre-
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1 sentation)’’ and inserting ‘‘such false statement 

2 or misrepresentation, in cases under paragraph 

3 (12), an assessment of not more than 3 times 

4 the total amount that would otherwise apply for 

5 any violation described in this section com6 mitted in furtherance of the conspiracy in7 volved, or in cases under paragraph (13), an as8 sessment of not more than 3 times the total 

9 amount of the obligation to which the false 

10 record or statement was material or that was 

11 avoided or decreased)’’. 

12 (2) in subsection (c)(1), by striking ‘‘six years’’ 

13 and inserting ‘‘10 years’’; and 

14 (3) in subsection (i)— 

15 (A) by amending paragraph (2) to read as 

16 follows: 

17 ‘‘(2) The term ‘claim’ means any application, 

18 request, or demand, whether under contract, or oth19 erwise, for money or property for items and services 

20 under a Federal health care program (as defined in 

21 section 1128B(f)), whether or not the United States 

22 or a State agency has title to the money or property, 

23 that— 

24 ‘‘(A) is presented or caused to be pre25 sented to an officer, employee, or agent of the 
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1 United States, or of any department or agency 

2 thereof, or of any State agency (as defined in 

3 subsection (i)(1)); or 

4 ‘‘(B) is made to a contractor, grantee, or 

5 other recipient if the money or property is to be 

6 spent or used on the Federal health care pro7 gram’s behalf or to advance a Federal health 

8 care program interest, and if the Federal health 

9 care program— 

10 ‘‘(i) provides or has provided any por11 tion of the money or property requested or 

12 demanded; or 

13 ‘‘(ii) will reimburse such contractor, 

14 grantee, or other recipient for any portion 

15 of the money or property which is re16 quested or demanded.’’; 

17 (B) by amending paragraph (3) to read as 

18 follows: 

19 ‘‘(3) The term ‘item or service’ means, without 

20 limitation, any medical, social, management, admin21 istrative, or other item or service used in connection 

22 with or directly or indirectly related to a Federal 

23 health care program.’’; 

24 (C) in paragraph (6)— 
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1 (i) in subparagraph (C), by striking at 

2 the end ‘‘or’’; 

3 (ii) in the first subparagraph (D), by 

4 striking at the end the period and inserting 

5 ‘‘; or’’; and 

6 (iii) by redesignating the second sub7 paragraph (D) as a subparagraph (E); 

8 (D) by amending paragraph (7) to read as 

9 follows: 

10 ‘‘(7) The terms ‘knowing’, ‘knowingly’, and 

11 ‘should know’ mean that a person, with respect to 

12 information— 

13 ‘‘(A) has actual knowledge of the informa14 tion; 

15 ‘‘(B) acts in deliberate ignorance of the 

16 truth or falsity of the information; or 

17 ‘‘(C) acts in reckless disregard of the truth 

18 or falsity of the information; 

19 and require no proof of specific intent to defraud.’’; 

20 and 

21 (E) by adding at the end the following new 

22 paragraphs: 

23 ‘‘(8) The term ‘obligation’ means an established 

24 duty, whether or not fixed, arising from an express 

25 or implied contractual, grantor-grantee, or licensor- 
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1 licensee relationship, from a fee-based or similar re2 lationship, from statute or regulation, or from the 

3 retention of any overpayment. 

4 ‘‘(9) The term ‘material’ means having a nat5 ural tendency to influence, or be capable of influ6 encing, the payment or receipt of money or prop7 erty.’’. 

8 SEC. 1646. REQUIRING PROVIDER AND SUPPLIER PAY9 MENTS UNDER MEDICARE TO BE MADE 

10 THROUGH DIRECT DEPOSIT OR ELECTRONIC 

11 FUNDS TRANSFER (EFT) AT INSURED DEPOSI12 TORY INSTITUTIONS. 

13 (a) MEDICARE.—Section 1874 of the Social Security 

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

15 the following new subsection: 

16 ‘‘(e) LIMITATION ON PAYMENT TO PROVIDERS OF

17 SERVICES AND SUPPLIERS.—No payment shall be made 

18 under this title for items and services furnished by a pro19 vider of services or supplier unless each payment to the 

20 provider of services or supplier is in the form of direct 

21 deposit or electronic funds transfer to the provider of serv22 ices’ or supplier’s account, as applicable, at a depository 

23 institution (as defined in section 19(b)(1)(A) of the Fed24 eral Reserve Act.’’. 
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1 (b) EFFECTIVE DATE.—The amendments made by 

2 this section shall apply to each payment made to a pro3 vider of services, provider, or supplier on or after such 

4 date (not later than July 1, 2012) as the Secretary of 

5 Health and Human Services shall specify, regardless of 

6 when the items and services for which such payment is 

7 made were furnished. 

8 SEC. 1647. INSPECTOR GENERAL FOR THE HEALTH 

9 CHOICES ADMINISTRATION. 

10 (a) ESTABLISHMENT; APPOINTMENT.—There is 

11 hereby established an Office of Inspector General for the 

12 Health Choices Administration, to be headed by the In13 spector General for the Health Choices Administration to 

14 be appointed by the President, by and with the advice and 

15 consent of the Senate. 

16 (b) AMENDMENTS TO THE INSPECTOR GENERAL ACT

17 OF 1978.— 

18 (1) APPLICATION TO HEALTH CHOICES ADMIN19 ISTRATION.—Section 12 of the Inspector General 

20 Act of 1978 (5 U.S.C. App.) is amended— 

21 (A) in paragraph (1), by striking ‘‘or the 

22 Federal Cochairpersons of the Commissions es23 tablished under section 15301 of title 40, 

24 United States Code’’ and inserting ‘‘the Federal 

25 Cochairpersons of the Commissions established 
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1 under section 15301 of title 40, United States 

2 Code; or the Commissioner of the Health 

3 Choices Administration established under sec4 tion 241 of the Affordable Health Care for 

5 America Act’’; and 

6 (B) in paragraph (2), by striking ‘‘or the 

7 Commissions established under section 15301 

8 of title 40, United States Code’’ and inserting 

9 ‘‘the Commissions established under section 

10 15301 of title 40, United States Code, or the 

11 Health Choices Administration established 

12 under section 241 of the Affordable Health 

13 Care for America Act’’. 

14 (2) SPECIAL PROVISIONS RELATING TO HEALTH

15 CHOICES ADMINISTRATION AND HHS.—The Inspec16 tor General Act of 1978 (5 U.S.C. App.) is further 

17 amended by inserting after section 8L the following 

18 new section: 

19 ‘‘SEC. 8M SPECIAL PROVISIONS RELATING TO THE HEALTH 

20 CHOICES ADMINISTRATION AND THE DE21 PARTMENT OF HEALTH AND HUMAN SERV22 ICES. 

23 ‘‘(a) The Inspector General of the Health Choices Ad24 ministration shall— 
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1 ‘‘(1) have the authority to conduct, supervise, 

2 and coordinate audits, evaluations, and investiga3 tions of the programs and operations of the Health 

4 Choices Administration established under section 

5 241 of the Affordable Health Care for America Act, 

6 including matters relating to fraud, abuse, and mis7 conduct in connection with the admission and con8 tinued participation of any health benefits plan par9 ticipating in the Health Insurance Exchange estab10 lished under section 301 of such Act; 

11 ‘‘(2) have the authority to conduct audits, eval12 uations, and investigations relating to any private 

13 Exchange-participating health benefits plan, as de14 fined in section 201(c) of such Act; 

15 ‘‘(3) have the authority, in consultation with 

16 the Office of Inspector General for the Department 

17 of Health and Human Services and subject to sub18 section (b), to conduct audits, evaluations, and in19 vestigations relating to the public health insurance 

20 option established under section 321 of such Act; 

21 and 

22 ‘‘(4) have access to all relevant records nec23 essary to carry out this section, including records re24 lating to claims paid by Exchange-participating 

25 health benefits plans. 
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1 ‘‘(b) Authority granted to the Health Choices Admin2 istration and the Inspector General of the Health Choices 

3 Administration by the Affordable Health Care for America 

4 Act does not limit the duties, authorities, and responsibil5 ities of the Office of Inspector General for the Department 

6 of Health and Human Services, as in existence as of the 

7 date of the enactment of the Affordable Health Care for 

8 America Act, to oversee programs and operations of such 

9 department. The Office of Inspector General for the De10 partment of Health and Human Services retains primary 

11 jurisdiction over fraud and abuse in connection with pay12 ments made under the public health insurance option es13 tablished under section 321 of such Act and administered 

14 by the Department of Health and Human Services.’’. 

15 (3) APPLICATION OF RULE OF CONSTRUC16 TION.—Section 8J of the Inspector General Act of 

17 1978 (5 U.S.C. App.) is amended by striking ‘‘or 

18 8H’’ and inserting ‘‘, 8H, or 8M’’. 

19 (c) EFFECTIVE DATE.—The provisions of and 

20 amendments made by this section shall take effect on the 

21 date of the enactment of this Act. 
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1 Subtitle D—Access to Information 

2 Needed to Prevent Fraud, 

3 Waste, and Abuse 

4 SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDEN5 TIFY FRAUD, WASTE, AND ABUSE. 

6 (a) GAO ACCESS.—Subchapter II of chapter 7 of 

7 title 31, United States Code, is amended by adding at the 

8 end the following: 

9 ‘‘§ 721. Access to certain information 

10 ‘‘No provision of the Social Security Act shall be con11 strued to limit, amend, or supersede the authority of the 

12 Comptroller General to obtain any information, to inspect 

13 any record, or to interview any officer or employee under 

14 section 716 of this title, including with respect to any in15 formation disclosed to or obtained by the Secretary of 

16 Health and Human Services under part C or D of title 

17 XVIII of the Social Security Act.’’. 

18 (b) ACCESS TO MEDICARE PART D DATA PROGRAM

19 INTEGRITY PURPOSES.— 

20 (1) PROVISION OF INFORMATION AS CONDITION

21 OF PAYMENT.—Section 1860D–15(d)(2)(B) of the 

22 Social Security Act (42 U.S.C. 1395w– 

23 115(d)(2)(B)) is amended— 
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1 (A) by striking ‘‘may be used by officers’’ 

2 and all that follows through the period and in3 serting ‘‘may be used by—’’; and 

4 (B) by adding at the end the following 

5 clauses: 

6 ‘‘(i) officers, employees, and contrac7 tors of the Department of Health and 

8 Human Services only for the purposes of, 

9 and to the extent necessary in, carrying 

10 out this section; and 

11 ‘‘(ii) the Inspector General of the De12 partment of Health and Human Services, 

13 the Administrator of the Centers for Medi14 care & Medicaid Services, and the Attorney 

15 General only for the purposes of protecting 

16 the integrity of the programs under this 

17 title and title XIX; conducting the activi18 ties described in section 1893 and subpara19 graphs (A) through (E) of section 

20 1128C(a)(1); and for investigation, audit, 

21 evaluation, oversight, and law enforce22 ment purposes to the extent consistent 

23 with applicable law.’’. 
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1 (2) GENERAL DISCLOSURE OF INFORMATION.— 

2 Section 1860D–15(f)(2) of the Social Security Act 

3 (42 U.S.C. 1395w–115(f)(2)) is amended— 

4 (A) by striking ‘‘may be used by officers’’ 

5 and all that follows through the period and in6 serting ‘‘may be used by—’’; and 

7 (B) by adding at the end the following sub8 paragraphs: 

9 ‘‘(A) officers, employees, and contractors 

10 of the Department of Health and Human Serv11 ices only for the purposes of, and to the extent 

12 necessary in, carrying out this section; and 

13 ‘‘(B) the Inspector General of the Depart14 ment of Health and Human Services, the Ad15 ministrator of the Centers for Medicare & Med16 icaid Services, and the Attorney General only 

17 for the purposes of protecting the integrity of 

18 the programs under this title and title XIX; 

19 conducting the activities described in section 

20 1893 and subparagraphs (A) through (E) of 

21 section 1128C(a)(1); and for investigation, 

22 audit, evaluation, oversight, and law enforce23 ment purposes to the extent consistent with ap24 plicable law.’’. 
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1 SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE 

2 HEALTHCARE INTEGRITY AND PROTECTION 

3 DATA BANK AND THE NATIONAL PRACTI4 TIONER DATA BANK. 

5 (a) IN GENERAL.—To eliminate duplication between 

6 the Healthcare Integrity and Protection Data Bank 

7 (HIPDB) established under section 1128E of the Social 

8 Security Act and the National Practitioner Data Bank 

9 (NPBD) established under the Health Care Quality Im10 provement Act of 1986, section 1128E of the Social Secu11 rity Act (42 U.S.C. 1320a–7e) is amended— 

12 (1) in subsection (a), by striking ‘‘Not later 

13 than’’ and inserting ‘‘Subject to subsection (h), not 

14 later than’’; 

15 (2) in the first sentence of subsection (d)(2), by 

16 striking ‘‘(other than with respect to requests by 

17 Federal agencies)’’; and 

18 (3) by adding at the end the following new sub19 section: 

20 ‘‘(h) SUNSET OF THE HEALTHCARE INTEGRITY AND

21 PROTECTION DATA BANK; TRANSITION PROCESS.—Ef22 fective upon the enactment of this subsection, the Sec23 retary shall implement a process to eliminate duplication 

24 between the Healthcare Integrity and Protection Data 

25 Bank (in this subsection referred to as the ‘HIPDB’ es26 tablished pursuant to subsection (a) and the National 
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1 Practitioner Data Bank (in this subsection referred to as 

2 the ‘NPDB’) as implemented under the Health Care Qual3 ity Improvement Act of 1986 and section 1921 of this Act, 

4 including systems testing necessary to ensure that infor5 mation formerly collected in the HIPDB will be accessible 

6 through the NPDB, and other activities necessary to 

7 eliminate duplication between the two data banks. Upon 

8 the completion of such process, notwithstanding any other 

9 provision of law, the Secretary shall cease the operation 

10 of the HIPDB and shall collect information required to 

11 be reported under the preceding provisions of this section 

12 in the NPDB. Except as otherwise provided in this sub13 section, the provisions of subsections (a) through (g) shall 

14 continue to apply with respect to the reporting of (or fail15 ure to report), access to, and other treatment of the infor16 mation specified in this section.’’. 

17 (b) ELIMINATION OF THE RESPONSIBILITY OF THE

18 HHS OFFICE OF THE INSPECTOR GENERAL.—Section 

19 1128C(a)(1) of the Social Security Act (42 U.S.C. 1320a– 

20 7c(a)(1)) is amended— 

21 (1) in subparagraph (C), by adding at the end 

22 ‘‘and’’; 

23 (2) in subparagraph (D), by striking at the end 

24 ‘‘, and’’ and inserting a period; and 

25 (3) by striking subparagraph (E). 
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1 (c) SPECIAL PROVISION FOR ACCESS TO THE NA2 TIONAL PRACTITIONER DATA BANK BY THE DEPART3 MENT OF VETERANS AFFAIRS.— 

4 (1) IN GENERAL.—Notwithstanding any other 

5 provision of law, during the one year period that be6 gins on the effective date specified in subsection 

7 (e)(1), the information described in paragraph (2) 

8 shall be available from the National Practitioner 

9 Data Bank (described in section 1921 of the Social 

10 Security Act) to the Secretary of Veterans Affairs 

11 without charge. 

12 (2) INFORMATION DESCRIBED.—For purposes 

13 of paragraph (1), the information described in this 

14 paragraph is the information that would, but for the 

15 amendments made by this section, have been avail16 able to the Secretary of Veterans Affairs from the 

17 Healthcare Integrity and Protection Data Bank. 

18 (d) FUNDING.—Notwithstanding any provisions of 

19 this Act, sections 1128E(d)(2) and 1817(k)(3) of the So20 cial Security Act, or any other provision of law, there shall 

21 be available for carrying out the transition process under 

22 section 1128E(h) of the Social Security Act over the pe23 riod required to complete such process, and for operation 

24 of the National Practitioner Data Bank until such process 

25 is completed, without fiscal year limitation— 
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1 (1) any fees collected pursuant to section 

2 1128E(d)(2) of such Act; and 

3 (2) such additional amounts as necessary, from 

4 appropriations available to the Secretary and to the 

5 Office of the Inspector General of the Department of 

6 Health and Human Services under clauses (i) and 

7 (ii), respectively, of section 1817(k)(3)(A) of such 

8 Act, for costs of such activities during the first 12 

9 months following the date of the enactment of this 

10 Act. 

11 (e) EFFECTIVE DATE.—The amendments made— 

12 (1) by subsection (a)(2) shall take effect on the 

13 first day after the Secretary of Health and Human 

14 Services certifies that the process implemented pur15 suant to section 1128E(h) of the Social Security Act 

16 (as added by subsection (a)(3)) is complete; and 

17 (2) by subsection (b) shall take effect on the 

18 earlier of the date specified in paragraph (1) or the 

19 first day of the second succeeding fiscal year after 

20 the fiscal year during which this Act is enacted. 

21 SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECU22 RITY STANDARDS. 

23 The provisions of sections 262(a) and 264 of the 

24 Health Insurance Portability and Accountability Act of 

25 1996 (and standards promulgated pursuant to such sec-
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1 tions) and the Privacy Act of 1974 shall apply with respect 

2 to the provisions of this subtitle and amendments made 

3 by this subtitle. 

4 SEC. 1654. DISCLOSURE OF MEDICARE FRAUD AND ABUSE 

5 HOTLINE NUMBER ON EXPLANATION OF BEN6 EFITS. 

7 (a) IN GENERAL.—Section 1804 of the Social Secu8 rity Act (42 U.S.C. 1395b–2) is amended by adding at 

9 the end the following new subsection: 

10 ‘‘(d) Any statement or notice containing an expla11 nation of the benefits available under this title, including 

12 the notice required by subsection (a), distributed for peri13 ods after July 1, 2011, shall prominently display in a man14 ner prescribed by the Secretary a separate toll-free tele15 phone number maintained by the Secretary for the receipt 

16 of complaints and information about waste, fraud, and 

17 abuse in the provision or billing of services under this 

18 title.’’. 

19 (b) CONFORMING AMENDMENTS.—Section 1804(c) 

20 of the Social Security Act (42 U.S.C. 1395b–2(c)) is 

21 amended— 

22 (1) in paragraph (2), by adding ‘‘and’’ at the 

23 end; 

24 (2) in paragraph (3), by striking ‘‘; and’’ and 

25 inserting a period; and 
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1 (3) by striking paragraph (4). 

2 TITLE VII—MEDICAID AND CHIP 

3 Subtitle A—Medicaid and Health 

4 Reform 

5 SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME 

6 BELOW 150 PERCENT OF THE FEDERAL POV7 ERTY LEVEL. 

8 (a) ELIGIBILITY FOR NON-TRADITIONAL INDIVID9 UALS WITH INCOME BELOW 150 PERCENT OF THE FED10 ERAL POVERTY LEVEL.— 

11 (1) FULL MEDICAID BENEFITS FOR NON-MEDI12 CARE ELIGIBLE INDIVIDUALS.—Section 

13 1902(a)(10)(A)(i) of the Social Security Act (42 

14 U.S.C. 1396b(a)(10)(A)(i)) is amended— 

15 (A) by striking ‘‘or’’ at the end of sub16 clause (VI); 

17 (B) by adding ‘‘or’’ at the end of subclause 

18 (VII); and 

19 (C) by adding at the end the following new 

20 subclause: 

21 ‘‘(VIII) who are under 65 years 

22 of age, who are not described in a pre23 vious subclause of this clause, who are 

24 not entitled to hospital insurance ben25 efits under part A of title XVIII, and 
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1 whose family income (determined 

2 using methodologies and procedures 

3 specified by the Secretary in consulta4 tion with the Health Choices Commis5 sioner) does not exceed 150 percent of 

6 the income official poverty line (as de7 fined by the Office of Management 

8 and Budget, and revised annually in 

9 accordance with section 673(2) of the 

10 Omnibus Budget Reconciliation Act of 

11 1981) applicable to a family of the 

12 size involved;’’. 

13 (2) MEDICARE COST SHARING ASSISTANCE FOR

14 MEDICARE-ELIGIBLE INDIVIDUALS.—Section 

15 1902(a)(10)(E) of such Act (42 U.S.C. 

16 1396b(a)(10)(E)) is amended— 

17 (A) in clause (iii), by striking ‘‘and’’ at the 

18 end; 

19 (B) in clause (iv), by adding ‘‘and’’ at the 

20 end; and 

21 (C) by adding at the end the following new 

22 clause: 

23 ‘‘(v) for making medical assistance avail24 able for medicare cost-sharing described in sub25 paragraphs (B) and (C) of section 1905(p)(3), 
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1 for individuals under 65 years of age who would 

2 be qualified medicare beneficiaries described in 

3 section 1905(p)(1) but for the fact that their 

4 income exceeds the income level established by 

5 the State under section 1905(p)(2) but is less 

6 than 150 percent of the official poverty line (re7 ferred to in such section) for a family of the 

8 size involved; and’’. 

9 (3) INCREASED FMAP FOR NON-TRADITIONAL

10 FULL MEDICAID ELIGIBLE INDIVIDUALS.—Section 

11 1905 of such Act (42 U.S.C. 1396d) is amended— 

12 (A) in the first sentence of subsection (b), 

13 by striking ‘‘and’’ before ‘‘(4)’’ and by inserting 

14 before the period at the end the following: ‘‘, 

15 and (5) 100 percent (for periods before 2015 

16 and 91 percent for periods beginning with 

17 2015) with respect to amounts described in 

18 subsection (y)’’; and 

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

20 subsection: 

21 ‘‘(y) ADDITIONAL EXPENDITURES SUBJECT TO IN22 CREASED FMAP.—For purposes of section 1905(b)(5), 

23 the amounts described in this subsection are the following: 
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1 ‘‘(1) Amounts expended for medical assistance 

2 for individuals described in subclause (VIII) of sec3 tion 1902(a)(10)(A)(i).’’. 

4 (4) CONSTRUCTION.—Nothing in this sub5 section shall be construed as not providing for cov6 erage under subparagraph (A)(i)(VIII) or (E)(v) of 

7 section 1902(a)(10) of the Social Security Act, as 

8 added by paragraphs (1) and (2), or an increased 

9 FMAP under the amendments made by paragraph 

10 (3), for an individual who has been provided medical 

11 assistance under title XIX of the Act under a dem12 onstration waiver approved under section 1115 of 

13 such Act or with State funds. 

14 (5) CONFORMING AMENDMENTS.— 

15 (A) Section 1903(f)(4) of the Social Secu16 rity Act (42 U.S.C. 1396b(f)(4)) is amended— 

17 (i) by inserting 

18 ‘‘1902(a)(10)(A)(i)(VIII),’’ after 

19 ‘‘1902(a)(10)(A)(i)(VII),’’; and 

20 (ii) by inserting ‘‘1902(a)(10)(E)(v),’’ 

21 before ‘‘1905(p)(1)’’. 

22 (B) Section 1905(a) of such Act (42 

23 U.S.C. 1396d(a)), as amended by sections 

24 1714(a)(4) and 1731(c), is further amended, in 

25 the matter preceding paragraph (1)— 
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1 (i) by striking ‘‘or’’ at the end of 

2 clause (xiv); 

3 (ii) by adding ‘‘or’’ at the end of 

4 clause (xv); and 

5 (iii) by inserting after clause (xv) the 

6 following: 

7 ‘‘(xvi) individuals described in section 

8 1902(a)(10)(A)(i)(VIII),’’. 

9 (b) ELIGIBILITY FOR TRADITIONAL MEDICAID ELI10 GIBLE INDIVIDUALS WITH INCOME NOT EXCEEDING 150 

11 PERCENT OF THE FEDERAL POVERTY LEVEL .— 

12 (1) IN GENERAL.—Section 1902(a)(10)(A)(i) of 

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

14 1396b(a)(10)(A)(i)), as amended by subsection (a), 

15 is amended— 

16 (A) by striking ‘‘or’’ at the end of sub17 clause (VII); and 

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

19 subclauses: 

20 ‘‘(IX) who are over 18, and 

21 under 65 years of age, who would be 

22 eligible for medical assistance under 

23 the State plan under subclause (I) or 

24 section 1931 (based on the income 

25 standards, methodologies, and proce-
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1 dures in effect as of June 16, 2009) 

2 but for income, who are in families 

3 whose income does not exceed 150 

4 percent of the income official poverty 

5 line (as defined by the Office of Man6 agement and Budget, and revised an7 nually in accordance with section 

8 673(2) of the Omnibus Budget Rec9 onciliation Act of 1981) applicable to 

10 a family of the size involved; or 

11 ‘‘(X) beginning with 2014, who 

12 are under 19, years of age, who would 

13 be eligible for medical assistance 

14 under the State plan under subclause 

15 (I), (IV) (insofar as it relates to sub16 section (l)(1)(B)), (VI), or (VII) 

17 (based on the income standards, 

18 methodologies, and procedures in ef19 fect as of June 16, 2009) but for in20 come, who are in families whose in21 come does not exceed 150 percent of 

22 the income official poverty line (as de23 fined by the Office of Management 

24 and Budget, and revised annually in 

25 accordance with section 673(2) of the 
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1 Omnibus Budget Reconciliation Act of 

2 1981) applicable to a family of the 

3 size involved; or 

4 ‘‘(XI) beginning with 2014, who 

5 are under 19 years of age, who are 

6 not described in subclause (X), and 

7 who would be eligible for child health 

8 assistance under a State child health 

9 plan insofar as such plan provides 

10 benefits under this title (as described 

11 in section 2101(a)(2)) based on such 

12 plan as in effect as of June 16, 2009; 

13 or’’. 

14 (2) INCREASED FMAP FOR CERTAIN TRADI15 TIONAL MEDICAID ELIGIBLE INDIVIDUALS.— 

16 (A) INCREASED FMAP FOR ADULTS.—Sec17 tion 1905(y) of such Act (42 U.S.C. 1396d(y)), 

18 as added by subsection (a)(2)(B), is amended 

19 by inserting ‘‘or (IX)’’ after ‘‘(VIII)’’. 

20 (B) ENHANCED FMAP FOR CHILDREN.— 

21 Section 1905(b)(4) of such Act is amended by 

22 inserting ‘‘1902(a)(10)(A)(i)(X), 

23 1902(a)(10)(A)(i)(XI), or’’ after ‘‘on the basis 

24 of section’’. 
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1 (3) CONSTRUCTION.—Nothing in this sub2 section shall be construed as not providing for cov3 erage under subclause (IX), (X), or (XI) of section 

4 1902(a)(10)(A)(i) of the Social Security Act, as 

5 added by paragraph (1), or an increased or en6 hanced FMAP under the amendments made by 

7 paragraph (2), for an individual who has been pro8 vided medical assistance under title XIX of the Act 

9 under a demonstration waiver approved under sec10 tion 1115 of such Act or with State funds. 

11 (4) CONFORMING AMENDMENT.—Section 

12 1903(f)(4) of the Social Security Act (42 U.S.C. 

13 1396b(f)(4)), as amended by subsection (a)(4), is 

14 amended by inserting ‘‘1902(a)(10)(A)(i)(IX), 

15 1902(a)(10)(A)(i)(X), 1902(a)(10)(A)(i)(XI),’’ after 

16 ‘‘1902(a)(10)(A)(i)(VIII),’’. 

17 (c) INCREASED MATCHING RATE FOR TEMPORARY

18 COVERAGE OF CERTAIN NEWBORNS.—Section 1905(y) of 

19 such Act, as added by subsection (a)(3)(B), is amended 

20 by adding at the end the following: 

21 ‘‘(2) Amounts expended for medical assistance 

22 for children described in section 305(d)(1) of the Af23 fordable Health Care for America Act during the 

24 time period specified in such section.’’. 
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1 (d) NETWORK ADEQUACY.—Section 1932(a)(2) of 

2 the Social Security Act (42 U.S.C. 1396u–2(a)(2)) is 

3 amended by adding at the end the following new subpara4 graph: 

5 ‘‘(D) ENROLLMENT OF NON-TRADITIONAL

6 MEDICAID ELIGIBLES.—A State may not re7 quire under paragraph (1) the enrollment in a 

8 managed care entity of an individual described 

9 in section 1902(a)(10)(A)(i)(VIII) unless the 

10 State demonstrates, to the satisfaction of the 

11 Secretary, that the entity, through its provider 

12 network and other arrangements, has the ca13 pacity to meet the health, mental health, and 

14 substance abuse needs of such individuals.’’. 

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

16 this section shall take effect on the first day of Y1, and 

17 shall apply with respect to items and services furnished 

18 on or after such date. 

19 SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CER20 TAIN MEDICAID ELIGIBLE INDIVIDUALS. 

21 (a) IN GENERAL.—Title XIX of the Social Security 

22 Act is amended by adding at the end the following new 

23 section: 
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1 ‘‘REQUIREMENTS AND SPECIAL RULES FOR CERTAIN

2 MEDICAID ELIGIBLE INDIVIDUALS

3 ‘‘SEC. 1943. (a) COORDINATION WITH NHI EX4 CHANGE THROUGH MEMORANDUM OF UNDER5 STANDING.— 

6 ‘‘(1) IN GENERAL.—The State shall enter into 

7 a Medicaid memorandum of understanding described 

8 in section 305(e)(2) of the Affordable Health Care 

9 for America Act with the Health Choices Commis10 sioner, acting in consultation with the Secretary, 

11 with respect to coordinating the implementation of 

12 the provisions of division A of such Act with the 

13 State plan under this title in order to ensure the en14 rollment of Medicaid eligible individuals in accept15 able coverage. Nothing in this section shall be con16 strued as permitting such memorandum to modify or 

17 vitiate any requirement of a State plan under this 

18 title. 

19 ‘‘(2) ENROLLMENT OF EXCHANGE-REFERRED

20 INDIVIDUALS.— 

21 ‘‘(A) NON-TRADITIONAL INDIVIDUALS.— 

22 Pursuant to such memorandum the State shall 

23 accept without further determination the enroll24 ment under this title of an individual deter25 mined by the Commissioner to be a non-tradi-
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1 tional Medicaid eligible individual. The State 

2 shall not do any redeterminations of eligibility 

3 for such individuals unless the periodicity of 

4 such redeterminations is consistent with the pe5 riodicity for redeterminations by the Commis6 sioner of eligibility for affordability credits 

7 under subtitle C of title II of division A of the 

8 Affordable Health Care for America Act, as 

9 specified under such memorandum. 

10 ‘‘(B) TRADITIONAL INDIVIDUALS.—Pursu11 ant to such memorandum, the State shall ac12 cept without further determination the enroll13 ment under this title of an individual deter14 mined by the Commissioner to be a traditional 

15 Medicaid eligible individual. The State may do 

16 redeterminations of eligibility of such individual 

17 consistent with such section and the memo18 randum. 

19 ‘‘(3) DETERMINATIONS OF ELIGIBILITY FOR

20 AFFORDABILITY CREDITS.—If the Commissioner de21 termines that a State Medicaid agency has the ca22 pacity to make determinations of eligibility for af23 fordability credits under subtitle C of title II of divi24 sion A of the Affordable Health Care for America 

25 Act, under such memorandum— 
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•HR 3962 EH

1 ‘‘(A) the State Medicaid agency shall con2 duct such determinations for any Exchange-eli3 gible individual who requests such a determina4 tion; 

5 ‘‘(B) in the case that a State Medicaid 

6 agency determines that an Exchange-eligible in7 dividual is not eligible for affordability credits, 

8 the agency shall forward the information on the 

9 basis of which such determination was made to 

10 the Commissioner; and 

11 ‘‘(C) the Commissioner shall reimburse the 

12 State Medicaid agency for the costs of con13 ducting such determinations. 

14 ‘‘(4) REFERRALS UNDER MEMORANDUM.—Pur15 suant to such memorandum, if an individual applies 

16 to the State for assistance in obtaining health cov17 erage and the State determines that the individual 

18 is not eligible for medical assistance under this title 

19 and is not authorized under such memorandum to 

20 make an determination with respect to eligibility for 

21 coverage and affordability credits through the 

22 Health Insurance Exchange, the State shall refer 

23 the individual to the Commissioner for a determina24 tion of such eligibility and, with the individual’s au25 thorization, provide to the Commissioner information 
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•HR 3962 EH

1 obtained by the State as part of the application 

2 process. 

3 ‘‘(5) ADDITIONAL TERMS.—Such memorandum 

4 shall include such additional provisions as are nec5 essary to implement efficiently the provisions of this 

6 section and title II of division A of the Affordable 

7 Health Care for America Act. 

8 ‘‘(b) TREATMENT OF CERTAIN NEWBORNS.— 

9 ‘‘(1) IN GENERAL.—In the case of a child who 

10 is deemed under section 305(d) of the Affordable 

11 Health Care for America Act to be a Medicaid eligi12 ble individual and enrolled under this title pursuant 

13 to such section, the State shall provide for a deter14 mination, by not later than the end of the period re15 ferred to in paragraph (2) of such section, of the 

16 child’s eligibility for medical assistance under this 

17 title. 

18 ‘‘(2) EXTENDED TREATMENT AS TRADITIONAL

19 MEDICAID ELIGIBLE INDIVIDUAL.—In accordance 

20 with paragraph (2) of section 305(d) of the Afford21 able Health Care for America Act, in the case of a 

22 child described in paragraph (1) of such section who 

23 at the end of the period referred to in such para24 graph is not otherwise covered under acceptable cov25 erage, the child shall be deemed (until such time as 
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•HR 3962 EH

1 the child obtains such coverage or the State other2 wise makes a determination of the child’s eligibility 

3 for medical assistance under its plan under this title 

4 pursuant to paragraph (1)) to be a Medicaid eligible 

5 individual described in section 1902(l)(1)(B). 

6 ‘‘(c) DEFINITIONS.—In this section: 

7 ‘‘(1) MEDICAID ELIGIBLE INDIVIDUAL.—The 

8 term ‘Medicaid eligible individual’ means an indi9 vidual who is eligible for medical assistance under 

10 Medicaid. 

11 ‘‘(2) TRADITIONAL MEDICAID ELIGIBLE INDI12 VIDUAL.—The term ‘traditional Medicaid eligible in13 dividual’ means a Medicaid eligible individual other 

14 than an individual who is— 

15 ‘‘(A) a Medicaid eligible individual by rea16 son of the application of subclause (VIII) of 

17 section 1902(a)(10)(A)(i) of the Social Security 

18 Act; or 

19 ‘‘(B) a childless adult not described in sec20 tion 1902(a)(10)(A) or (C) of such Act (as in 

21 effect as of the day before the date of the en22 actment of this Act). 

23 ‘‘(3) NON-TRADITIONAL MEDICAID ELIGIBLE

24 INDIVIDUAL.—The term ‘non-traditional Medicaid 

25 eligible individual’ means a Medicaid eligible indi-
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•HR 3962 EH

1 vidual who is not a traditional Medicaid eligible indi2 vidual. 

3 ‘‘(4) MEMORANDUM.—The term ‘memorandum’ 

4 means a Medicaid memorandum of understanding 

5 under section 305(e)(2) of the Affordable Health 

6 Care for America Act. 

7 ‘‘(5) Y1.—The term ‘Y1’ has the meaning given 

8 such term in section 100(c) of the Affordable Health 

9 Care for America Act.’’. 

10 (b) CONFORMING AMENDMENTS TO ERROR RATE.— 

11 (1) Section 1903(u)(1)(D) of the Social Secu12 rity Act (42 U.S.C. 1396b(u)(1)(D)) is amended by 

13 adding at the end the following new clause: 

14 ‘‘(vi) In determining the amount of erroneous excess 

15 payments, there shall not be included any erroneous pay16 ments made that are attributable to an error in an eligi17 bility determination under subtitle C of title II of division 

18 A of the Affordable Health Care for America Act.’’. 

19 (2) Section 2105(c)(11) of such Act (42 U.S.C. 

20 1397ee(c)(11)) is amended by adding at the end the 

21 following new sentence: ‘‘Clause (vi) of section 

22 1903(u)(1)(D) shall apply with respect to the appli23 cation of such requirements under this title and title 

24 XIX.’’. 
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1 SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF ELIGI2 BILITY. 

3 (a) CHIP MAINTENANCE OF ELIGIBILITY.—Section 

4 1902 of the Social Security Act (42 U.S.C. 1396a) is 

5 amended— 

6 (1) in subsection (a), as amended by section 

7 1631(b)(1)(D)— 

8 (A) by striking ‘‘and’’ at the end of para9 graph (73); 

10 (B) by striking the period at the end of 

11 paragraph (74) and inserting ‘‘; and’’; and 

12 (C) by inserting after paragraph (74) the 

13 following new paragraph: 

14 ‘‘(75) provide for maintenance of effort under 

15 the State child health plan under title XXI in ac16 cordance with subsection (gg).’’; and 

17 (2) by adding at the end the following new sub18 section: 

19 ‘‘(gg) CHIP MAINTENANCE OF ELIGIBILITY RE20 QUIREMENT.— 

21 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

22 as a condition of its State plan under this title under 

23 subsection (a)(75) and receipt of any Federal finan24 cial assistance under section 1903(a) for calendar 

25 quarters beginning after the date of the enactment 

26 of this subsection and before CHIP MOE termi-
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1 nation date specified in paragraph (3), a State shall 

2 not have in effect eligibility standards, methodolo3 gies, or procedures under its State child health plan 

4 under title XXI (including any waiver under such 

5 title or demonstration project under section 1115) 

6 that are more restrictive than the eligibility stand7 ards, methodologies, or procedures, respectively, 

8 under such plan (or waiver) as in effect on June 16, 

9 2009. 

10 ‘‘(2) LIMITATION.—Paragraph (1) shall not be 

11 construed as preventing a State from imposing a 

12 limitation described in section 2110(b)(5)(C)(i)(II) 

13 for a fiscal year in order to limit expenditures under 

14 its State child health plan under title XXI to those 

15 for which Federal financial participation is available 

16 under section 2105 for the fiscal year. 

17 ‘‘(3) CHIP MOE TERMINATION DATE.—In para18 graph (1), the ‘CHIP MOE termination date’ for a 

19 State is the date that is the last day of Y1 (as de20 fined in section 100(c) of the Affordable Health 

21 Care for America Act). 

22 ‘‘(4) CHIP TRANSITION REPORT.—Not later 

23 than December 31, 2011, the Secretary shall submit 

24 to Congress a report— 
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1 ‘‘(A) that compares the benefits packages 

2 offered under an average State child health 

3 plan under title XXI in 2011 and to the benefit 

4 standards initially adopted under section 224(b) 

5 of the Affordable Health Care for America Act 

6 and for affordability credits under subtitle C of 

7 title II of division C of such Act; and 

8 ‘‘(B) that includes such recommendations 

9 as may be necessary to ensure that— 

10 ‘‘(i) such coverage is at least com11 parable to the coverage provided to chil12 dren under such an average State child 

13 health plan; and 

14 ‘‘(ii) there are procedures in effect for 

15 the enrollment of CHIP enrollees (includ16 ing CHIP-eligible pregnant women) at the 

17 end of Y1 under this title, into a qualified 

18 health benefits plan offered through the 

19 Health Insurance Exchange, or into other 

20 acceptable coverage (as defined for pur21 poses of such Act) without interruption of 

22 coverage or a written plan of treatment.’’. 

23 (b) MEDICAID MAINTENANCE OF EFFORT; SIMPLI24 FYING AND COORDINATING ELIGIBILITY RULES BE25 TWEEN EXCHANGE AND MEDICAID.— 
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1 (1) IN GENERAL.—Section 1903 of such Act 

2 (42 U.S.C. 1396b) is amended by adding at the end 

3 the following new subsection: 

4 ‘‘(aa) MAINTENANCE OF MEDICAID EFFORT; SIMPLI5 FYING AND COORDINATING ELIGIBILITY RULES BE6 TWEEN HEALTH INSURANCE EXCHANGE AND MED7 ICAID.— 

8 ‘‘(1) MAINTENANCE OF EFFORT.— 

9 ‘‘(A) IN GENERAL.—Subject to subpara10 graph (B), a State is not eligible for payment 

11 under subsection (a) for a calendar quarter be12 ginning after the date of the enactment of this 

13 subsection if eligibility standards, methodolo14 gies, or procedures under its plan under this 

15 title (including any waiver under this title or 

16 demonstration project under section 1115) that 

17 are more restrictive than the eligibility stand18 ards, methodologies, or procedures, respectively, 

19 under such plan (or waiver) as in effect on 

20 June 16, 2009. The Secretary shall extend such 

21 a waiver (including the availability of Federal 

22 financial participation under such waiver) for 

23 such period as may be required for a State to 

24 meet the requirement of the previous sentence. 
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•HR 3962 EH

1 ‘‘(B) EXCEPTION FOR CERTAIN DEM2 ONSTRATION PROJECTS.—In the case of a State 

3 demonstration project under section 1115 in ef4 fect on June 16, 2009, that permits individuals 

5 to be eligible solely to receive a premium or 

6 cost-sharing subsidy for individual or group 

7 health insurance coverage, effective for coverage 

8 provided in Y1— 

9 ‘‘(i) the Secretary shall permit the 

10 State to amend such waiver to apply more 

11 restrictive eligibility standards, methodolo12 gies, or procedures with respect to such in13 dividuals under such waiver; and 

14 ‘‘(ii) the application of such more re15 strictive, standards, methodologies, or pro16 cedures under such an amendment shall 

17 not be considered in violation of the re18 quirement of subparagraph (A). 

19 ‘‘(2) REMOVAL OF ASSET TEST FOR CERTAIN

20 ELIGIBILITY CATEGORIES.— 

21 ‘‘(A) IN GENERAL.—A State is not eligible 

22 for payment under subsection (a) for a calendar 

23 quarter beginning on or after the first day of 

24 Y1 (as defined in section 100(c) of the Afford25 able Health Care for America Act), if the State 
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•HR 3962 EH

1 applies any asset or resource test in deter2 mining (or redetermining) eligibility of any indi3 vidual on or after such first day under any of 

4 the following: 

5 ‘‘(i) Subclause (I), (III), (IV), (VI), 

6 (VIII), (IX), (X), or (XI) of section 

7 1902(a)(10)(A)(i). 

8 ‘‘(ii) Subclause (II), (IX), (XIV) or 

9 (XVII) of section 1902(a)(10)(A)(ii). 

10 ‘‘(iii) Section 1931(b). 

11 ‘‘(B) OVERRIDING CONTRARY PROVISIONS; 

12 REFERENCES.—The provisions of this title that 

13 prevent the waiver of an asset or resource test 

14 described in subparagraph (A) are hereby 

15 waived. 

16 ‘‘(C) REFERENCES.—Any reference to a 

17 provision described in a provision in subpara18 graph (A) shall be deemed to be a reference to 

19 such provision as modified through the applica20 tion of subparagraphs (A) and (B).’’. 

21 (2) CONFORMING AMENDMENTS.—(A) Section 

22 1902(a)(10)(A) of such Act (42 U.S.C. 

23 1396a(a)(10)(A)) is amended, in the matter before 

24 clause (i), by inserting ‘‘subject to section 

25 1903(aa)(2),’’ after ‘‘(A)’’. 
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1 (B) Section 1931(b)(1) of such Act (42 U.S.C. 

2 1396u–1(b)(1)) is amended by inserting ‘‘and sec3 tion 1903(aa)(2)’’ after ‘‘and (3)’’. 

4 (c) STANDARDS FOR BENCHMARK PACKAGES.—Sec5 tion 1937(b) of such Act (42 U.S.C. 1396u–7(b)) is 

6 amended— 

7 (1) in each of paragraphs (1) and (2), by in8 serting ‘‘subject to paragraph (5),’’ after ‘‘subsection 

9 (a)(1),’’; and 

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

11 paragraph: 

12 ‘‘(5) MINIMUM STANDARDS.—Effective January 

13 1, 2013, any benchmark benefit package (or bench14 mark equivalent coverage under paragraph (2)) 

15 must meet the minimum benefits and cost-sharing 

16 standards of a basic plan offered through the Health 

17 Insurance Exchange.’’. 

18 (d) REPEAL OF CHIP.—Section 2104(a) of the So19 cial Security Act is amended by inserting at the end the 

20 following: 

21 ‘‘No funds shall be appropriated or authorized to be 

22 appropriated under this section for fiscal year 2014 

23 and subsequent years.’’. 

24 SEC. 1704. REDUCTION IN MEDICAID DSH. 

25 (a) REPORT.— 
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1 (1) IN GENERAL.—Not later than January 1, 

2 2016, the Secretary of Health and Human Services 

3 (in this title referred to as the ‘‘Secretary’’) shall 

4 submit to Congress a report concerning the extent to 

5 which, based upon the impact of the health care re6 forms carried out under division A in reducing the 

7 number of uninsured individuals, there is a contin8 ued role for Medicaid DSH. In preparing the report, 

9 the Secretary shall consult with community-based 

10 health care networks serving low-income bene11 ficiaries. 

12 (2) MATTERS TO BE INCLUDED.—The report 

13 shall include the following: 

14 (A) RECOMMENDATIONS.—Recommenda15 tions regarding— 

16 (i) the appropriate targeting of Med17 icaid DSH within States; and 

18 (ii) the distribution of Medicaid DSH 

19 among the States, taking into account the 

20 ratio of the amount of DSH funds allo21 cated to a State to the number of unin22 sured individuals in such State. 

23 (B) SPECIFICATION OF DSH HEALTH RE24 FORM METHODOLOGY.—The DSH Health Re25 form methodology described in paragraph (2) of 
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•HR 3962 EH

1 subsection (b) for purposes of implementing the 

2 requirements of such subsection. 

3 (3) COORDINATION WITH MEDICARE DSH RE4 PORT.—The Secretary shall coordinate the report 

5 under this subsection with the report on Medicare 

6 DSH under section 1112. 

7 (4) MEDICAID DSH.—In this section, the term 

8 ‘‘Medicaid DSH’’ means adjustments in payments 

9 under section 1923 of the Social Security Act for in10 patient hospital services furnished by dispropor11 tionate share hospitals. 

12 (b) MEDICAID DSH REDUCTIONS.— 

13 (1) REDUCTIONS.— 

14 (A) IN GENERAL.—For each of fiscal years 

15 2017 through 2019 the Secretary shall effect 

16 the following reductions: 

17 (i) REDUCTION DSH ALLOTMENTS.— 

18 The Secretary shall reduce DSH allot19 ments to States in the amount specified 

20 under the DSH health reform methodology 

21 under paragraph (2) for the State for the 

22 fiscal year. 

23 (ii) REDUCTIONS IN PAYMENTS.—The 

24 Secretary shall reduce payments to States 

25 under section 1903(a) of the Social Secu-
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1 rity Act (42 U.S.C. 1396b(a)) for each cal2 endar quarter in the fiscal year, in the 

3 manner specified in subparagraph (C), in 

an amount equal to 1 4 ⁄4 of the DSH allot5 ment reduction under clause (i) for the 

6 State for the fiscal year. 

7 (B) AGGREGATE REDUCTIONS.—The ag8 gregate reductions in DSH allotments for all 

9 States under subparagraph (A)(i) shall be equal 

10 to— 

11 (i) $1,500,000,000 for fiscal year 

12 2017; 

13 (ii) $2,500,000,000 for fiscal year 

14 2018; and 

15 (iii) $6,000,000,000 for fiscal year 

16 2019. 

17 The Secretary shall distribute such aggregate 

18 reduction among States in accordance with 

19 paragraph (2). 

20 (C) MANNER OF PAYMENT REDUCTION.— 

21 The amount of the payment reduction under 

22 subparagraph (A)(ii) for a State for a quarter 

23 shall be deemed an overpayment to the State 

24 under title XIX of the Social Security Act to be 

25 disallowed against the State’s regular quarterly 
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1 draw for all Medicaid spending under section 

2 1903(d)(2) of such Act (42 U.S.C. 

3 1396b(d)(2)). Such a disallowance is not sub4 ject to a reconsideration under 1116(d) of such 

5 Act (42 U.S.C. 1316(d)). 

6 (D) DEFINITIONS.—In this section: 

7 (i) STATE.—The term ‘‘State’’ means 

8 the 50 States and the District of Colum9 bia. 

10 (ii) DSH ALLOTMENT.—The term 

11 ‘‘DSH allotment’’ means, with respect to a 

12 State for a fiscal year, the allotment made 

13 under section 1923(f) of the Social Secu14 rity Act (42 U.S.C. 1396r–4(f)) to the 

15 State for the fiscal year. 

16 (2) DSH HEALTH REFORM METHODOLOGY.— 

17 The Secretary shall carry out paragraph (1) through 

18 use of a DSH Health Reform methodology issued by 

19 the Secretary that imposes the largest percentage re20 ductions on the States that— 

21 (A) have the lowest percentages of unin22 sured individuals (determined on the basis of 

23 audited hospital cost reports) during the most 

24 recent year for which such data are available; 

25 or 
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1 (B) do not target their DSH payments 

2 on— 

3 (i) hospitals with high volumes of 

4 Medicaid inpatients (as defined in section 

5 1923(b)(1)(A) of the Social Security Act 

6 (42 U.S.C. 1396r–4(b)(1)(A)); and 

7 (ii) hospitals that have high levels of 

8 uncompensated care (excluding bad debt). 

9 (3) DSH ALLOTMENT PUBLICATIONS.— 

10 (A) IN GENERAL.—Not later than the pub11 lication deadline specified in subparagraph (B), 

12 the Secretary shall publish in the Federal Reg13 ister a notice specifying the DSH allotment to 

14 each State under 1923(f) of the Social Security 

15 Act for the respective fiscal year specified in 

16 such subparagraph, consistent with the applica17 tion of the DSH Health Reform methodology 

18 described in paragraph (2). 

19 (B) PUBLICATION DEADLINE.—The publi20 cation deadline specified in this subparagraph 

21 is— 

22 (i) January 1, 2016, with respect to 

23 DSH allotments described in subparagraph 

24 (A) for fiscal year 2017; 
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1 (ii) January 1, 2017, with respect to 

2 DSH allotments described in subparagraph 

3 (A) for fiscal year 2018; and 

4 (iii) January 1, 2018, with respect to 

5 DSH allotments described in subparagraph 

6 (A) for fiscal year 2019. 

7 (c) CONFORMING AMENDMENTS.— 

8 (1) Section 1923(f) of the Social Security Act 

9 (42 U.S.C. 1396r–4(f)) is amended— 

10 (A) by redesignating paragraph (7) as 

11 paragraph (8); and 

12 (B) by inserting after paragraph (6) the 

13 following new paragraph: 

14 ‘‘(7) SPECIAL RULE FOR FISCAL YEARS 2017, 

15 2018, AND 2019.—For each of fiscal years 2017, 

16 2018, and 2018, the DSH allotments under this 

17 subsection are subject to reduction under section 

18 1704(b) of the Affordable Health Care for America 

19 Act.’’. 

20 (2) The second sentence of section 1923(b)(4) 

21 of such Act (42 U.S.C. 1396r–4(b)(4)) is amended 

22 by inserting before the period the following: ‘‘or to 

23 affect the authority of the Secretary to issue and im24 plement the DSH Health Reform methodology under 
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1 section 1704(b)(2) of the Affordable Health Care for 

2 America Act’’. 

3 (d) DISPROPORTIONATE SHARE HOSPITALS (DSH) 

4 AND ESSENTIAL ACCESS HOSPITAL (EAH) NON-DIS5 CRIMINATION.— 

6 (1) IN GENERAL.—Section 1923(d) of the So7 cial Security Act (42 U.S.C. 1396r–4) is amended 

8 by adding at the end the following new paragraph: 

9 ‘‘(4) No hospital may be defined or deemed as 

10 a disproportionate share hospital, or as an essential 

11 access hospital (for purposes of subsection 

12 (f)(6)(A)(iv)), under a State plan under this title or 

13 subsection (b) of this section (including any dem14 onstration project under section 1115) unless the 

15 hospital— 

16 ‘‘(A) provides services to beneficiaries 

17 under this title without discrimination on the 

18 ground of race, color, national origin, creed, 

19 source of payment, status as a beneficiary 

20 under this title, or any other ground unrelated 

21 to such beneficiary’s need for the services or the 

22 availability of the needed services in the hos23 pital; and 
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1 ‘‘(B) makes arrangements for, and accepts, 

2 reimbursement under this title for services pro3 vided to eligible beneficiaries under this title.’’. 

4 (2) EFFECTIVE DATE.—The amendment made 

5 by paragraph (1) shall apply to expenditures made 

6 on or after July 1, 2010. 

7 SEC. 1705. EXPANDED OUTSTATIONING. 

8 (a) IN GENERAL.—Section 1902(a)(55) of the Social 

9 Security Act (42 U.S.C. 1396a(a)(55)) is amended by 

10 striking ‘‘under subsection (a)(10)(A)(i)(IV), 

11 (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or 

12 (a)(10)(A)(ii)(IX)’’ and inserting ‘‘(including receipt and 

13 processing of applications of individuals for affordability 

14 credits under subtitle C of title II of division A of the Af15 fordable Health Care for America Act pursuant to a Med16 icaid memorandum of understanding under section 

17 1943(a)(1))’’. 

18 (b) EFFECTIVE DATE.—Except as provided in sec19 tion 1790, the amendment made by subsection (a) shall 

20 apply to services furnished on or after July 1, 2010, with21 out regard to whether or not final regulations to carry out 

22 such amendment have been promulgated by such date. 
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1 Subtitle B—Prevention 

2 SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERV3 ICES. 

4 (a) COVERAGE.—Section 1905 of the Social Security 

5 Act (42 U.S.C. 1396d), as amended by section 

6 1701(a)(3)(B), is amended— 

7 (1) in subsection (a)(4)— 

8 (A) by striking ‘‘and’’ before ‘‘(C)’’; and 

9 (B) by inserting before the semicolon at 

10 the end the following: ‘‘; and (D) preventive 

11 services described in subsection (z)’’; and 

12 (2) by adding at the end the following new sub13 section: 

14 ‘‘(z) PREVENTIVE SERVICES.—The preventive serv15 ices described in this subsection are services not otherwise 

16 described in subsection (a) or (r) that the Secretary deter17 mines are— 

18 ‘‘(1)(A) recommended with a grade of A or B 

19 by the Task Force for Clinical Preventive Services; 

20 or 

21 ‘‘(B) vaccines recommended for use as appro22 priate by the Director of the Centers for Disease 

23 Control and Prevention; and 

24 ‘‘(2) appropriate for individuals entitled to med25 ical assistance under this title.’’. 
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1 (b) ELIMINATION OF COST-SHARING.— 

2 (1) Subsections (a)(2)(D) and (b)(2)(D) of sec3 tion 1916 of such Act (42 U.S.C. 1396o) are each 

4 amended by inserting ‘‘preventive services described 

5 in section 1905(z),’’ after ‘‘emergency services (as 

6 defined by the Secretary),’’. 

7 (2) Section 1916A(a)(1) of such Act (42 U.S.C. 

8 1396o–1 (a)(1)) is amended by inserting ‘‘, preven9 tive services described in section 1905(z),’’ after 

10 ‘‘subsection (c)’’. 

11 (c) CONFORMING AMENDMENT.—Section 1928 of 

12 such Act (42 U.S.C. 1396s) is amended— 

13 (1) in subsection (c)(2)(B)(i), by striking ‘‘the 

14 advisory committee referred to in subsection (e)’’ 

15 and inserting ‘‘the Director of the Centers for Dis16 ease Control and Prevention’’; 

17 (2) in subsection (e), by striking ‘‘Advisory 

18 Committee’’ and all that follows and inserting ‘‘Di19 rector of the Centers for Disease Control and Pre20 vention.’’; and 

21 (3) by striking subsection (g). 

22 (d) EFFECTIVE DATE.—Except as provided in sec23 tion 1790, the amendments made by this section shall 

24 apply to services furnished on or after July 1, 2010, with-
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1 out regard to whether or not final regulations to carry out 

2 such amendments have been promulgated by such date. 

3 SEC. 1712. TOBACCO CESSATION. 

4 (a) DROPPING TOBACCO CESSATION EXCLUSION

5 FROM COVERED OUTPATIENT DRUGS.—Section 

6 1927(d)(2) of the Social Security Act (42 U.S.C. 1396r– 

7 8(d)(2)) is amended— 

8 (1) by striking subparagraph (E); 

9 (2) in subparagraph (G), by inserting before the 

10 period at the end the following: ‘‘, except agents ap11 proved by the Food and Drug Administration for 

12 purposes of promoting, and when used to promote, 

13 tobacco cessation’’; and 

14 (3) by redesignating subparagraphs (F) 

15 through (K) as subparagraphs (E) through (J), re16 spectively. 

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

18 this section shall apply to drugs and services furnished 

19 on or after January 1, 2010. 

20 SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITA21 TION SERVICES. 

22 (a) IN GENERAL.—Section 1905 of the Social Secu23 rity Act (42 U.S.C. 1396d), as amended by sections 

24 1701(a)(3)(B) and 1711(a), is amended— 

25 (1) in subsection (a)— 
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1 (A) in paragraph (27), by striking ‘‘and’’ 

2 at the end; 

3 (B) by redesignating paragraph (28) as 

4 paragraph (29); and 

5 (C) by inserting after paragraph (27) the 

6 following new paragraph: 

7 ‘‘(28) nurse home visitation services (as defined 

8 in subsection (aa)); and’’; and 

9 (2) by adding at the end the following new sub10 section: 

11 ‘‘(aa) The term ‘nurse home visitation services’ 

12 means home visits by trained nurses to families with a 

13 first-time pregnant woman, or a child (under 2 years of 

14 age), who is eligible for medical assistance under this title, 

15 but only, to the extent determined by the Secretary based 

16 upon evidence, that such services are effective in one or 

17 more of the following: 

18 ‘‘(1) Improving maternal or child health and 

19 pregnancy outcomes or increasing birth intervals be20 tween pregnancies. 

21 ‘‘(2) Reducing the incidence of child abuse, ne22 glect, and injury, improving family stability (includ23 ing reduction in the incidence of intimate partner vi24 olence), or reducing maternal and child involvement 

25 in the criminal justice system. 
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1 ‘‘(3) Increasing economic self-sufficiency, em2 ployment advancement, school-readiness, and edu3 cational achievement, or reducing dependence on 

4 public assistance.’’. 

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

6 this section shall apply to services furnished on or after 

7 January 1, 2010. 

8 (c) CONSTRUCTION.—Nothing in the amendments 

9 made by this section shall be construed as affecting the 

10 ability of a State under title XIX or XXI of the Social 

11 Security Act to provide nurse home visitation services as 

12 part of another class of items and services falling within 

13 the definition of medical assistance or child health assist14 ance under the respective title, or as an administrative ex15 penditure for which payment is made under section 

16 1903(a) or 2105(a) of such Act, respectively, on or after 

17 the date of the enactment of this Act. 

18 SEC. 1714. STATE ELIGIBILITY OPTION FOR FAMILY PLAN19 NING SERVICES. 

20 (a) COVERAGE AS OPTIONAL CATEGORICALLY

21 NEEDY GROUP.— 

22 (1) IN GENERAL.—Section 1902(a)(10)(A)(ii) 

23 of the Social Security Act (42 U.S.C. 

24 1396a(a)(10)(A)(ii)) is amended— 
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1 (A) in subclause (XVIII), by striking ‘‘or’’ 

2 at the end; 

3 (B) in subclause (XIX), by adding ‘‘or’’ at 

4 the end; and 

5 (C) by adding at the end the following new 

6 subclause: 

7 ‘‘(XX) who are described in sub8 section (hh) (relating to individuals 

9 who meet certain income standards);’’. 

10 (2) GROUP DESCRIBED.—Section 1902 of such 

11 Act (42 U.S.C. 1396a), as amended by section 1703, 

12 is amended by adding at the end the following new 

13 subsection: 

14 ‘‘(hh)(1) Individuals described in this subsection are 

15 individuals— 

16 ‘‘(A) whose income does not exceed an in17 come eligibility level established by the State 

18 that does not exceed the highest income eligi19 bility level established under the State plan 

20 under this title (or under its State child health 

21 plan under title XXI) for pregnant women; and 

22 ‘‘(B) who are not pregnant. 

23 ‘‘(2) At the option of a State, individuals described 

24 in this subsection may include individuals who, had indi25 viduals applied on or before January 1, 2007, would have 
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1 been made eligible pursuant to the standards and proc2 esses imposed by that State for benefits described in 

3 clause (XV) of the matter following subparagraph (G) of 

4 subsection (a)(10) pursuant to a demonstration project 

5 waiver granted under section 1115. 

6 ‘‘(3) At the option of a State, for purposes of sub7 section (a)(17)(B), in determining eligibility for services 

8 under this subsection, the State may consider only the in9 come of the applicant or recipient.’’. 

10 (3) LIMITATION ON BENEFITS.—Section 

11 1902(a)(10) of such Act (42 U.S.C. 1396a(a)(10)) 

12 is amended in the matter following subparagraph 

13 (G)— 

14 (A) by striking ‘‘and (XIV)’’ and inserting 

15 ‘‘(XIV)’’; and 

16 (B) by inserting ‘‘, and (XV) the medical 

17 assistance made available to an individual de18 scribed in subsection (hh) shall be limited to 

19 family planning services and supplies described 

20 in section 1905(a)(4)(C) including medical di21 agnosis and treatment services that are pro22 vided pursuant to a family planning service in 

23 a family planning setting’’ after ‘‘cervical can24 cer’’. 
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1 (4) CONFORMING AMENDMENTS.—Section 

2 1905(a) of such Act (42 U.S.C. 1396d(a)), as 

3 amended by section 1731(c), is amended in the mat4 ter preceding paragraph (1)— 

5 (A) in clause (xiii), by striking ‘‘or’’ at the 

6 end; 

7 (B) in clause (xiv), by adding ‘‘or’’ at the 

8 end; and 

9 (C) by inserting after clause (xiv) the fol10 lowing: 

11 ‘‘(xv) individuals described in section 

12 1902(hh),’’. 

13 (b) PRESUMPTIVE ELIGIBILITY.— 

14 (1) IN GENERAL.—Title XIX of the Social Se15 curity Act (42 U.S.C. 1396 et seq.) is amended by 

16 inserting after section 1920B the following: 

17 ‘‘PRESUMPTIVE ELIGIBILITY FOR FAMILY PLANNING

18 SERVICES

19 ‘‘SEC. 1920C. (a) STATE OPTION.—State plan ap20 proved under section 1902 may provide for making med21 ical assistance available to an individual described in sec22 tion 1902(hh) (relating to individuals who meet certain 

23 income eligibility standard) during a presumptive eligi24 bility period. In the case of an individual described in sec25 tion 1902(hh), such medical assistance shall be limited to 

26 family planning services and supplies described in 
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1 1905(a)(4)(C) and, at the State’s option, medical diag2 nosis and treatment services that are provided in conjunc3 tion with a family planning service in a family planning 

4 setting. 

5 ‘‘(b) DEFINITIONS.—For purposes of this section: 

6 ‘‘(1) PRESUMPTIVE ELIGIBILITY PERIOD.—The 

7 term ‘presumptive eligibility period’ means, with re8 spect to an individual described in subsection (a), 

9 the period that— 

10 ‘‘(A) begins with the date on which a 

11 qualified entity determines, on the basis of pre12 liminary information, that the individual is de13 scribed in section 1902(hh); and 

14 ‘‘(B) ends with (and includes) the earlier 

15 of— 

16 ‘‘(i) the day on which a determination 

17 is made with respect to the eligibility of 

18 such individual for services under the State 

19 plan; or 

20 ‘‘(ii) in the case of such an individual 

21 who does not file an application by the last 

22 day of the month following the month dur23 ing which the entity makes the determina24 tion referred to in subparagraph (A), such 

25 last day. 
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1 ‘‘(2) QUALIFIED ENTITY.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (B), the term ‘qualified entity’ means 

4 any entity that— 

5 ‘‘(i) is eligible for payments under a 

6 State plan approved under this title; and 

7 ‘‘(ii) is determined by the State agen8 cy to be capable of making determinations 

9 of the type described in paragraph (1)(A). 

10 ‘‘(B) RULE OF CONSTRUCTION.—Nothing 

11 in this paragraph shall be construed as pre12 venting a State from limiting the classes of en13 tities that may become qualified entities in 

14 order to prevent fraud and abuse. 

15 ‘‘(c) ADMINISTRATION.— 

16 ‘‘(1) IN GENERAL.—The State agency shall pro17 vide qualified entities with— 

18 ‘‘(A) such forms as are necessary for an 

19 application to be made by an individual de20 scribed in subsection (a) for medical assistance 

21 under the State plan; and 

22 ‘‘(B) information on how to assist such in23 dividuals in completing and filing such forms. 

24 ‘‘(2) NOTIFICATION REQUIREMENTS.—A quali25 fied entity that determines under subsection 
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1 (b)(1)(A) that an individual described in subsection 

2 (a) is presumptively eligible for medical assistance 

3 under a State plan shall— 

4 ‘‘(A) notify the State agency of the deter5 mination within 5 working days after the date 

6 on which determination is made; and 

7 ‘‘(B) inform such individual at the time 

8 the determination is made that an application 

9 for medical assistance is required to be made by 

10 not later than the last day of the month fol11 lowing the month during which the determina12 tion is made. 

13 ‘‘(3) APPLICATION FOR MEDICAL ASSIST14 ANCE.—In the case of an individual described in 

15 subsection (a) who is determined by a qualified enti16 ty to be presumptively eligible for medical assistance 

17 under a State plan, the individual shall apply for 

18 medical assistance by not later than the last day of 

19 the month following the month during which the de20 termination is made. 

21 ‘‘(d) PAYMENT.—Notwithstanding any other provi22 sion of law, medical assistance that— 

23 ‘‘(1) is furnished to an individual described in 

24 subsection (a)— 
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1 ‘‘(A) during a presumptive eligibility pe2 riod; 

3 ‘‘(B) by a entity that is eligible for pay4 ments under the State plan; and 

5 ‘‘(2) is included in the care and services covered 

6 by the State plan, 

7 shall be treated as medical assistance provided by such 

8 plan for purposes of clause (4) of the first sentence of 

9 section 1905(b).’’. 

10 (2) CONFORMING AMENDMENTS.— 

11 (A) Section 1902(a)(47) of the Social Se12 curity Act (42 U.S.C. 1396a(a)(47)) is amend13 ed by inserting before the semicolon at the end 

14 the following: ‘‘and provide for making medical 

15 assistance available to individuals described in 

16 subsection (a) of section 1920C during a pre17 sumptive eligibility period in accordance with 

18 such section’’. 

19 (B) Section 1903(u)(1)(D)(v) of such Act 

20 (42 U.S.C. 1396b(u)(1)(D)(v)) is amended— 

21 (i) by striking ‘‘or for’’ and inserting 

22 ‘‘for’’; and 

23 (ii) by inserting before the period the 

24 following: ‘‘, or for medical assistance pro25 vided to an individual described in sub-
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1 section (a) of section 1920C during a pre2 sumptive eligibility period under such sec3 tion’’. 

4 (c) CLARIFICATION OF COVERAGE OF FAMILY PLAN5 NING SERVICES AND SUPPLIES.—Section 1937(b) of the 

6 Social Security Act (42 U.S.C. 1396u–7(b)), as amended 

7 by section 1703(c)(2), is amended by adding at the end 

8 the following: 

9 ‘‘(6) COVERAGE OF FAMILY PLANNING SERV10 ICES AND SUPPLIES.—Notwithstanding the previous 

11 provisions of this section, a State may not provide 

12 for medical assistance through enrollment of an indi13 vidual with benchmark coverage or benchmark-equiv14 alent coverage under this section unless such cov15 erage includes for any individual described in section 

16 1905(a)(4)(C), medical assistance for family plan17 ning services and supplies in accordance with such 

18 section.’’. 

19 (d) EFFECTIVE DATE.—The amendments made by 

20 this section take effect on the date of the enactment of 

21 this Act and shall apply to items and services furnished 

22 on or after such date. 

23 Subtitle C—Access 

24 SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS. 

25 (a) IN GENERAL.— 
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1 (1) FEE-FOR-SERVICE PAYMENTS.—Section 

2 1902 of the Social Security Act (42 U.S.C. 1396b)as 

3 amended by sections 1703(a), 1714(a), 1731(a), and 

4 1746, is amended— 

5 (A) in subsection (a)(13)— 

6 (i) by striking ‘‘and’’ at the end of 

7 subparagraph (A); 

8 (ii) by adding ‘‘and’’ at the end of 

9 subparagraph (B); and 

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

12 ‘‘(C) payment for primary care services (as 

13 defined in subsection (kk)(1)) furnished by phy14 sicians (or for services furnished by other 

15 health care professionals that would be primary 

16 care services under such section if furnished by 

17 a physician) at a rate not less than 80 percent 

18 of the payment rate that would be applicable if 

19 the adjustment described in subsection (kk)(2) 

20 were to apply to such services and physicians or 

21 professionals (as the case may be) under part 

22 B of title XVIII for services furnished in 2010, 

23 90 percent of such adjusted payment rate for 

24 services and physicians (or professionals) fur25 nished in 2011, or 100 percent of such adjusted 
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1 payment rate for services and physicians (or 

2 professionals) furnished in 2012 and each sub3 sequent year;’’; and 

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

5 subsection: 

6 ‘‘(kk) INCREASED PAYMENT FOR PRIMARY CARE

7 SERVICES.—For purposes of subsection (a)(13)(C): 

8 ‘‘(1) PRIMARY CARE SERVICES DEFINED.—The 

9 term ‘primary care services’ means evaluation and 

10 management services, without regard to the specialty 

11 of the physician furnishing the services, that are 

12 procedure codes (for services covered under title 

13 XVIII) for services in the category designated Eval14 uation and Management in the Health Care Com15 mon Procedure Coding System (established by the 

16 Secretary under section 1848(c)(5) as of December 

17 31, 2009, and as subsequently modified by the Sec18 retary). 

19 ‘‘(2) ADJUSTMENT.—The adjustment described 

20 in this paragraph is the substitution of 1.25 percent 

21 for the update otherwise provided under section 

22 1848(d)(4) for each year beginning with 2010.’’. 

23 (2) UNDER MEDICAID MANAGED CARE

24 PLANS.—Section 1932(f) of such Act (42 U.S.C. 

25 1396u–2(f)) is amended— 
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1 (A) in the heading, by adding at the end 

2 the following: ‘‘; ADEQUACY OF PAYMENT FOR

3 PRIMARY CARE SERVICES’’; and 

4 (B) by inserting before the period at the 

5 end the following: ‘‘and, in the case of primary 

6 care services described in section 

7 1902(a)(13)(C), consistent with the minimum 

8 payment rates specified in such section (regard9 less of the manner in which such payments are 

10 made, including in the form of capitation or 

11 partial capitation)’’. 

12 (b) INCREASE IN PAYMENT USING INCREASED

13 FMAP.—Section 1905(y) of the Social Security Act, as 

14 added by section 1701(a)(3)(B) and as amended by sec15 tion 1701(c)(2), is amended by adding at the end the fol16 lowing: 

17 ‘‘(3)(A) The portion of the amounts expended 

18 for medical assistance for services described in sec19 tion 1902(a)(13)(C) furnished on or after January 

20 1, 2010, that is attributable to the amount by which 

21 the minimum payment rate required under such sec22 tion (or, by application, section 1932(f)) exceeds the 

23 payment rate applicable to such services under the 

24 State plan as of June 16, 2009. 
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1 ‘‘(B) Subparagraph (A) shall not be construed 

2 as preventing the payment of Federal financial par3 ticipation based on the Federal medical assistance 

4 percentage for amounts in excess of those specified 

5 under such subparagraph.’’. 

6 (c) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to services furnished on or after 

8 January 1, 2010. 

9 SEC. 1722. MEDICAL HOME PILOT PROGRAM. 

10 (a) IN GENERAL.—The Secretary of Health and 

11 Human Services shall establish under this section a med12 ical home pilot program under which a State may apply 

13 to the Secretary for approval of a medical home pilot 

14 project described in subsection (b) (in this section referred 

15 to as a ‘‘pilot project’’) for the application of the medical 

16 home concept under title XIX of the Social Security Act. 

17 The pilot program shall operate for a period of up to 5 

18 years. 

19 (b) PILOT PROJECT DESCRIBED.— 

20 (1) IN GENERAL.—A pilot project is a project 

21 that applies one or more of the medical home models 

22 described in section 1866F(a)(3) of the Social Secu23 rity Act (as inserted by section 1302(a)) or such 

24 other model as the Secretary may approve, to indi25 viduals (including medically fragile children and 
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1 high-risk pregnant women) who are eligible for med2 ical assistance under title XIX of the Social Security 

3 Act. The Secretary shall provide for appropriate co4 ordination of the pilot program under this section 

5 with the medical home pilot program under section 

6 1866F of such Act. 

7 (2) LIMITATION.—A pilot project shall be for a 

8 duration of not more than 5 years. 

9 (3) CONSIDERATION FOR CERTAIN TECH10 NOLOGIES.—In considering applications for pilots 

11 projects under this section, the Secretary may ap12 prove a project which tests the effectiveness of appli13 cations and devices, such as wireless patient man14 agement technologies, that are approved by the Food 

15 and Drug Administration and enable providers and 

16 practitioners to communicate directly with their pa17 tients in managing chronic illness. 

18 (c) ADDITIONAL INCENTIVES.—In the case of a pilot 

19 project, the Secretary may— 

20 (1) waive the requirements of section 

21 1902(a)(1) of the Social Security Act (relating to 

22 statewideness) and section 1902(a)(10)(B) of such 

23 Act (relating to comparability); and 

24 (2) increase to up to 90 percent (for the first 

25 2 years of the pilot program) or 75 percent (for the 
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1 next 3 years) the matching percentage for adminis2 trative expenditures (such as those for community 

3 care workers). 

4 (d) MEDICALLY FRAGILE CHILDREN.—In the case of 

5 a model involving medically fragile children, the model 

6 shall ensure that the patient-centered medical home serv7 ices received by each child, in addition to fulfilling the re8 quirements under 1866F(b)(1) of the Social Security Act, 

9 provide for continuous involvement and education of the 

10 parent or caregiver and for assistance to the child in ob11 taining necessary transitional care if a child’s enrollment 

12 ceases for any reason. 

13 (e) EVALUATION; REPORT.— 

14 (1) EVALUATION.—The Secretary, using the 

15 criteria described in section 1866F(e)(1) of the So16 cial Security Act (as inserted by section 1123), shall 

17 conduct an evaluation of the pilot program under 

18 this section. 

19 (2) REPORT.—Not later than 60 days after the 

20 date of completion of the evaluation under para21 graph (1), the Secretary shall submit to Congress 

22 and make available to the public a report on the 

23 findings of the evaluation under such paragraph. 

24 (f) FUNDING.—The additional Federal financial par25 ticipation resulting from the implementation of the pilot 
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1 program under this section may not exceed in the aggre2 gate $1,235,000,000 over the 5-year period of the pro3 gram. 

4 SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES. 

5 (a) IN GENERAL.—Section 1903(a)(2)(E) of the So6 cial Security Act (42 U.S.C. 1396b(a)(2)), as added by 

7 section 201(b)(2)(A) of the Children’s Health Insurance 

8 Program Reauthorization Act of 2009 (Public Law 111– 

9 3), is amended by inserting ‘‘and other individuals’’ after 

10 ‘‘children of families’’. 

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

12 subsection (a) shall apply to payment for translation or 

13 interpretation services furnished on or after January 1, 

14 2010. 

15 SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING 

16 BIRTH CENTER SERVICES. 

17 (a) IN GENERAL.—Section 1905 of the Social Secu18 rity Act (42 U.S.C. 1396d), as amended by section 

19 1713(a), is amended— 

20 (1) in subsection (a)— 

21 (A) by redesignating paragraph (29) as 

22 paragraph (30); 

23 (B) in paragraph (28), by striking at the 

24 end ‘‘and’’; and 
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1 (C) by inserting after paragraph (28) the 

2 following new paragraph: 

3 ‘‘(29) freestanding birth center services (as de4 fined in subsection (l)(3)(A)) and other ambulatory 

5 services that are offered by a freestanding birth cen6 ter (as defined in subsection (l)(3)(B)) and that are 

7 otherwise included in the plan; and’’; and 

8 (2) in subsection (l), by adding at the end the 

9 following new paragraph: 

10 ‘‘(3)(A) The term ‘freestanding birth center services’ 

11 means services furnished to an individual at a freestanding 

12 birth center (as defined in subparagraph (B)), including 

13 by a licensed birth attendant (as defined in subparagraph 

14 (C)) at such center. 

15 ‘‘(B) The term ‘freestanding birth center’ means a 

16 health facility— 

17 ‘‘(i) that is not a hospital; and 

18 ‘‘(ii) where childbirth is planned to occur away 

19 from the pregnant woman’s residence. 

20 ‘‘(C) The term ‘licensed birth attendant’ means an 

21 individual who is licensed or registered by the State in22 volved to provide health care at childbirth and who pro23 vides such care within the scope of practice under which 

24 the individual is legally authorized to perform such care 

25 under State law (or the State regulatory mechanism pro-
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1 vided by State law), regardless of whether the individual 

2 is under the supervision of, or associated with, a physician 

3 or other health care provider. Nothing in this subpara4 graph shall be construed as changing State law require5 ments applicable to a licensed birth attendant.’’. 

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

7 this section shall apply to items and services furnished on 

8 or after the date of the enactment of this Act. 

9 SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER 

10 THE VACCINES FOR CHILDREN PROGRAM. 

11 Section 1928(b)(2)(A)(iii)(I) of the Social Security 

12 Act (42 U.S.C. 1396s(b)(2)(A)(iii)(I)) is amended— 

13 (1) by striking ‘‘or a rural health clinic’’ and in14 serting ‘‘, a rural health clinic’’; and 

15 (2) by inserting ‘‘or a public health clinic,’’ 

16 after ‘‘1905(l)(1)),’’. 

17 SEC. 1726. REQUIRING COVERAGE OF SERVICES OF PODIA18 TRISTS. 

19 (a) IN GENERAL.—Section 1905(a)(5)(A) of the So20 cial Security Act (42 U.S.C. 1396d(a)(5)(A)) is amended 

21 by striking ‘‘section 1861(r)(1)’’ and inserting ‘‘para22 graphs (1) and (3) of section 1861(r)’’. 

23 (b) EFFECTIVE DATE.—Except as provided in sec24 tion 1790, the amendment made by subsection (a) shall 

25 apply to services furnished on or after January 1, 2010. 
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1 SEC. 1726A. REQUIRING COVERAGE OF SERVICES OF OP2 TOMETRISTS. 

3 (a) IN GENERAL.—Section 1905(a)(5) of the Social 

4 Security Act (42 U.S.C. 1396d(a)(5)) is amended— 

5 (1) by striking ‘‘and’’ before ‘‘(B)’’; and 

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

7 the following: ‘‘, and (C) medical and other health 

8 services (as defined in section 1861(s)) as authorized 

9 by State law, furnished by an optometrist (described 

10 in section 1861(r)(4)) to the extent such services 

11 may be performed under State law’’. 

12 (b) EFFECTIVE DATE.—Except as provided in sec13 tion 1790, the amendments made by subsection (a) shall 

14 take effect 90 days after the date of the enactment of this 

15 Act and shall apply to services furnished or other actions 

16 required on or after such date. 

17 SEC. 1727. THERAPEUTIC FOSTER CARE. 

18 (a) RULE OF CONSTRUCTION.—Nothing in this title 

19 shall prevent or limit a State from covering therapeutic 

20 foster care for eligible children in out-of-home placements 

21 under section 1905(a) of the Social Security Act (42 

22 U.S.C. 1396d(a)). 

23 (b) THERAPEUTIC FOSTER CARE DEFINED.—For 

24 purposes of this section, the term ‘‘therapeutic foster 

25 care’’ means a foster care program that provides— 

26 (1) to the child— 
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1 (A) structured daily activities that develop, 

2 improve, monitor, and reinforce age-appropriate 

3 social, communications, and behavioral skills; 

4 (B) crisis intervention and crisis support 

5 services; 

6 (C) medication monitoring; 

7 (D) counseling; and 

8 (E) case management services; and 

9 (2) specialized training for the foster parent 

10 and consultation with the foster parent on the man11 agement of children with mental illnesses and re12 lated health and developmental conditions. 

13 SEC. 1728. ASSURING ADEQUATE PAYMENT LEVELS FOR 

14 SERVICES. 

15 (a) IN GENERAL.—Title XIX of the Social Security 

16 Act is amended by inserting after section 1925 the fol17 lowing new section: 

18 ‘‘ASSURING ADEQUATE PAYMENT LEVELS FOR SERVICES

19 ‘‘SEC. 1926. (a) IN GENERAL.—A State plan under 

20 this title shall not be considered to meet the requirement 

21 of section 1902(a)(30)(A) for a year (beginning with 

22 2011) unless, by not later than April 1 before the begin23 ning of such year, the State submits to the Secretary an 

24 amendment to the plan that specifies the payment rates 

25 to be used for such services under the plan in such year 

26 and includes in such submission such additional data as 
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1 will assist the Secretary in evaluating the State’s compli2 ance with such requirement, including data relating to how 

3 rates established for payments to medicaid managed care 

4 organizations under sections 1903(m) and 1932 take into 

5 account such payment rates. 

6 ‘‘(b) SECRETARIAL REVIEW.—The Secretary, by not 

7 later than 90 days after the date of submission of a plan 

8 amendment under subsection (a), shall— 

9 ‘‘(1) review each such amendment for compli10 ance with the requirement of section 

11 1902(a)(30)(A); and 

12 ‘‘(2) approve or disapprove each such amend13 ment. 

14 If the Secretary disapproves such an amendment, the 

15 State shall immediately submit a revised amendment that 

16 meets such requirement.’’. 

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

18 subsection (a) shall take effect on the date of the enact19 ment of this Act. 

20 SEC. 1729. PRESERVING MEDICAID COVERAGE FOR 

21 YOUTHS UPON RELEASE FROM PUBLIC INSTI22 TUTIONS. 

23 Section 1902(a) of the Social Security Act (42 U.S.C. 

24 1396a), as amended by section 1631(b) and 1703(a), is 

25 amended— 
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1 (1) by striking ‘‘and’’ at the end of paragraph 

2 (74); 

3 (2) by striking the period at the end of para4 graph (75) and inserting ‘‘; and’’; and 

5 (3) by inserting after paragraph (75) the fol6 lowing new paragraph: 

7 ‘‘(76) provide that in the case of any youth who 

8 is 18 years of age or younger, was enrolled for med9 ical assistance under the State plan immediately be10 fore becoming an inmate of a public institution, is 

11 18 years of age or younger upon release from such 

12 institution, and is eligible for such medical assist13 ance under the State plan at the time of release 

14 from such institution— 

15 ‘‘(A) during the period such youth is incar16 cerated in a public institution, the State shall 

17 not terminate eligibility for medical assistance 

18 under the State plan for such youth; 

19 ‘‘(B) during the period such youth is incar20 cerated in a public institution, the State shall 

21 establish a process that ensures— 

22 ‘‘(i) that the State does not claim 

23 Federal financial participation for services 

24 that are provided to such youth and that 
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1 are excluded under subsection 

2 1905(a)(28)(A); and 

3 ‘‘(ii) that the youth receives medical 

4 assistance for which Federal participation 

5 is available under this title; 

6 ‘‘(C) on or before the date such youth is 

7 released from such institution, the State shall 

8 ensure that such youth is enrolled for medical 

9 assistance under this title, unless and until 

10 there is a determination that the individual is 

11 no longer eligible to be so enrolled; and 

12 ‘‘(D) the State shall ensure that enroll13 ment under subparagraph (C) will be completed 

14 before such date so that the youth can access 

15 medical assistance under this title immediately 

16 upon leaving the institution.’’. 

17 SEC. 1730. QUALITY MEASURES FOR MATERNITY AND 

18 ADULT HEALTH SERVICES UNDER MEDICAID 

19 AND CHIP. 

20 Title XI of the Social Security Act (42 U.S.C. 1301 

21 et seq.) is amended by inserting after section 1139A the 

22 following new section: 
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1 ‘‘SEC. 1139B. QUALITY MEASURES FOR MATERNITY AND 

2 ADULT HEALTH SERVICES UNDER MEDICAID 

3 AND CHIP. 

4 ‘‘(a) MATERNITY CARE QUALITY MEASURES UNDER

5 MEDICAID AND CHIP.— 

6 ‘‘(1) DEVELOPMENT OF MEASURES.—No later 

7 than January 1, 2011, the Secretary shall develop 

8 and publish for comment a proposed set of measures 

9 that accurately describe the quality of maternity 

10 care provided under State plans under titles XIX 

11 and XXI. The Secretary shall publish a final rec12 ommended set of such measures no later than July 

13 1, 2011. 

14 ‘‘(2) STANDARDIZED REPORTING FORMAT.—No 

15 later than January 1, 2012, the Secretary shall de16 velop and publish a standardized reporting format 

17 for maternity care quality measures for use by State 

18 programs under titles XIX and XXI to collect data 

19 from managed care entities and providers and prac20 titioners that participate in such programs and to 

21 report maternity care quality measures to the Sec22 retary. 

23 ‘‘(b) OTHER ADULT HEALTH QUALITY MEASURES

24 UNDER MEDICAID.— 

25 ‘‘(1) DEVELOPMENT OF MEASURES.—The Sec26 retary shall develop quality measures that are not 
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1 otherwise developed under section 1192 for services 

2 received under State plans under title XIX by indi3 viduals who are 21 years of age or older but have 

4 not attained age 65. The Secretary shall publish 

5 such quality measures through notice and comment 

6 rulemaking. 

7 ‘‘(2) STANDARDIZED REPORTING FORMAT.— 

8 The Secretary shall develop and publish a standard9 ized reporting format for quality measures developed 

10 under paragraph (1) and section 1192 for services 

11 furnished under State plans under title XIX to indi12 viduals who are 21 years of age or older but have 

13 not attained age 65 for use under such plans and 

14 State plans under title XXI. The format shall enable 

15 State agencies administering such plans to collect 

16 data from managed care entities and providers and 

17 practitioners that participate in such plans and to 

18 report quality measures to the Secretary. 

19 ‘‘(c) DEVELOPMENT PROCESS.—With respect to the 

20 development of quality measures under subsections (a) 

21 and (b)— 

22 ‘‘(1) USE OF QUALIFIED ENTITIES.—The Sec23 retary may enter into agreements with public, non24 profit, or academic institutions with technical exper25 tise in the area of health quality measurement to as-
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1 sist in such development. The Secretary may carry 

2 out these agreements by contract, grant, or other3 wise. 

4 ‘‘(2) MULTI-STAKEHOLDER PRE-RULEMAKING

5 INPUT.—The Secretary shall obtain the input of 

6 stakeholders with respect to such quality measures 

7 using a process similar to that described in section 

8 1808(d). 

9 ‘‘(3) COORDINATION.—The Secretary shall co10 ordinate the development of such measures under 

11 such subsections and with the development of child 

12 health quality measures under section 1139A. 

13 ‘‘(d) ANNUAL REPORT TO CONGRESS.—No later than 

14 January 1, 2013, and annually thereafter, the Secretary 

15 shall report to the Committee on Energy and Commerce 

16 of the House of Representatives the Committee on Fi17 nance of the Senate regarding— 

18 ‘‘(1) the availability of reliable data relating to 

19 the quality of maternity care furnished under State 

20 plans under titles XIX and XXI; 

21 ‘‘(2) the availability of reliable data relating to 

22 the quality of services furnished under State plans 

23 under title XIX to adults who are 21 years of age 

24 or older but have not attained age 65; and 
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1 ‘‘(3) recommendations for improving the quality 

2 of such care and services furnished under such State 

3 plans. 

4 ‘‘(e) RULE OF CONSTRUCTION.—Notwithstanding 

5 any other provision in this section, no quality measure de6 veloped, published, or used as a basis of measurement or 

7 reporting under this section may be used to establish an 

8 irrebuttable presumption regarding either the medical ne9 cessity of care or the maximum permissible coverage for 

10 any individual who receives medical assistance under title 

11 XIX or child health assistance under title XXI. 

12 ‘‘(f) APPROPRIATION.—For purposes of carrying out 

13 this section, in addition to funds otherwise available, out 

14 of any funds in the Treasury not otherwise appropriated, 

15 there are appropriated $40,000,000 for the 5-fiscal-year 

16 period beginning with fiscal year 2010. Funds appro17 priated under this subsection shall remain available until 

18 expended.’’. 

19 SEC. 1730A. ACCOUNTABLE CARE ORGANIZATION PILOT 

20 PROGRAM. 

21 (a) IN GENERAL.—The Secretary of Health and 

22 Human Services shall establish under this section an ac23 countable care program under which a State may apply 

24 to the Secretary for approval of an accountable care orga25 nization pilot program described in subsection (b) (in this 
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1 section referred to as a ‘‘pilot program’’) for the applica2 tion of the accountable care organization concept under 

3 title XIX of the Social Security Act. 

4 (b) PILOT PROGRAM DESCRIBED.— 

5 (1) IN GENERAL.—The pilot program described 

6 in this subsection is a program that applies one or 

7 more of the accountable care organization models 

8 described in section 1866E of the Social Security 

9 Act, as added by section 1301 of this Act. 

10 (2) LIMITATION.—The pilot program shall op11 erate for a period of not more than 5 years. 

12 (c) ADDITIONAL INCENTIVES.—In the case of the 

13 pilot program under this section, the Secretary may— 

14 (1) waive the requirements of— 

15 (A) section 1902(a)(1) of the Social Secu16 rity Act (relating to statewideness); 

17 (B) section 1902(a)(10)(B) of such Act 

18 (relating to comparability); and 

19 (2) increase the matching percentage for ad20 ministrative expenditures up to— 

21 (A) 90 percent (for the first 2 years of the 

22 pilot program); and 

23 (B) 75 percent (for the next 3 years). 

24 (d) EVALUATION; REPORT.— 
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1 (1) EVALUATION.—The Secretary shall conduct 

2 an evaluation of the pilot program under this sec3 tion. In conducting such evaluation, the Secretary 

4 shall use the criteria used under subsection (g)(1) of 

5 section 1866E of the Social Security Act (as in6 serted by section 1301 of this Act) to evaluate pilot 

7 programs under such section. 

8 (2) REPORT.—Not later than 60 days after the 

9 date of completion of the evaluation under para10 graph (1), the Secretary shall submit to Congress 

11 and make available to the public a report on the 

12 findings of the evaluation under such paragraph. 

13 SEC. 1730B. FQHC COVERAGE. 

14 Section 1905(l)(2)(B) of the Social Security Act (42 

15 U.S.C. 1396d(l)(2)(B)) is amended— 

16 (1) by striking ‘‘or’’ at the end of clause (iii); 

17 (2) by striking the semicolon at the end of 

18 clause (iv) and inserting ‘‘, and’’; and 

19 (3) by inserting after clause (iv) the following 

20 new clause: 

21 ‘‘(v) is receiving a grant under section 399Z–1 

22 of the Public Health Service Act;’’. 
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1 Subtitle D—Coverage 

2 SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-IN3 COME HIV-INFECTED INDIVIDUALS. 

4 (a) IN GENERAL.— Section 1902 of the Social Secu5 rity Act (42 U.S.C. 1396a), as amended by section 

6 1714(a)(1), is amended— 

7 (1) in subsection (a)(10)(A)(ii)— 

8 (A) by striking ‘‘or’’ at the end of sub9 clause (XIX); 

10 (B) by adding ‘‘or’’ at the end of subclause 

11 (XX); and 

12 (C) by adding at the end the following: 

13 ‘‘(XXI) who are described in sub14 section (ii) (relating to HIV-infected 

15 individuals);’’; and 

16 (2) by adding at the end, as amended by sec17 tions 1703 and 1714(a), the following: 

18 ‘‘(ii) Individuals described in this subsection are indi19 viduals not described in subsection (a)(10)(A)(i)— 

20 ‘‘(1) who have HIV infection; 

21 ‘‘(2) whose income (as determined under the 

22 State plan under this title with respect to disabled 

23 individuals) does not exceed the maximum amount 

24 of income a disabled individual described in sub-
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1 section (a)(10)(A)(i) may have and obtain medical 

2 assistance under the plan; and 

3 ‘‘(3) whose resources (as determined under the 

4 State plan under this title with respect to disabled 

5 individuals) do not exceed the maximum amount of 

6 resources a disabled individual described in sub7 section (a)(10)(A)(i) may have and obtain medical 

8 assistance under the plan.’’. 

9 (b) ENHANCED MATCH.—The first sentence of sec10 tion 1905(b) of such Act (42 U.S.C. 1396d(b)) is amended 

11 by striking ‘‘section 1902(a)(10)(A)(ii)(XVIII)’’ and in12 serting ‘‘subclause (XVIII) or (XXI) of section 

13 1902(a)(10)(A)(ii)’’. 

14 (c) CONFORMING AMENDMENTS.—Section 1905(a) of 

15 such Act (42 U.S.C. 1396d(a)) is amended, in the matter 

16 preceding paragraph (1)— 

17 (1) by striking ‘‘or’’ at the end of clause (xii); 

18 (2) by adding ‘‘or’’ at the end of clause (xiii); 

19 and 

20 (3) by inserting after clause (xiii) the following: 

21 ‘‘(xiv) individuals described in section 

22 1902(ii),’’. 

23 (d) EXEMPTION FROM FUNDING LIMITATION FOR

24 TERRITORIES.—Section 1108(g) of the Social Security 
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1 Act (42 U.S.C. 1308(g)) is amended by adding at the end 

2 the following: 

3 ‘‘(5) DISREGARDING MEDICAL ASSISTANCE FOR

4 OPTIONAL LOW-INCOME HIV-INFECTED INDIVID5 UALS.—The limitations under subsection (f) and the 

6 previous provisions of this subsection shall not apply 

7 to amounts expended for medical assistance for indi8 viduals described in section 1902(ii) who are only el9 igible for such assistance on the basis of section 

10 1902(a)(10)(A)(ii)(XXI).’’. 

11 (e) EFFECTIVE DATE; SUNSET.—The amendments 

12 made by this section shall apply to expenditures for cal13 endar quarters beginning on or after the date of the enact14 ment of this Act, and before January 1, 2013, without 

15 regard to whether or not final regulations to carry out 

16 such amendments have been promulgated by such date. 

17 SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSIST18 ANCE (TMA). 

19 Sections 1902(e)(1)(B) and 1925(f) of the Social Se20 curity Act (42 U.S.C. 1396a(e)(1)(B), 1396r–6(f)), as 

21 amended by section 5004(a)(1) of the American Recovery 

22 and Reinvestment Act of 2009 (Public Law 111–5), are 

23 each amended by striking ‘‘December 31, 2010’’ and in24 serting ‘‘December 31, 2012’’. 
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1 SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COV2 ERAGE UNDER CERTAIN CHIP PROGRAMS. 

3 (a) IN GENERAL.—Section 2102(b) of the Social Se4 curity Act (42 U.S.C. 1397bb(b)) is amended by adding 

5 at the end the following new paragraph: 

6 ‘‘(6) REQUIREMENT FOR 12-MONTH CONTIN7 UOUS ELIGIBILITY.—In the case of a State child 

8 health plan that provides child health assistance 

9 under this title through a means other than de10 scribed in section 2101(a)(2), the plan shall provide 

11 for implementation under this title of the 12-month 

12 continuous eligibility option described in section 

13 1902(e)(12) for targeted low-income children whose 

14 family income is below 200 percent of the poverty 

15 line.’’. 

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

17 subsection (a) shall apply to determinations (and redeter18 minations) of eligibility made on or after January 1, 2010. 

19 SEC. 1734. PREVENTING THE APPLICATION UNDER CHIP OF 

20 COVERAGE WAITING PERIODS FOR CERTAIN 

21 CHILDREN. 

22 (a) IN GENERAL.—Section 2102(b)(1) of the Social 

23 Security Act (42 U.S.C. 1397bb(b)(1)) is amended— 

24 (1) in subparagraph (B)— 

25 (A) in clause (iii), by striking ‘‘and’’ at the 

26 end; 
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1 (B) in clause (iv), by striking the period at 

2 the end and inserting ‘‘; and’’; and 

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

4 clause: 

5 ‘‘(v) may not apply a waiting period 

6 (including a waiting period to carry out 

7 paragraph (3)(C)) in the case of a child 

8 described in subparagraph (C).’’; and 

9 (2) by adding at the end the following new sub10 paragraph: 

11 ‘‘(C) DESCRIPTION OF CHILDREN NOT

12 SUBJECT TO WAITING PERIOD.—For purposes 

13 of this paragraph, a child described in this sub14 paragraph is a child who, on the date an appli15 cation is submitted for such child for child 

16 health assistance under this title, meets any of 

17 the following requirements: 

18 ‘‘(i) INFANTS AND TODDLERS.—The 

19 child is under two years of age. 

20 ‘‘(ii) LOSS OF GROUP HEALTH PLAN

21 COVERAGE.—The child previously had pri22 vate health insurance coverage through a 

23 group health plan or health insurance cov24 erage offered through an employer and lost 

25 such coverage due to— 
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1 ‘‘(I) termination of an individ2 ual’s employment; 

3 ‘‘(II) a reduction in hours that 

4 an individual works for an employer; 

5 ‘‘(III) elimination of an individ6 ual’s retiree health benefits; or 

7 ‘‘(IV) termination of an individ8 ual’s group health plan or health in9 surance coverage offered through an 

10 employer. 

11 ‘‘(iii) UNAFFORDABLE PRIVATE COV12 ERAGE.— 

13 ‘‘(I) IN GENERAL.—The family of 

14 the child demonstrates that the cost 

15 of health insurance coverage (includ16 ing the cost of premiums, co-pay17 ments, deductibles, and other cost 

18 sharing) for such family exceeds 10 

19 percent of the income of such family. 

20 ‘‘(II) DETERMINATION OF FAM21 ILY INCOME.—For purposes of sub22 clause (I), family income shall be de23 termined in the same manner speci24 fied by the State for purposes of de-
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1 termining a child’s eligibility for child 

2 health assistance under this title.’’. 

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

4 this section shall take effect as of the date that is 90 days 

5 after the date of the enactment of this Act. 

6 SEC. 1735. ADULT DAY HEALTH CARE SERVICES. 

7 (a) IN GENERAL.—The Secretary of Health and 

8 Human Services shall not— 

9 (1) withhold, suspend, disallow, or otherwise 

10 deny Federal financial participation under section 

11 1903(a) of the Social Security Act (42 U.S.C. 

12 1396b(a)) for the provision of adult day health care 

13 services, day activity and health services, or adult 

14 medical day care services, as defined under a State 

15 Medicaid plan approved during or before 1994, dur16 ing such period if such services are provided con17 sistent with such definition and the requirements of 

18 such plan; or 

19 (2) withdraw Federal approval of any such 

20 State plan or part thereof regarding the provision of 

21 such services (by regulation or otherwise). 

22 (b) EFFECTIVE DATE.—Subsection (a) shall apply 

23 with respect to services provided on or after October 1, 

24 2008. 
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1 SEC. 1736. MEDICAID COVERAGE FOR CITIZENS OF FREELY 

2 ASSOCIATED STATES. 

3 (a) IN GENERAL.—Section 402(b)(2) of the Personal 

4 Responsibility and Work Opportunity Reconciliation Act 

5 of 1996 (8 U.S.C. 1612(b)(2)) is amended by adding at 

6 the end the following: 

7 ‘‘(G) MEDICAID EXCEPTION FOR CITIZENS

8 OF FREELY ASSOCIATED STATES.—With respect 

9 to eligibility for benefits for the designated Fed10 eral program defined in paragraph (3)(C) (re11 lating to the Medicaid program), section 401(a) 

12 and paragraph (1) shall not apply to any indi13 vidual who lawfully resides in 1 of the 50 States 

14 or the District of Columbia in accordance with 

15 the Compacts of Free Association between the 

16 Government of the United States and the Gov17 ernments of the Federated States of Micro18 nesia, the Republic of the Marshall Islands, and 

19 the Republic of Palau and shall not apply, at 

20 the option of the Governor of Puerto Rico, the 

21 Virgin Islands, Guam, the Northern Mariana 

22 Islands, or American Samoa as communicated 

23 to the Secretary of Health and Human Services 

24 in writing, to any individual who lawfully re25 sides in the respective territory in accordance 

26 with such Compacts.’’. 
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1 (b) EXCEPTION TO 5-YEAR LIMITED ELIGIBILITY.— 

2 Section 403(d) of such Act (8 U.S.C. 1613(d)) is amend3 ed— 

4 (1) in paragraph (1), by striking ‘‘or’’ at the 

5 end; 

6 (2) in paragraph (2), by striking the period at 

7 the end and inserting ‘‘; or’’; and 

8 (3) by adding at the end the following: 

9 ‘‘(3) an individual described in section 

10 402(b)(2)(G), but only with respect to the des11 ignated Federal program defined in section 

12 402(b)(3)(C).’’. 

13 (c) DEFINITION OF QUALIFIED ALIEN.—Section 

14 431(b) of such Act (8 U.S.C. 1641(b)) is amended— 

15 (1) in paragraph (6), by striking ‘‘; or’’ at the 

16 end and inserting a comma; 

17 (2) in paragraph (7), by striking the period at 

18 the end and inserting ‘‘, or’’; and 

19 (3) by adding at the end the following: 

20 ‘‘(8) an individual who lawfully resides in the 

21 United States in accordance with a Compact of Free 

22 Association referred to in section 402(b)(2)(G), but 

23 only with respect to the designated Federal program 

24 defined in section 402(b)(3)(C) (relating to the Med25 icaid program).’’. 
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1 SEC. 1737. CONTINUING REQUIREMENT OF MEDICAID COV2 ERAGE OF NONEMERGENCY TRANSPOR3 TATION TO MEDICALLY NECESSARY SERV4 ICES. 

5 (a) REQUIREMENT.—Section 1902(a)(10) of the So6 cial Security Act (42 U.S.C. 1396a(a)(10)) is amended— 

7 (1) in subparagraph (A), in the matter pre8 ceding clause (i), by striking ‘‘and (21)’’ and insert9 ing ‘‘, (21), and (30)’’; and 

10 (2) in subparagraph (C)(iv), by striking ‘‘and 

11 (17)’’ and inserting ‘‘, (17), and (30)’’. 

12 (b) DESCRIPTION OF SERVICES.—Section 1905(a) of 

13 such Act (42 U.S.C. 1396d(a)), as amended by sections 

14 1713(a)(1) and 1724(a)(1), is amended— 

15 (1) in paragraph (29), by striking ‘‘and’’ at the 

16 end; 

17 (2) by redesignating paragraph (30) as para18 graph (31) and by striking the comma at the end 

19 and inserting a semicolon; and 

20 (3) by inserting after paragraph (29) the fol21 lowing new paragraph: 

22 ‘‘(30) nonemergency transportation to medically 

23 necessary services, consistent with the requirement 

24 of section 431.53 of title 42, Code of Federal Regu25 lations, as in effect as of June 1, 2008; and’’. 
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1 (c) EFFECTIVE DATE.—The amendments made by 

2 this section shall take effect on the date of the enactment 

3 of this Act and shall apply to transportation on or after 

4 such date. 

5 SEC. 1738. STATE OPTION TO DISREGARD CERTAIN INCOME 

6 IN PROVIDING CONTINUED MEDICAID COV7 ERAGE FOR CERTAIN INDIVIDUALS WITH EX8 TREMELY HIGH PRESCRIPTION COSTS. 

9 Section 1902(e) of the Social Security Act (42 U.S.C. 

10 1396b(e)), as amended by section 203(a) of the Children’s 

11 Health Insurance Program Reauthorization Act of 2009 

12 (Public Law 111–3), is amended by adding at the end the 

13 following new paragraph: 

14 ‘‘(14)(A) At the option of the State, in the case of 

15 an individual with extremely high prescription drug costs 

16 described in subparagraph (B) who has been determined 

17 (without the application of this paragraph) to be eligible 

18 for medical assistance under this title, the State may, in 

19 redetermining the individual’s eligibility for medical assist20 ance under this title, disregard any family income of the 

21 individual to the extent such income is less than an 

22 amount that is specified by the State and does not exceed 

23 the amount specified in subparagraph (C), or, if greater, 

24 income equal to the cost of the orphan drugs described 

25 in subparagraph (B)(iii). 
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1 ‘‘(B) An individual with extremely high prescription 

2 drug costs described in this subparagraph for a 12-month 

3 period is an individual— 

4 ‘‘(i) who is covered under health insurance or a 

5 health benefits plan that has a maximum lifetime 

6 limit of not less than $1,000,000 which includes all 

7 prescription drug coverage; 

8 ‘‘(ii) who has exhausted all available prescrip9 tion drug coverage under the plan as of the begin10 ning of such period; 

11 ‘‘(iii) who incurs (or is reasonably expected to 

12 incur) on an annual basis during the period costs for 

13 orphan drugs in excess of the amount specified in 

14 subparagraph (C) for the period; and 

15 ‘‘(iv) whose annual family income (determined 

16 without regard to this paragraph) as of the begin17 ning of the period does not exceed 75 percent of the 

18 amount incurred for such drugs (as described in 

19 clause (iii)). 

20 ‘‘(C) The amount specified in this subparagraph for 

21 a 12-month period beginning in— 

22 ‘‘(i) 2009 or 2010, is $200,000; or 

23 ‘‘(ii) a subsequent year, is the amount specified 

24 in clause (i) (or this subparagraph) for the previous 

25 year increased by the annual rate of increase in the 
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1 medical care component of the consumer price index 

2 (United States city average) for the 12-month period 

3 ending in August of the previous year. 

4 Any amount computed under clause (ii) that is not a mul5 tiple of $1,000 shall be rounded to the nearest multiple 

6 of $1,000. 

7 ‘‘(D) In applying this paragraph, amounts incurred 

8 for prescription drugs for cosmetic purposes shall not be 

9 taken into account. 

10 ‘‘(E) With respect to an individual described in sub11 paragraph (A), notwithstanding section 1916, the State 

12 plan— 

13 ‘‘(i) shall provide for the application of cost14 sharing that is at least nominal as determined under 

15 section 1916; and 

16 ‘‘(ii) may provide, consistent with section 

17 1916A, for such additional cost-sharing as does not 

18 exceed a maximum level of cost-sharing that is speci19 fied by the Secretary and is adjusted by the Sec20 retary on an annual basis. 

21 ‘‘(F) A State electing the option under this para22 graph shall provide for a determination on an individual’s 

23 application for continued medical assistance under this 

24 title within 30 days of the date the application if filed with 

25 the State. 
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1 ‘‘(G) In this paragraph: 

2 ‘‘(i) The term ‘orphan drugs’ means prescrip3 tion drugs designated under section 526 of the Fed4 eral Food, Drug, and Cosmetic Act (21 U.S.C. 

5 360bb) as a drug for a rare disease or condition. 

6 ‘‘(ii) The term ‘health benefits plan’ includes 

7 coverage under a plan offered under a State high 

8 risk pool.’’. 

9 SEC. 1739. PROVISIONS RELATING TO COMMUNITY LIVING 

10 ASSISTANCE SERVICES AND SUPPORTS 

11 (CLASS). 

12 (a) COORDINATION WITH CLASS PROVISIONS.— 

13 Section 1902(a) of the Social Security Act (42 U.S.C. 

14 1396a(a)), as amended by sections 1631(b), 1703(a), 

15 1729, 1753, 1757(a), 1759(a), 1783(a), and 1907(b), is 

16 amended— 

17 (1) in paragraph (80), by striking ‘‘and’’ at the 

18 end; 

19 (2) in paragraph (81), by striking the period 

20 and inserting ‘‘; and’’; and 

21 (3) by inserting after paragraph (81) the fol22 lowing: 

23 ‘‘(82) provide that the State will comply with 

24 such regulations regarding the application of pri25 mary and secondary payor rules with respect to indi-
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1 viduals who are eligible for medical assistance under 

2 this title and are eligible beneficiaries under the 

3 CLASS program established under title XXXII of 

4 the Public Health Service Act as the Secretary shall 

5 establish.’’. 

6 (b) ASSURANCE OF ADEQUATE INFRASTRUCTURE

7 FOR THE PROVISION OF PERSONAL CARE ATTENDANT

8 WORKERS.—Section 1902(a) of such Act (42 U.S.C. 

9 1396a(a)), as amended by subsection (a), is amended— 

10 (1) in paragraph (81), by striking ‘‘and’’ at the 

11 end; 

12 (2) in paragraph (82), by striking the period at 

13 the end and inserting ‘‘; and’’; and 

14 (3) by inserting after paragraph (82), the fol15 lowing: 

16 ‘‘(83) provide that, not later than 2 years after 

17 the date of enactment of this paragraph, each State 

18 shall— 

19 ‘‘(A) assess the extent to which entities 

20 such as providers of home care, home health 

21 services, home and community service providers, 

22 public authorities created to provide personal 

23 care services to individuals eligible for medical 

24 assistance under the State plan, and nonprofit 

25 organizations, are serving or have the capacity 
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1 to serve as fiscal agents for, employers of, and 

2 providers of employment-related benefits for, 

3 personal care attendant workers who provide 

4 personal care services to individuals receiving 

5 benefits under the CLASS program established 

6 under title XXXII of the Public Health Service 

7 Act, including in rural and underserved areas; 

8 ‘‘(B) designate or create such entities to 

9 serve as fiscal agents for, employers of, and 

10 providers of employment-related benefits for, 

11 such workers to ensure an adequate supply of 

12 the workers for individuals receiving benefits 

13 under the CLASS program, including in rural 

14 and underserved areas; and 

15 ‘‘(C) ensure that the designation or cre16 ation of such entities will not negatively alter or 

17 impede existing programs, models, methods, or 

18 administration of service delivery that provide 

19 for consumer controlled or self-directed home 

20 and community services and further ensure that 

21 such entities will not impede the ability of indi22 viduals to direct and control their home and 

23 community services, including the ability to se24 lect, manage, dismiss, co-employ, or employ 

25 such workers or inhibit such individuals from 
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1 relying on family members for the provision of 

2 personal care services.’’. 

3 (c) INCLUSION OF INFORMATION ON SUPPLEMENTAL

4 COVERAGE IN THE NATIONAL CLEARINGHOUSE FOR

5 LONG-TERM CARE INFORMATION; EXTENSION OF FUND6 ING.—Section 6021(d) of the Deficit Reduction Act of 

7 2005 (42 U.S.C. 1396p note) is amended— 

8 (1) in paragraph (2)(A)— 

9 (A) in clause (ii), by striking ‘‘and’’ at the 

10 end; 

11 (B) in clause (iii), by striking the period at 

12 the end and inserting ‘‘; and’’; and 

13 (C) by adding at the end the following: 

14 ‘‘(iv) include information regarding 

15 the CLASS program established under 

16 title XXXII of the Public Health Service 

17 Act.’’; and 

18 (2) in paragraph (3)— 

19 (A) by striking ‘‘2010’’ and inserting 

20 ‘‘2015’’; and 

21 (B) by adding at the end the following: ‘‘In 

22 addition to the amount appropriated under the 

23 previous sentence, there are authorized to be 

24 appropriated to carry out this subsection, 
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1 $7,000,000 for each of fiscal years 2011, 2012, 

2 and 2013.’’. 

3 (d) EFFECTIVE DATE.—The amendments made by 

4 this section take effect on January 1, 2011. 

5 SEC. 1739A. SENSE OF CONGRESS REGARDING COMMUNITY 

6 FIRST CHOICE OPTION TO PROVIDE MED7 ICAID COVERAGE OF COMMUNITY-BASED AT8 TENDANT SERVICES AND SUPPORTS. 

9 It is the sense of Congress that States should be al10 lowed to elect under their Medicaid State plans under title 

11 XIX of the Social Security Act to implement a Community 

12 First Choice Option under which— 

13 (1) coverage of community-based attendant 

14 services and supports furnished in homes and com15 munities is available, at an individual’s option, to in16 dividuals who would otherwise qualify for Medicaid 

17 institutional coverage under the respective State 

18 plan; 

19 (2) such supports and services include assist20 ance to individuals with disabilities in accomplishing 

21 activities of daily living, instrumental activities of 

22 daily living, and health-related tasks; 

23 (3) the Federal matching assistance percentage 

24 (FMAP) under such title for medical assistance for 

25 such supports and services is enhanced; 
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1 (4) States, consistent with minimum Federal 

2 standards, ensure quality of such supports and serv3 ices; and 

4 (5) States collect and provide data to the Sec5 retary of Health and Human Services on the cost 

6 and effectiveness and quality of supports and serv7 ices provided through such option. 

8 Subtitle E—Financing 

9 SEC. 1741. PAYMENTS TO PHARMACISTS. 

10 (a) PHARMACY REIMBURSEMENT LIMITS.— 

11 (1) IN GENERAL.—Section 1927(e) of the So12 cial Security Act (42 U.S.C. 1396r–8(e)) is amend13 ed— 

14 (A) by striking paragraph (5) and insert15 ing the following: 

16 ‘‘(5) USE OF AMP IN UPPER PAYMENT LIM17 ITS.—The Secretary shall calculate the Federal 

18 upper reimbursement limit established under para19 graph (4) as 130 percent of the weighted average 

20 (determined on the basis of manufacturer utiliza21 tion) of monthly average manufacturer prices. Noth22 ing in the previous sentence shall be construed as 

23 preventing the Secretary from performing such cal24 culation using a smoothing process in order to re25 duce significant variations from month to month as 
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1 a result of rebates, discounts, and other pricing 

2 practices, such as in the manner such a process is 

3 used by the Secretary in determining the average 

4 sales price of a drug or biological under section 

5 1847A.’’ 

6 (2) DEFINITION OF AMP.—Section 

7 1927(k)(1)(B) of such Act (42 U.S.C. 1396r– 

8 8(k)(1)(B)) is amended— 

9 (B) in the heading, by striking ‘‘EX10 TENDED TO WHOLESALERS’’ and inserting 

11 ‘‘AND OTHER PAYMENTS’’; and 

12 (C) by striking ‘‘regard to’’ and all that 

13 follows through the period and inserting the fol14 lowing: ‘‘regard to— 

15 ‘‘(i) customary prompt pay discounts 

16 extended to wholesalers; 

17 ‘‘(ii) bona fide service fees paid by 

18 manufacturers; 

19 ‘‘(iii) reimbursement by manufactur20 ers for recalled, damaged, expired, or oth21 erwise unsalable returned goods, including 

22 reimbursement for the cost of the goods 

23 and any reimbursement of costs associated 

24 with return goods handling and processing, 

25 reverse logistics, and drug destruction; 
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1 ‘‘(iv) sales directly to, or rebates, dis2 counts, or other price concessions provided 

3 to, pharmacy benefit managers, managed 

4 care organizations, health maintenance or5 ganizations, insurers, mail order phar6 macies that are not open to all members of 

7 the public, or long term care providers, 

8 provided that these rebates, discounts, or 

9 price concessions are not passed through to 

10 retail pharmacies; 

11 ‘‘(v) sales directly to, or rebates, dis12 counts, or other price concessions provided 

13 to, hospitals, clinics, and physicians, unless 

14 the drug is an inhalation, infusion, or 

15 injectable drug, or unless the Secretary de16 termines, as allowed for in Agency admin17 istrative procedures, that it is necessary to 

18 include such sales, rebates, discounts, and 

19 price concessions in order to obtain an ac20 curate AMP for the drug. Such a deter21 mination shall not be subject to judicial re22 view; or 

23 ‘‘(vi) rebates, discounts, and other 

24 price concessions required to be provided 
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1 under agreements under subsections (f) 

2 and (g) of section 1860D–2(f).’’. 

3 (3) MANUFACTURER REPORTING REQUIRE4 MENTS.—Section 1927(b)(3)(A) of such Act (42 

5 U.S.C. 1396r–8(b)(3)(A)) is amended— 

6 (A) in clause (ii), by striking ‘‘and’’ at the 

7 end; 

8 (B) by striking the period at the end of 

9 clause (iii) and inserting ‘‘; and’’; and 

10 (C) by inserting after clause (iii) the fol11 lowing new clause: 

12 ‘‘(iv) not later than 30 days after the 

13 last day of each month of a rebate period 

14 under the agreement, on the manufactur15 er’s total number of units that are used to 

16 calculate the monthly average manufac17 turer price for each covered outpatient 

18 drug.’’. 

19 (4) AUTHORITY TO PROMULGATE REGULA20 TION.—The Secretary of Health and Human Serv21 ices may promulgate regulations to clarify the re22 quirements for upper payment limits and for the de23 termination of the average manufacturer price in an 

24 expedited manner. Such regulations may become ef-
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1 fective on an interim final basis, pending oppor2 tunity for public comment. 

3 (5) PHARMACY REIMBURSEMENTS THROUGH

4 DECEMBER 31, 2010.—The specific upper limit under 

5 section 447.332 of title 42, Code of Federal Regula6 tions (as in effect on December 31, 2006) applicable 

7 to payments made by a State for multiple source 

8 drugs under a State Medicaid plan shall continue to 

9 apply through December 31, 2010, for purposes of 

10 the availability of Federal financial participation for 

11 such payments. 

12 (b) DISCLOSURE OF PRICE INFORMATION TO THE

13 PUBLIC.—Section 1927(b)(3) of such Act (42 U.S.C. 

14 1396r–8(b)(3)) is amended— 

15 (1) in subparagraph (A)— 

16 (A) in clause (i), in the matter preceding 

17 subclause (I), by inserting ‘‘month of a’’ after 

18 ‘‘each’’; and 

19 (B) in the last sentence, by striking ‘‘and 

20 shall,’’ and all that follows up to the period; 

21 and 

22 (2) in subparagraph (D)(v), by inserting 

23 ‘‘weighted’’ before ‘‘average manufacturer prices’’. 
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1 SEC. 1742. PRESCRIPTION DRUG REBATES. 

2 (a) ADDITIONAL REBATE FOR NEW FORMULATIONS

3 OF EXISTING DRUGS.— 

4 (1) IN GENERAL.—Section 1927(c)(2) of the 

5 Social Security Act (42 U.S.C. 1396r–8(c)(2)) is 

6 amended by adding at the end the following new 

7 subparagraph: 

8 ‘‘(C) TREATMENT OF NEW FORMULA9 TIONS.—In the case of a drug that is a line ex10 tension of a single source drug or an innovator 

11 multiple source drug that is an oral solid dos12 age form, the rebate obligation with respect to 

13 such drug under this section shall be the 

14 amount computed under this section for such 

15 new drug or, if greater, the product of— 

16 ‘‘(i) the average manufacturer price of 

17 the line extension of a single source drug 

18 or an innovator multiple source drug that 

19 is an oral solid dosage form; 

20 ‘‘(ii) the highest additional rebate 

21 (calculated as a percentage of average 

22 manufacturer price) under this section for 

23 any strength of the original single source 

24 drug or innovator multiple source drug; 

25 and 
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1 ‘‘(iii) the total number of units of 

2 each dosage form and strength of the line 

3 extension product paid for under the State 

4 plan in the rebate period (as reported by 

5 the State). 

6 In this subparagraph, the term ‘line extension’ 

7 means, with respect to a drug, a new formula8 tion of the drug, such as an extended release 

9 formulation.’’. 

10 (2) EFFECTIVE DATE.—The amendment made 

11 by paragraph (1) shall apply to drugs dispensed 

12 after December 31, 2009. 

13 (b) INCREASE MINIMUM REBATE PERCENTAGE FOR

14 SINGLE SOURCE DRUGS.— 

15 (1) IN GENERAL.—Section 1927(c)(1)(B)(i) of 

16 the Social Security Act (42 U.S.C. 1396r– 

17 8(c)(1)(B)(i)) is amended— 

18 (A) in subclause (IV), by striking ‘‘and’’ at 

19 the end; 

20 (B) in subclause (V)— 

21 (i) by inserting ‘‘and before January 

22 1, 2010’’ after ‘‘December 31, 1995,’’; and 

23 (ii) by striking the period at the end 

24 and inserting ‘‘; and’’; and 
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1 (C) by adding at the end the following new 

2 subclause: 

3 ‘‘(VI) after December 31, 2009, 

4 is 23.1 percent.’’. 

5 (2) RECAPTURE OF TOTAL SAVINGS DUE TO IN6 CREASE.—Section 1927(b)(1) of such Act is amend7 ed by adding at the end the following new subpara8 graph: 

9 ‘‘(C) SPECIAL RULE FOR INCREASED MIN10 IMUM REBATE PERCENTAGE.— 

11 ‘‘(i) IN GENERAL.—In addition to the 

12 amounts applied as a reduction under sub13 paragraph (B), for rebate periods begin14 ning on or after January 1, 2010, during 

15 a fiscal year, the Secretary shall reduce 

16 payments to a State under section 1903(a) 

17 in the manner specified in clause (ii), in an 

18 amount equal to the product of— 

19 ‘‘(I) 100 percent minus the Fed20 eral medical assistance percentage ap21 plicable to the rebate period for the 

22 State; and 

23 ‘‘(II) the amounts received by the 

24 State under such subparagraph that 

25 are attributable (as estimated by the 
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1 Secretary based on utilization and 

2 other data) to the increase in the min3 imum rebate percentage effected by 

4 the amendments made by section 

5 1742(b)(1) of the Affordable Health 

6 Care for America Act, taking into ac7 count the additional drugs included 

8 under the amendments made by sec9 tion 1743 of such Act. 

10 The Secretary shall adjust such payment 

11 reduction for a calendar quarter to the ex12 tent the Secretary determines, based upon 

13 subsequent utilization and other data, that 

14 the reduction for such quarter was greater 

15 or less than the amount of payment reduc16 tion that should have been made. 

17 ‘‘(ii) MANNER OF PAYMENT REDUC18 TION.—The amount of the payment reduc19 tion under clause (i) for a State for a 

20 quarter shall be deemed an overpayment to 

21 the State under this title to be disallowed 

22 against the State’s regular quarterly draw 

23 for all Medicaid spending under section 

24 1903(d)(2). Such a disallowance is not 
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1 subject to a reconsideration under 

2 1116(d).’’. 

3 SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DIS4 COUNTS TO ENROLLEES OF MEDICAID MAN5 AGED CARE ORGANIZATIONS. 

6 (a) IN GENERAL.—Section 1903(m)(2)(A) of the So7 cial Security Act (42 U.S.C. 1396b(m)(2)(A)) is amend8 ed— 

9 (1) in clause (xi), by striking ‘‘and’’ at the end; 

10 (2) in clause (xii), by striking the period at the 

11 end and inserting ‘‘; and’’; and 

12 (3) by adding at the end the following: 

13 ‘‘(xiii) such contract provides that the entity 

14 shall report to the State such information, on such 

15 timely and periodic basis as specified by the Sec16 retary, as the State may require in order to include, 

17 in the information submitted by the State to a man18 ufacturer under section 1927(b)(2)(A) and to the 

19 Secretary under section 1927(b)(2)(C), information 

20 on covered outpatient drugs dispensed to individuals 

21 eligible for medical assistance who are enrolled with 

22 the entity and for which the entity is responsible for 

23 coverage of such drugs under this subsection.’’. 

24 (b) CONFORMING AMENDMENTS.—Section 1927 of 

25 such Act (42 U.S.C. 1396r–8) is amended—— 
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1 (1) in the first sentence of subsection (b)(1)(A), 

2 by inserting before the period at the end the fol3 lowing: ‘‘, including such drugs dispensed to individ4 uals enrolled with a medicaid managed care organi5 zation if the organization is responsible for coverage 

6 of such drugs’’; 

7 (2) in subsection (b)(2), by adding at the end 

8 the following new subparagraph: 

9 ‘‘(C) REPORTING ON MMCO DRUGS.—On a 

10 quarterly basis, each State shall report to the 

11 Secretary the total amount of rebates in dollars 

12 received from pharmacy manufacturers for 

13 drugs provided to individuals enrolled with 

14 Medicaid managed care organizations that con15 tract under section 1903(m) and such other in16 formation as the Secretary may require to carry 

17 out paragraph (1)(C) with respect to such re18 bates.’’; and 

19 (3) in subsection (j)— 

20 (A) in the heading by striking ‘‘EXEMP21 TION’’ and inserting ‘‘SPECIAL RULES’’; and 

22 (B) in paragraph (1), by striking ‘‘are not 

23 subject to the requirements of this section’’ and 

24 inserting ‘‘are subject to the requirements of 

25 this section unless such drugs are subject to 
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1 discounts under section 340B of the Public 

2 Health Service Act’’. 

3 (c) EFFECTIVE DATE.—The amendments made by 

4 this section take effect on January 1, 2010, and shall 

5 apply to drugs dispensed on or after such date, without 

6 regard to whether or not final regulations to carry out 

7 such amendments have been promulgated by such date. 

8 SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDU9 CATION. 

10 (a) IN GENERAL.—Section 1905 of the Social Secu11 rity Act (42 U.S.C. 1396d), as amended by sections 

12 1701(a)(3)(B), 1711(a), and 1713(a), is amended by add13 ing at the end the following new subsection: 

14 ‘‘(bb) PAYMENT FOR GRADUATE MEDICAL EDU15 CATION.— 

16 ‘‘(1) IN GENERAL.—The term ‘medical assist17 ance’ includes payment for costs of graduate medical 

18 education consistent with this subsection, whether 

19 provided in or outside of a hospital. 

20 ‘‘(2) SUBMISSION OF INFORMATION.—For pur21 poses of paragraph (1) and section 

22 1902(a)(13)(A)(v), payment for such costs is not 

23 consistent with this subsection unless— 

24 ‘‘(A) the State submits to the Secretary, in 

25 a timely manner and on an annual basis speci-
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1 fied by the Secretary, information on total pay2 ments for graduate medical education and how 

3 such payments are being used for graduate 

4 medical education, including— 

5 ‘‘(i) the institutions and programs eli6 gible for receiving the funding; 

7 ‘‘(ii) the manner in which such pay8 ments are calculated; 

9 ‘‘(iii) the types and fields of education 

10 being supported; 

11 ‘‘(iv) the workforce or other goals to 

12 which the funding is being applied; 

13 ‘‘(v) State progress in meeting such 

14 goals; and 

15 ‘‘(vi) such other information as the 

16 Secretary determines will assist in carrying 

17 out paragraphs (3) and (4); and 

18 ‘‘(B) such expenditures are made con19 sistent with such goals and requirements as are 

20 established under paragraph (4). 

21 ‘‘(3) REVIEW OF INFORMATION.—The Secretary 

22 shall make the information submitted under para23 graph (2) available to the Advisory Committee on 

24 Health Workforce Evaluation and Assessment (es25 tablished under section 2261 of the Public Health 
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1 Service Act). The Secretary and the Advisory Com2 mittee shall independently review the information 

3 submitted under paragraph (2), taking into account 

4 State and local workforce needs. 

5 ‘‘(4) SPECIFICATION OF GOALS AND REQUIRE6 MENTS.—The Secretary shall specify by rule, ini7 tially published by not later than December 31, 

8 2011— 

9 ‘‘(A) program goals for the use of funds 

10 described in paragraph (1), taking into account 

11 recommendations of the such Advisory Com12 mittee and the goals for approved medical resi13 dency training programs described in section 

14 1886(h)(1)(B); and 

15 ‘‘(B) requirements for use of such funds 

16 consistent with such goals. 

17 Such rule may be effective on an interim basis pend18 ing revision after an opportunity for public com19 ment.’’. 

20 (b) CONFORMING AMENDMENT.—Section 

21 1902(a)(13)(A) of such Act (42 U.S.C. 1396a(a)(13)(A)), 

22 as amended by section 1721(a)(1)(A), is amended— 

23 (1) by striking ‘‘and’’ at the end of clause (iii); 

24 (2) by striking the semicolon in clause (iv) and 

25 inserting ‘‘, and’’; and 
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1 (3) by adding at the end the following new 

2 clause: 

3 ‘‘(v) in the case of hospitals and at 

4 the option of a State, such rates may in5 clude, to the extent consistent with section 

6 1905(bb), payment for graduate medical 

7 education; and’’. 

8 (c) EFFECTIVE DATE.—The amendments made by 

9 this section shall take effect on the date of the enactment 

10 of this Act. Nothing in this section shall be construed as 

11 affecting payments made before such date under a State 

12 plan under title XIX of the Social Security Act for grad13 uate medical education. 

14 SEC. 1745. NURSING FACILITY SUPPLEMENTAL PAYMENT 

15 PROGRAM. 

16 (a) TOTAL AMOUNT AVAILABLE FOR PAYMENTS.— 

17 (1) IN GENERAL.—Out of any funds in the 

18 Treasury not otherwise appropriated, there are ap19 propriated to the Secretary of Health and Human 

20 Services (in this section referred to as the ‘‘Sec21 retary’’) to carry out this section $6,000,000,000, of 

22 which the following amounts shall be available for 

23 obligation in the following years: 

24 (A) $1,500,000,000 shall be available be25 ginning in 2010. 
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1 (B) $1,500,000,000 shall be available be2 ginning in 2011. 

3 (C) $1,500,000,000 shall be available be4 ginning in 2012. 

5 (D) $1,500,000,000 shall be available be6 ginning in 2013. 

7 (2) AVAILABILITY.—Funds appropriated under 

8 paragraph (1) shall remain available until all eligible 

9 dually-certified facilities (as defined in subsection 

10 (b)(3)) have been reimbursed for underpayments 

11 under this section during cost reporting periods end12 ing during calendar years 2010 through 2013. 

13 (3) LIMITATION OF AUTHORITY.—The Sec14 retary may not make payments under this section 

15 that exceed the funds appropriated under paragraph 

16 (1). 

17 (4) DISPOSITION OF REMAINING FUNDS INTO

18 MIF.—Any funds appropriated under paragraph (1) 

19 which remain available after the application of para20 graph (2) shall be deposited into the Medicaid Im21 provement Fund under section 1941 of the Social 

22 Security Act. 

23 (b) USE OF FUNDS.— 

24 (1) AUTHORITY TO MAKE PAYMENTS.—From 

25 the amounts available for obligation in a year under 
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1 subsection (a), the Secretary, acting through the Ad2 ministrator of the Centers for Medicare & Medicaid 

3 Services, shall pay the amount determined under 

4 paragraph (2) directly to an eligible dually-certified 

5 facility for the purpose of providing funding to reim6 burse such facility for furnishing quality care to 

7 Medicaid-eligible individuals. 

8 (2) DETERMINATION OF PAYMENT AMOUNTS.— 

9 (A) IN GENERAL.—Subject to subpara10 graphs (B) and (C), the payment amount deter11 mined under this paragraph for a year for an 

12 eligible dually-certified facility shall be an 

13 amount determined by the Secretary as re14 ported on the facility’s latest available Medicare 

15 cost report. 

16 (B) LIMITATION ON PAYMENT AMOUNT.— 

17 In no case shall the payment amount for an eli18 gible dually-certified facility for a year under 

19 subparagraph (A) be more than the payment 

20 deficit described in paragraph (3)(D) for such 

21 facility as reported on the facility’s latest avail22 able Medicare cost report. 

23 (C) PRO-RATA REDUCTION.—If the 

24 amount available for obligation under sub25 section (a) for a year (as reduced by allowable 
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1 administrative costs under this section) is insuf2 ficient to ensure that each eligible dually-cer3 tified facility receives the amount of payment 

4 calculated under subparagraph (A), the Sec5 retary shall reduce that amount of payment 

6 with respect to each such facility in a pro-rata 

7 manner to ensure that the entire amount avail8 able for such payments for the year be paid. 

9 (D) NO REQUIRED MATCH.—The Secretary 

10 may not require that a State provide matching 

11 funds for any payment made under this sub12 section. 

13 (3) ELIGIBLE DUALLY-CERTIFIED FACILITY DE14 FINED.—For purposes of this section, the term ‘‘eli15 gible dually-certified facility’’ means, for a cost re16 porting period ending during a year (beginning no 

17 earlier than 2010) that is covered by the latest avail18 able Medicare cost report, a nursing facility that 

19 meets all of the following requirements: 

20 (A) The facility is participating as a nurs21 ing facility under title XIX of the Social Secu22 rity Act and as a skilled nursing facility under 

23 title XVIII of such Act during the entire year. 

24 (B) The base Medicaid payment rate (ex25 cluding any supplemental payments) to the fa-
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1 cility is not less than the base Medicaid pay2 ment rate (excluding any supplemental pay3 ments) to such facility as of June 16, 2009. 

4 (C) As reported on the facility’s latest 

5 Medicare cost report— 

6 (i) the Medicaid share of patient days 

7 for such facility is not less than 60 percent 

8 of the combined Medicare and Medicaid 

9 share of resident days for such facility; and 

10 (ii) the combined Medicare and Med11 icaid share of resident days for such facil12 ity, as reported on the facility’s latest 

13 available Medicare cost report, is not less 

14 than 75 percent of the total resident days 

15 for such facility. 

16 (D) The facility has received Medicaid re17 imbursement (including any supplemental pay18 ments) for the provision of covered services to 

19 Medicaid eligible individuals, as reported on the 

20 facility’s latest available Medicare cost report, 

21 that is significantly less (as determined by the 

22 Secretary) than the allowable costs (as deter23 mined by the Secretary) incurred by the facility 

24 in providing such services. 
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1 (E) The facility is not in the highest quar2 tile of costs costs per day, as determined by the 

3 Secretary and as adjusted for case mix, wages, 

4 and type of facility. 

5 (F) The facility provides quality care, as 

6 determined by the Secretary, to— 

7 (i) Medicaid eligible individuals; and 

8 (ii) individuals who are entitled to 

9 items and services under part A of title 

10 XVIII of the Social Security Act. 

11 (G) In the most recent standard survey 

12 available, the facility was not cited for any im13 mediate jeopardy deficiencies as defined by the 

14 Secretary. 

15 (H) In the most recent standard survey 

16 available, the facility maintains an appropriate 

17 staffing level to attain or maintain the highest 

18 practicable well-being of each resident as de19 fined by the Secretary. 

20 (I) The facility complies with all the re21 quirements, as determined by the Secretary, 

22 contained in sections 1411 through 1416 and 

23 the amendments made by such sections. 

24 (J) The facility was not listed as a Centers 

25 for Medicare & Medicaid Services Special Focus 
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1 Facility (SFF) nor as a SFF on a State-based 

2 list. 

3 (4) FREQUENCY OF PAYMENT.—Payment of an 

4 amount under this subsection to an eligible dually5 certified facility shall be made for a year in a lump 

6 sum or in such periodic payments in such frequency 

7 as the Secretary determines appropriate. 

8 (5) DIRECT PAYMENTS.—Such payment— 

9 (A) shall be made directly by the Secretary 

10 to an eligible dually-certified facility or a con11 tractor designated by such facility; and 

12 (B) shall not be made through a State. 

13 (c) ADMINISTRATION.— 

14 (1) ANNUAL APPLICATIONS; DEADLINES.—The 

15 Secretary shall establish a process, including dead16 lines, under which facilities may apply on an annual 

17 basis to qualify as eligible dually-certified facilities 

18 for payment under subsection (b). 

19 (2) CONTRACTING AUTHORITY.—The Secretary 

20 may enter into one or more contracts with entities 

21 for the purpose of implementation of this section. 

22 (3) LIMITATION.—The Secretary may not 

23 spend more than 0.75 percent of the amount made 

24 available under subsection (a) in any year on the 
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1 costs of administering the program of payments 

2 under this section for the year. 

3 (4) IMPLEMENTATION.—Notwithstanding any 

4 other provision of law, the Secretary may implement, 

5 by program instruction or otherwise, the provisions 

6 of this section. 

7 (5) LIMITATIONS ON REVIEW.—There shall be 

8 no administrative or judicial review of— 

9 (A) the determination of the eligibility of a 

10 facility for payments under subsection (b); or 

11 (B) the determination of the amount of 

12 any payment made to a facility under such sub13 section. 

14 (d) ANNUAL REPORTS.—The Secretary shall submit 

15 an annual report to the committees with jurisdiction in 

16 the Congress on payments made under subsection (b). 

17 Each such report shall include information on— 

18 (1) the facilities receiving such payments; 

19 (2) the amount of such payments to such facili20 ties; and 

21 (3) the basis for selecting such facilities and the 

22 amount of such payments. 

23 (e) REFERENCE TO REPORT.—For report by the 

24 Medicaid and CHIP Payment and Access Commission on 

25 the adequacy of payments to nursing facilities under the 
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1 Medicaid program, see section 1900(b)(2)(B) of the Social 

2 Security Act, as amended by section 1784. 

3 (f) DEFINITIONS.—For purposes of this section: 

4 (1) DUALLY-CERTIFIED FACILITY.—The term 

5 ‘‘dually-certified facility’’ means a facility that is 

6 participating as a nursing facility under title XIX of 

7 the Social Security Act and as a skilled nursing fa8 cility under title XVIII of such Act. 

9 (2) MEDICAID ELIGIBLE INDIVIDUAL.—The 

10 term ‘‘Medicaid eligible individual’’ means an indi11 vidual who is eligible for medical assistance, with re12 spect to nursing facility services (as defined in sec13 tion 1905(f) of the Social Security Act), under title 

14 XIX of the such Act. 

15 (3) STATE.—The term ‘‘State’’ means the 50 

16 States and the District of Columbia. 

17 SEC. 1746. REPORT ON MEDICAID PAYMENTS. 

18 Section 1902 of the Social Security Act (42 U.S.C. 

19 1396), as amended by sections 1703(a), 1714(a), and 

20 1731(a), is amended by adding at the end the following 

21 new subsection: 

22 ‘‘(jj) REPORT ON MEDICAID PAYMENTS.—Each year, 

23 on or before a date determined by the Secretary, a State 

24 participating in the Medicaid program under this title 
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1 shall submit to the Administrator of the Centers for Medi2 care & Medicaid Services— 

3 ‘‘(1) information on the determination of rates 

4 of payment to providers for covered services under 

5 the State plan, including— 

6 ‘‘(A) the final rates; 

7 ‘‘(B) the methodologies used to determine 

8 such rates; and 

9 ‘‘(C) justifications for the rates; and 

10 ‘‘(2) an explanation of the process used by the 

11 State to allow providers, beneficiaries and their rep12 resentatives, and other concerned State residents a 

13 reasonable opportunity to review and comment on 

14 such rates, methodologies, and justifications before 

15 the State made such rates final.’’. 

16 SEC. 1747. REVIEWS OF MEDICAID. 

17 (a) GAO STUDY ON FMAP.—. 

18 (1) STUDY.—The Comptroller General of the 

19 United States shall conduct a study regarding Fed20 eral payments made to the State Medicaid programs 

21 under title XIX of the Social Security Act for the 

22 purposes of making recommendations to Congress. 

23 (2) REPORT.—Not later than February 15, 

24 2011, the Comptroller General shall submit to the 

25 appropriate committees of Congress a report on the 
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1 study conducted under paragraph (1) and the effect 

2 on the Federal government, States, providers, and 

3 beneficiaries of— 

4 (A) removing the 50 percent floor, or 83 

5 percent ceiling, or both, in the Federal medical 

6 assistance percentage under section 1905(b)(1) 

7 of the Social Security Act; and 

8 (B) revising the current formula for such 

9 Federal medical assistance percentage to better 

10 reflect State fiscal capacity and State effort to 

11 pay for health and long-term care services and 

12 to better adjust for national or regional eco13 nomic downturns. 

14 (b) GAO STUDY ON MEDICAID ADMINISTRATIVE

15 COSTS.— 

16 (1) STUDY.—The Comptroller General of the 

17 United States shall conduct a study of the adminis18 tration of the Medicaid program by the Department 

19 of Health and Human Services, State Medicaid 

20 agencies, and local government agencies. The report 

21 shall address the following issues: 

22 (A) The extent to which Federal funds for 

23 each administrative function, such as survey 

24 and certification and claims processing, are 

25 being used effectively and efficiently. 
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1 (B) The administrative functions on which 

2 Federal Medicaid funds are expended and the 

3 amounts of such expenditures (whether spent 

4 directly or by contract). 

5 (2) REPORT.—Not later than February 15, 

6 2011, the Comptroller General shall submit to the 

7 appropriate committees of Congress a report on the 

8 study conducted under paragraph (1). 

9 SEC. 1748. EXTENSION OF DELAY IN MANAGED CARE ORGA10 NIZATION PROVIDER TAX ELIMINATION. 

11 Effective as if included in the enactment of section 

12 6051 of the Deficit Reduction Act of 2005 (Public Law 

13 109–171), subsection (b)(2)(A) of such section is amended 

14 by striking ‘‘October 1, 2009’’ and inserting ‘‘October 1, 

15 2010’’. 

16 SEC. 1749. EXTENSION OF ARRA INCREASE IN FMAP. 

17 Section 5001 of the American Recovery and Reinvest18 ment Act of 2009 (Public Law 111–5) is amended— 

19 (1) in subsection (a)(3), by striking ‘‘first cal20 endar quarter’’ and inserting ‘‘first 3 calendar quar21 ters’’; 

22 (2) in subsection (b)(2), by inserting before the 

23 period at the end the following: ‘‘and such para24 graph shall not apply to calendar quarters beginning 

25 on or after October 1, 2010’’; 
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1 (3) in subsection (c)(4)(C)(ii), by striking ‘‘De2 cember 2009’’ and ‘‘January 2010’’ and inserting 

3 ‘‘June 2010’’ and ‘‘July 2010’’, respectively; 

4 (4) in subsection (d), by inserting ‘‘ending be5 fore October 1, 2010’’ after ‘‘entire fiscal years’’ and 

6 after ‘‘with respect to fiscal years’’; 

7 (5) in subsection (g)(1), by striking ‘‘September 

8 30, 2011’’ and inserting ‘‘December 31, 2011’’; and 

9 (6) in subsection (h)(3), by striking ‘‘December 

10 31, 2010’’ and inserting ‘‘June 30, 2011’’. 

11 Subtitle F—Waste, Fraud, and 

12 Abuse 

13 SEC. 1751. HEALTH CARE ACQUIRED CONDITIONS. 

14 (a) MEDICAID NON-PAYMENT FOR CERTAIN HEALTH

15 CARE-ACQUIRED CONDITIONS.—Section 1903(i) of the 

16 Social Security Act (42 U.S.C. 1396b(i)) is amended— 

17 (1) by striking ‘‘or’’ at the end of paragraph 

18 (23); 

19 (2) by striking the period at the end of para20 graph (24) and inserting ‘‘; or’’; and 

21 (3) by inserting after paragraph (24) the fol22 lowing new paragraph: 

23 ‘‘(25) with respect to amounts expended for 

24 services related to the presence of a condition that 

25 could be identified by a secondary diagnostic code 
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1 described in section 1886(d)(4)(D)(iv) and for any 

2 health care acquired condition determined as a non3 covered service under title XVIII.’’. 

4 (b) APPLICATION TO CHIP.—Section 2107(e)(1)(G) 

5 of such Act (42 U.S.C. 1397gg(e)(1)(G)) is amended by 

6 striking ‘‘and (17)’’ and inserting ‘‘(17), and (25)’’. 

7 (c) PERMISSION TO INCLUDE ADDITIONAL HEALTH

8 CARE-ACQUIRED CONDITIONS.—Nothing in this section 

9 shall prevent a State from including additional health 

10 care-acquired conditions for non-payment in its Medicaid 

11 program under title XIX of the Social Security Act. 

12 (d) EFFECTIVE DATE.—The amendments made by 

13 this section shall apply to discharges occurring on or after 

14 January 1, 2010. 

15 SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER 

16 MEDICAID INTEGRITY PROGRAM. 

17 Section 1936(c)(2)) of the Social Security Act (42 

18 U.S.C. 1396u–7(c)(2)) is amended— 

19 (1) by redesignating subparagraph (D) as sub20 paragraph (E); and 

21 (2) by inserting after subparagraph (C) the fol22 lowing new subparagraph: 

23 ‘‘(D) For the contract year beginning in 

24 2011 and each subsequent contract year, the 

25 entity provides assurances to the satisfaction of 
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1 the Secretary that the entity will conduct peri2 odic evaluations of the effectiveness of the ac3 tivities carried out by such entity under the 

4 Program and will submit to the Secretary an 

5 annual report on such activities.’’. 

6 SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO 

7 ADOPT PROGRAMS TO REDUCE WASTE, 

8 FRAUD, AND ABUSE. 

9 Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 

10 1396a(a)), as amended by sections 1631(b)(1), 1703, and 

11 1729, is further amended— 

12 (1) in paragraph (75), by striking at the end 

13 ‘‘and’’; 

14 (2) in paragraph (76), by striking at the end 

15 the period and inserting ‘‘; and’’; and 

16 (3) by inserting after paragraph (76) the fol17 lowing new paragraph: 

18 ‘‘(77) provide that any provider or supplier 

19 (other than a physician or nursing facility) providing 

20 services under such plan shall, subject to paragraph 

21 (5) of section 1874(d), establish a compliance pro22 gram described in paragraph (1) of such section in 

23 accordance with such section.’’. 
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1 SEC. 1754. OVERPAYMENTS. 

2 (a) IN GENERAL.—Section 1903(d)(2)(C) of the So3 cial Security Act (42 U.S.C. 1396b(d)(2)(C)) is amend4 ed— 

5 (1) in the first sentence, by inserting ‘‘(or of 1 

6 year in the case of overpayments due to fraud)’’ 

7 after ‘‘60 days’’; and 

8 (2) in the second sentence, by striking ‘‘the 60 

9 days’’ and inserting ‘‘such period’’. 

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

11 subsection (a) shall apply in the case of overpayments dis12 covered on or after the date of the enactment of this Act. 

13 SEC. 1755. MANAGED CARE ORGANIZATIONS. 

14 (a) MINIMUM MEDICAL LOSS RATIO.— 

15 (1) MEDICAID.—Section 1903(m)(2)(A) of the 

16 Social Security Act (42 U.S.C. 1396b(m)(2)(A)), as 

17 amended by section 1743(a)(3), is amended— 

18 (A) by striking ‘‘and’’ at the end of clause 

19 (xii); 

20 (B) by striking the period at the end of 

21 clause (xiii) and inserting ‘‘; and’’; and 

22 (C) by adding at the end the following new 

23 clause: 

24 ‘‘(xiv) such contract has a medical loss ratio, as 

25 determined in accordance with a methodology speci-
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1 fied by the Secretary that is a percentage (not less 

2 than 85 percent) as specified by the Secretary.’’. 

3 (2) CHIP.—Section 2107(e)(1) of such Act (42 

4 U.S.C. 1397gg(e)(1)) is amended— 

5 (A) by redesignating subparagraphs (H) 

6 through (L) as subparagraphs (I) through (M); 

7 and 

8 (B) by inserting after subparagraph (G) 

9 the following new subparagraph: 

10 ‘‘(H) Section 1903(m)(2)(A)(xiv) (relating 

11 to application of minimum loss ratios), with re12 spect to comparable contracts under this title.’’. 

13 (3) EFFECTIVE DATE.—The amendments made 

14 by this subsection shall apply to contracts entered 

15 into or renewed on or after July 1, 2010. 

16 (b) PATIENT ENCOUNTER DATA.— 

17 (1) IN GENERAL.—Section 1903(m)(2)(A)(xi) 

18 of the Social Security Act (42 U.S.C. 

19 1396b(m)(2)(A)(xi)) is amended by inserting ‘‘and 

20 for the provision of such data to the State at a fre21 quency and level of detail to be specified by the Sec22 retary’’ after ‘‘patients’’. 

23 (2) EFFECTIVE DATE.—The amendment made 

24 by paragraph (1) shall apply with respect to contract 

25 years beginning on or after January 1, 2010. 
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1 SEC. 1756. TERMINATION OF PROVIDER PARTICIPATION 

2 UNDER MEDICAID AND CHIP IF TERMINATED 

3 UNDER MEDICARE OR OTHER STATE PLAN 

4 OR CHILD HEALTH PLAN. 

5 (a) STATE PLAN REQUIREMENT.—Section 

6 1902(a)(39) of the Social Security Act (42 U.S.C. 42 

7 U.S.C. 1396a(a)) is amended by inserting after ‘‘1128A,’’ 

8 the following: ‘‘terminate the participation of any indi9 vidual or entity in such program if (subject to such excep10 tions are permitted with respect to exclusion under sec11 tions 1128(b)(3)(C) and 1128(d)(3)(B)) participation of 

12 such individual or entity is terminated under title XVIII, 

13 any other State plan under this title, or any child health 

14 plan under title XXI,’’. 

15 (b) APPLICATION TO CHIP.—Section 2107(e)(1)(A) 

16 of such Act (42 U.S.C. 1397gg(e)(1)(A)) is amended by 

17 inserting before the period at the end the following: ‘‘and 

18 section 1902(a)(39) (relating to exclusion and termination 

19 of participation)’’. 

20 (c) EFFECTIVE DATE.—Except as provided in section 

21 1790, the amendments made by this section shall apply 

22 to services furnished on or after January 1, 2011, without 

23 regard to whether or not final regulations to carry out 

24 such amendments have been promulgated by such date. 
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1 SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICI2 PATION RELATING TO CERTAIN OWNERSHIP, 

3 CONTROL, AND MANAGEMENT AFFILIATIONS. 

4 (a) STATE PLAN REQUIREMENT.—Section 1902(a) 

5 of the Social Security Act (42 U.S.C. 1396a(a)), as 

6 amended by sections 1631(b)(1), 1703(a), 1729, and 

7 1753, is further amended— 

8 (1) in paragraph (76), by striking at the end 

9 ‘‘and’’; 

10 (2) in paragraph (77), by striking at the end 

11 the period and inserting ‘‘; and’’; and 

12 (3) by inserting after paragraph (77) the fol13 lowing new paragraph: 

14 ‘‘(78) provide that the State agency described 

15 in paragraph (9) exclude, with respect to a period, 

16 any individual or entity from participation in the 

17 program under the State plan if such individual or 

18 entity owns, controls, or manages an entity that (or 

19 if such entity is owned, controlled, or managed by an 

20 individual or entity that)— 

21 ‘‘(A) has unpaid overpayments under this 

22 title during such period determined by the Sec23 retary or the State agency to be delinquent; 

24 ‘‘(B) is suspended or excluded from par25 ticipation under or whose participation is termi26 nated under this title during such period; or 
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1 ‘‘(C) is affiliated with an individual or enti2 ty that has been suspended or excluded from 

3 participation under this title or whose participa4 tion is terminated under this title during such 

5 period.’’. 

6 (b) CHILD HEALTH PLAN REQUIREMENT.—Section 

7 2107(e)(1)(A) of such Act (42 U.S.C. 1397gg(e)(1)(A)), 

8 as amended by section 1756(b), is amended by striking 

9 ‘‘section 1902(a)(39)’’ and inserting ‘‘sections 

10 1902(a)(39) and 1902(a)(78)’’. 

11 (c) EFFECTIVE DATE.—Except as provided in section 

12 1790, the amendments made by this section shall apply 

13 to services furnished on or after January 1, 2011, without 

14 regard to whether or not final regulations to carry out 

15 such amendments have been promulgated by such date. 

16 SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF 

17 DATA ELEMENTS UNDER MMIS TO DETECT 

18 FRAUD AND ABUSE. 

19 Section 1903(r)(1)(F) of the Social Security Act (42 

20 U.S.C. 1396b(r)(1)(F)) is amended by inserting after 

21 ‘‘necessary’’ the following: ‘‘and including, for data sub22 mitted to the Secretary on or after July 1, 2010, data 

23 elements from the automated data system that the Sec24 retary determines to be necessary for detection of waste, 

25 fraud, and abuse’’. 
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1 SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER 

2 ALTERNATE PAYEES REQUIRED TO REG3 ISTER UNDER MEDICAID. 

4 (a) IN GENERAL.—Section 1902(a) of the Social Se5 curity Act (42 U.S.C. 42 U.S.C. 1396a(a)), as amended 

6 by sections 1631(b), 1703(a), 1729, 1753, and 1757(a), 

7 is further amended— 

8 (1) in paragraph (77); by striking at the end 

9 ‘‘and’’; 

10 (2) in paragraph (78), by striking the period at 

11 the end and inserting ‘‘and’’; and 

12 (3) by inserting after paragraph (78) the fol13 lowing new paragraph: 

14 ‘‘(79) provide that any agent, clearinghouse, or 

15 other alternate payee that submits claims on behalf 

16 of a health care provider must register with the 

17 State and the Secretary in a form and manner speci18 fied by the Secretary under section 1866(j)(1)(D).’’. 

19 (b) DENIAL OF PAYMENT.—Section 1903(i) of such 

20 Act (42 U.S.C. 1396b(i)), as amended by section 1751, 

21 is amended— 

22 (1) by striking ‘‘or’’ at the end of paragraph 

23 (24); 

24 (2) by striking the period at the end of para25 graph (25) and inserting ‘‘; or’’; and 
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1 (3) by inserting after paragraph (25) the fol2 lowing new paragraph: 

3 ‘‘(26) with respect to any amount paid to a bill4 ing agent, clearinghouse, or other alternate payee 

5 that is not registered with the State and the Sec6 retary as required under section 1902(a)(79).’’. 

7 (c) EFFECTIVE DATE.—Except as provided in section 

8 1790, the amendments made by this section shall apply 

9 to claims submitted on or after January 1, 2012, without 

10 regard to whether or not final regulations to carry out 

11 such amendments have been promulgated by such date. 

12 SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RE13 LATED MISCONDUCT. 

14 (a) IN GENERAL.—Section 1903(i) of the Social Se15 curity Act (42 U.S.C. 1396b(i)), as amended by sections 

16 1751(a) and 1759(b), is amended— 

17 (1) by striking ‘‘or’’ at the end of paragraph 

18 (25); 

19 (2) by striking the period at the end of para20 graph (26) and inserting ‘‘; or’’; and 

21 (3) by inserting after paragraph (26) the fol22 lowing new paragraph: 

23 ‘‘(27) with respect to any amount expended— 
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1 ‘‘(A) on litigation in which a court imposes 

2 sanctions on the State, its employees, or its 

3 counsel for litigation-related misconduct; or 

4 ‘‘(B) to reimburse (or otherwise com5 pensate) a managed care entity for payment of 

6 legal expenses associated with any action in 

7 which a court imposes sanctions on the man8 aged care entity for litigation-related mis9 conduct.’’. 

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

11 subsection (a) shall apply to amounts expended on or after 

12 January 1, 2010. 

13 SEC. 1761. MANDATORY STATE USE OF NATIONAL CORRECT 

14 CODING INITIATIVE. 

15 Section 1903(r) of the Social Security Act (42 U.S.C. 

16 1396b(r)) is amended— 

17 (1) in paragraph (1)(B)— 

18 (A) in clause (ii), by striking ‘‘and’’ at the 

19 end; 

20 (B) in clause (iii), by adding ‘‘and’’ at the 

21 end; and 

22 (C) by adding at the end the following new 

23 clause: 

24 ‘‘(iv) effective for claims filed on or 

25 after October 1, 2010, incorporate compat-
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1 ible methodologies of the National Correct 

2 Coding Initiative administered by the Sec3 retary (or any successor initiative to pro4 mote correct coding and to control im5 proper coding leading to inappropriate pay6 ment) and such other methodologies of 

7 that Initiative (or such other national cor8 rect coding methodologies) as the Sec9 retary identifies in accordance with para10 graph (4);’’; and 

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

12 paragraph: 

13 ‘‘(4) Not later than September 1, 2010, the Secretary 

14 shall do the following: 

15 ‘‘(A) Identify those methodologies of the Na16 tional Correct Coding Initiative administered by the 

17 Secretary (or any successor initiative to promote cor18 rect coding and to control improper coding leading 

19 to inappropriate payment) which are compatible to 

20 claims filed under this title. 

21 ‘‘(B) Identify those methodologies of such Ini22 tiative (or such other national correct coding meth23 odologies) that should be incorporated into claims 

24 filed under this title with respect to items or services 

25 for which States provide medical assistance under 
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1 this title and no national correct coding methodolo2 gies have been established under such Initiative with 

3 respect to title XVIII. 

4 ‘‘(C) Notify States of— 

5 ‘‘(i) the methodologies identified under 

6 subparagraphs (A) and (B) (and of any other 

7 national correct coding methodologies identified 

8 under subparagraph (B)); and 

9 ‘‘(ii) how States are to incorporate such 

10 methodologies into claims filed under this title. 

11 ‘‘(D) Submit a report to Congress that includes 

12 the notice to States under subparagraph (C) and an 

13 analysis supporting the identification of the meth14 odologies made under subparagraphs (A) and (B).’’. 

15 Subtitle G—Payments to the 

16 Territories 

17 SEC. 1771. PAYMENT TO TERRITORIES. 

18 (a) INCREASE IN CAP.—Section 1108 of the Social 

19 Security Act (42 U.S.C. 1308) is amended— 

20 (1) in subsection (f), by striking ‘‘subsection 

21 (g)’’ and inserting ‘‘subsections (g) and (h)’’; 

22 (2) in subsection (g)(1), by striking ‘‘With re23 spect to’’ and inserting ‘‘Subject to subsection (h), 

24 with respect to’’; and 
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1 (3) by adding at the end the following new sub2 section: 

3 ‘‘(h) ADDITIONAL INCREASE FOR FISCAL YEARS

4 2011 THROUGH 2019.—Subject to section 347(b)(1) of 

5 the Affordable Health Care for America Act, with respect 

6 to fiscal years 2011 through 2019, the amounts otherwise 

7 determined under subsections (f) and (g) for Puerto Rico, 

8 the Virgin Islands, Guam, the Northern Mariana Islands 

9 and American Samoa shall be increased by the following 

10 amounts: 

11 ‘‘(1) For Puerto Rico, for fiscal year 2011, 

12 $727,600,000; for fiscal year 2012, $775,000,000; 

13 for fiscal year 2013, $850,000,000; for fiscal year 

14 2014, $925,000,000; for fiscal year 2015, 

15 $1,000,000,000; for fiscal year 2016, 

16 $1,075,000,000; for fiscal year 2017, 

17 $1,150,000,000; for fiscal year 2018, 

18 $1,225,000,000; and for fiscal year 2019, 

19 $1,396,400,000. 

20 ‘‘(2) For the Virgin Islands, for fiscal year 

21 2011, $34,000,000; for fiscal year 2012, 

22 $37,000,000; for fiscal year 2013, $40,000,000; for 

23 fiscal year 2014, $43,000,000; for fiscal year 2015, 

24 $46,000,000; for fiscal year 2016, $49,000,000; for 
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1 fiscal year 2017, $52,000,000; for fiscal year 2018, 

2 $55,000,000; and for fiscal year 2019, $58,000,000. 

3 ‘‘(3) For Guam, for fiscal year 2011, 

4 $34,000,000; for fiscal year 2012, $37,000,000; for 

5 fiscal year 2013, $40,000,000; for fiscal year 2014, 

6 $43,000,000; for fiscal year 2015, $46,000,000; for 

7 fiscal year 2016, $49,000,000; for fiscal year 2017, 

8 $52,000,000; for fiscal year 2018, $55,000,000; and 

9 for fiscal year 2019, $58,000,000. 

10 ‘‘(4) For the Northern Mariana Islands, for fis11 cal year 2011, $13,500,000; fiscal year 2012, 

12 $14,500,000; for fiscal year 2013, $15,500,000; for 

13 fiscal year 2014, $16,500,000; for fiscal year 2015, 

14 $17,500,000; for fiscal year 2016, $18,500,000; for 

15 fiscal year 2017, $19,500,000; for fiscal year 2018, 

16 $21,000,000; and for fiscal year 2019, $22,000,000. 

17 ‘‘(5) For American Samoa, fiscal year 2011, 

18 $22,000,000; fiscal year 2012, $23,687,500; for fis19 cal year 2013, $24,687,500; for fiscal year 2014, 

20 $25,687,500; for fiscal year 2015, $26,687,500; for 

21 fiscal year 2016, $27,687,500; for fiscal year 2017, 

22 $28,687,500; for fiscal year 2018, $29,687,500; and 

23 for fiscal year 2019, $30,687,500.’’. 

24 (b) REPORT ON ACHIEVING MEDICAID PARITY PAY25 MENTS BEGINNING WITH FISCAL YEAR 2020.— 
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1 (1) IN GENERAL.—Not later than October 1, 

2 2013, the Secretary of Health and Human Services 

3 shall submit to Congress a report that details a plan 

4 for the transition of each territory to full parity in 

5 Medicaid with the 50 States and the District of Co6 lumbia in fiscal year 2020 by modifying their exist7 ing Medicaid programs and outlining actions the 

8 Secretary and the governments of each territory 

9 must take by fiscal year 2020 to ensure parity in fi10 nancing. Such report shall include what the Federal 

11 medical assistance percentages would be for each 

12 territory if the formula applicable to the 50 States 

13 were applied. Such report shall also include any rec14 ommendations that the Secretary may have as to 

15 whether the mandatory ceiling amounts for each ter16 ritory provided for in section 1108 of the Social Se17 curity Act (42 U.S.C. 1308) should be increased any 

18 time before fiscal year 2020 due to any factors that 

19 the Secretary deems relevant. 

20 (2) PER CAPITA DATA.—As part of such report 

21 the Secretary shall include information about per 

22 capita income data that could be used to calculate 

23 Federal medical assistance percentages under section 

24 1905(b) of the Social Security Act, under section 

25 1108(a)(8)(B) of such Act, for each territory on how 
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1 such data differ from the per capita income data 

2 used to promulgate Federal medical assistance per3 centages for the 50 States. The report under this 

4 subsection shall include recommendations on how 

5 the Federal medical assistance percentages can be 

6 calculated for the territories beginning in fiscal year 

7 2020 to ensure parity with the 50 States. 

8 (3) SUBSEQUENT REPORTS.—The Secretary 

9 shall submit subsequent reports to Congress in 

10 2015, 2017, and 2019 detailing the progress that 

11 the Secretary and the governments of each territory 

12 have made in fulfilling the actions outlined in the 

13 plan submitted under paragraph (1). 

14 (c) APPLICATION OF FMAP FOR ADDITIONAL

15 FUNDS.—Section 1905(b) of such Act (42 U.S.C. 

16 1396d(b)) is amended by adding at the end the following 

17 sentence: ‘‘Notwithstanding the first sentence of this sub18 section and any other provision of law, for fiscal years 

19 2011 through 2019, the Federal medical assistance per20 centage for Puerto Rico, the Virgin Islands, Guam, the 

21 Northern Mariana Islands, and American Samoa shall be 

22 the highest Federal medical assistance percentage applica23 ble to any of the 50 States or the District of Columbia 

24 for the fiscal year involved, taking into account the appli25 cation of subsections (a) and (b)(1) of section 5001 of di-
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1 vision B of the American Recovery and Reinvestment Act 

2 of 2009 (Public Law 111–5) to such States and the Dis3 trict for calendar quarters during such fiscal years for 

4 which such subsections apply.’’. 

5 (d) WAIVERS.— 

6 (1) IN GENERAL.—Section 1902(j) of the Social 

7 Security Act (42 U.S.C. 1396a(j)) is amended— 

8 (A) by striking ‘‘American Samoa and the 

9 Northern Mariana Islands’’ and inserting 

10 ‘‘Puerto Rico, the Virgin Islands, Guam, the 

11 Northern Mariana Islands, and American 

12 Samoa’’; and 

13 (B) by striking ‘‘American Samoa or the 

14 Northern Mariana Islands’’ and inserting 

15 ‘‘Puerto Rico, the Virgin Islands, Guam, the 

16 Northern Mariana Islands, or American 

17 Samoa’’. 

18 (2) EFFECTIVE DATE.—The amendments made 

19 by paragraph (1) shall apply beginning with fiscal 

20 year 2011. 

21 (e) TECHNICAL ASSISTANCE.—The Secretary shall 

22 provide nonmonetary technical assistance to the govern23 ments of Puerto Rico, the Virgin Islands, Guam, the 

24 Northern Mariana Islands, and American Samoa in up25 grading their existing computer systems in order to antici-
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1 pate meeting reporting requirements necessary to imple2 ment the plan contained in the report under subsection 

3 (b)(1). 

4 Subtitle H—Miscellaneous 

5 SEC. 1781. TECHNICAL CORRECTIONS. 

6 (a) TECHNICAL CORRECTION TO SECTION 1144 OF

7 THE SOCIAL SECURITY ACT.—The first sentence of sec8 tion 1144(c)(3) of the Social Security Act (42 U.S.C. 

9 1320b—14(c)(3)) is amended— 

10 (1) by striking ‘‘transmittal’’; and 

11 (2) by inserting before the period the following: 

12 ‘‘as specified in section 1935(a)(4)’’. 

13 (b) CLARIFYING AMENDMENT TO SECTION 1935 OF

14 THE SOCIAL SECURITY ACT.—Section 1935(a)(4) of the 

15 Social Security Act (42 U.S.C. 1396u—5(a)(4)), as 

16 amended by section 113(b) of Public Law 110–275, is 

17 amended— 

18 (1) by striking the second sentence; 

19 (2) by redesignating the first sentence as a sub20 paragraph (A) with appropriate indentation and 

21 with the following heading: ‘‘IN GENERAL.—’’; 

22 (3) by adding at the end the following subpara23 graphs: 

24 ‘‘(B) FURNISHING MEDICAL ASSISTANCE

25 WITH REASONABLE PROMPTNESS.—For the 
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1 purpose of a State’s obligation under section 

2 1902(a)(8) to furnish medical assistance with 

3 reasonable promptness, the date of the elec4 tronic transmission of low-income subsidy pro5 gram data, as described in section 1144(c), 

6 from the Commissioner of Social Security to the 

7 State Medicaid Agency, shall constitute the date 

8 of filing of such application for benefits under 

9 the Medicare Savings Program. 

10 ‘‘(C) DETERMINING AVAILABILITY OF

11 MEDICAL ASSISTANCE.—For the purpose of de12 termining when medical assistance will be made 

13 available, the State shall consider the date of 

14 the individual’s application for the low income 

15 subsidy program to constitute the date of filing 

16 for benefits under the Medicare Savings Pro17 gram.’’. 

18 (c) EFFECTIVE DATE RELATING TO MEDICAID

19 AGENCY CONSIDERATION OF LOW-INCOME SUBSIDY AP20 PLICATION AND DATA TRANSMITTAL.—The amendments 

21 made by subsections (a) and (b) shall be effective as if 

22 included in the enactment of section 113(b) of Public Law 

23 110–275. 

24 (d) TECHNICAL CORRECTION TO SECTION 605 OF

25 CHIPRA.—Section 605 of the Children’s Health Insur-
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1 ance Program Reauthorization Act of 2009 (Public Law 

2 111–3) is amended by striking ‘‘legal residents’’ and in3 serting ‘‘lawfully residing in the United States’’. 

4 (e) TECHNICAL CORRECTION TO SECTION 1905 OF

5 THE SOCIAL SECURITY ACT.—Section 1905(a) of the So6 cial Security Act (42 U.S.C. 1396d(a)) is amended by in7 serting ‘‘or the care and services themselves, or both’’ be8 fore ‘‘(if provided in or after’’. 

9 (f) CLARIFYING AMENDMENT TO SECTION 1115 OF

10 THE SOCIAL SECURITY ACT.—Section 1115(a) of the So11 cial Security Act (42 U.S.C. 1315(a)) is amended by add12 ing at the end the following: ‘‘If an experimental, pilot, 

13 or demonstration project that relates to title XIX is ap14 proved pursuant to any part of this subsection, such 

15 project shall be treated as part of the State plan, all med16 ical assistance provided on behalf of any individuals af17 fected by such project shall be medical assistance provided 

18 under the State plan, and all provisions of this Act not 

19 explicitly waived in approving such project shall remain 

20 fully applicable to all individuals receiving benefits under 

21 the State plan.’’. 

22 SEC. 1782. EXTENSION OF QI PROGRAM. 

23 (a) IN GENERAL.—Section 1902(a)(10)(E)(iv) of the 

24 Social Security Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is 

25 amended— 
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1 (1) by striking ‘‘sections 1933 and’’ and by in2 serting ‘‘section’’; and 

3 (2) by striking ‘‘December 2010’’ and inserting 

4 ‘‘December 2012’’. 

5 (b) ELIMINATION OF FUNDING LIMITATION.— 

6 (1) IN GENERAL.—Section 1933 of such Act 

7 (42 U.S.C. 1396u–3) is amended— 

8 (A) in subsection (a), by striking ‘‘who are 

9 selected to receive such assistance under sub10 section (b)’’; 

11 (B) by striking subsections (b), (c), (e), 

12 and (g); 

13 (C) in subsection (d), by striking ‘‘fur14 nished in a State’’ and all that follows and in15 serting ‘‘the Federal medical assistance percent16 age shall be equal to 100 percent.’’; and 

17 (D) by redesignating subsections (d) and 

18 (f) as subsections (b) and (c), respectively. 

19 (2) CONFORMING AMENDMENT.—Section 

20 1905(b) of such Act (42 U.S.C. 1396d(b)) is amend21 ed by striking ‘‘1933(d)’’ and inserting ‘‘1933(b)’’. 

22 (3) EFFECTIVE DATE.—The amendments made 

23 by paragraph (1) shall take effect on January 1, 

24 2011. 
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1 SEC. 1783. ASSURING TRANSPARENCY OF INFORMATION. 

2 (a) IN GENERAL.—Section 1902(a) of the Social Se3 curity Act (42 U.S.C. 1396a(a)), as amended by sections 

4 1631(b), 1703(a), 1729, 1753, 1757(a), 1759(a), and 

5 1907(b), is amended— 

6 (1) by striking ‘‘and’’ at the end of paragraph 

7 (79); 

8 (2) by striking the period at the end of para9 graph (80) and inserting ‘‘; and’’; and 

10 (3) by inserting after paragraph (80) the fol11 lowing new paragraph: 

12 ‘‘(81) provide that the State will establish and 

13 maintain laws, in accordance with the requirements 

14 of section 1921A, to require disclosure of informa15 tion on hospital charges and quality and to make 

16 such information available to the public and the Sec17 retary.’’; and 

18 (4) by inserting after section 1921 the following 

19 new section: 

20 ‘‘HOSPITAL PRICE TRANSPARENCY

21 ‘‘SEC. 1921A. (a) IN GENERAL.—The requirements 

22 referred to in section 1902(a)(81) are that the laws of a 

23 State must— 

24 ‘‘(1) require reporting to the State (or its 

25 agent) by each hospital located therein, of informa26 tion on— 
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1 ‘‘(A) the charges for the most common in2 patient and outpatient hospital services; 

3 ‘‘(B) the Medicare and Medicaid reim4 bursement amount for such services; and 

5 ‘‘(C) if the hospitals allows for or provides 

6 reduced charges for individuals based on finan7 cial need, the factors considered in making de8 terminations for reductions in charges, includ9 ing any formula for such determination and the 

10 contact information for the specific department 

11 of a hospital that responds to such inquiries; 

12 ‘‘(2) provide for notice to individuals seeking or 

13 requiring such services of the availability of informa14 tion on charges described in paragraph (1); 

15 ‘‘(3) provide for timely access to such informa16 tion, including at least through an Internet website, 

17 by individuals seeking or requiring such services; 

18 and 

19 ‘‘(4) provide for timely access to information re20 garding the quality of care at each hospital made 

21 publicly available in accordance with section 501 of 

22 the Medicare Prescription Drug, Improvement, and 

23 Modernization Act of 2003 (Public Law 108–173), 

24 section 1139A, or section 1139B. 
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1 The Secretary shall consult with stakeholders (including 

2 those entities in section 1808(d)(6) and the National Gov3 ernors Association) through a formal process to obtain 

4 guidance prior to issuing implementing policies under this 

5 section. 

6 ‘‘(b) HOSPITAL DEFINED.—For purposes of this sec7 tion, the term ‘hospital’ means an institution that meets 

8 the requirements of paragraphs (1) and (7) of section 

9 1861(e) and includes those to which section 1820(c) ap10 plies.’’. 

11 (b) EFFECTIVE DATE; ADMINISTRATION.— 

12 (1) IN GENERAL.—Except as provided in para13 graphs (2)(B) and section 1790, the amendments 

14 made by subsection (a) shall take effect on October 

15 1, 2010. 

16 (2) EXISTING PROGRAMS.— 

17 (A) IN GENERAL.—The Secretary of 

18 Health and Human Services shall establish a 

19 process by which a State with an existing pro20 gram may certify to the Secretary that its pro21 gram satisfies the requirements of section 

22 1921A of the Social Security Act, as inserted 

23 by subsection (a). 

24 (B) 2-YEAR PERIOD TO BECOME IN COM25 PLIANCE.—States that, as of the date of the en-
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1 actment of this Act, administer hospital price 

2 transparency policies that do not meet such re3 quirements shall have 2 years from such date to 

4 make necessary modifications to come into com5 pliance and shall not be regarded as failing to 

6 comply with such requirements during such 2- 

7 year period. 

8 SEC. 1784. MEDICAID AND CHIP PAYMENT AND ACCESS 

9 COMMISSION. 

10 (a) REPORT ON NURSING FACILITY PAYMENT POLI11 CIES.—Section 1900(b) of the Social Security Act (42 

12 U.S.C. 1396(b)) is amended by adding at the end the fol13 lowing new paragraph: 

14 ‘‘(10) REPORTS ON SPECIAL TOPICS ON PAY15 MENT POLICIES.— 

16 ‘‘(A) NURSING FACILITY PAYMENT POLI17 CIES.—Not later than January 1, 2012, the 

18 Commission shall submit to Congress a report 

19 on nursing facility payment policies under Med20 icaid that includes— 

21 ‘‘(i) information on the difference be22 tween the amount paid by each State to 

23 nursing facilities in such State under the 

24 Medicaid program under this title and the 

25 cost to such facilities of providing efficient 
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1 quality care to Medicaid eligible individ2 uals; 

3 ‘‘(ii) an evaluation of patient out4 comes and quality as a result of the sup5 plemental payments under section 1745(b) 

6 of the Affordable Health Care for America 

7 Act; and 

8 ‘‘(iii) whether adjustments should be 

9 made under the Medicaid program to the 

10 rates that States pay skilled nursing facili11 ties to ensure that such rates are sufficient 

12 to provide efficient quality care to Med13 icaid eligible individuals.’’. 

14 (b) PEDIATRIC SUBSPECIALIST PAYMENT POLI15 CIES.—Section 1900(b)(10) of the Social Security Act, as 

16 added by subsection (a) is amended by adding at the end 

17 the following new subparagraph: 

18 ‘‘(B) PEDIATRIC SUBSPECIALIST PAYMENT

19 POLICIES.—Not later than January 1, 2011, 

20 the Commission shall submit to Congress a re21 port on payment policies for pediatric sub22 specialist services under Medicaid that in23 cludes— 

24 ‘‘(i) a comprehensive review of each 

25 State’s Medicaid payment rates for inpa-
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1 tient and outpatient pediatric speciality 

2 services; 

3 ‘‘(ii) a comparison, on a State-by4 State basis, of the rates under clause (i) to 

5 Medicare payments for similar services; 

6 ‘‘(iii) information on any limitations 

7 in patient access to pediatric speciality 

8 care, such as delays in receiving care or 

9 wait times for receiving care; 

10 ‘‘(iv) an analysis of the extent to 

11 which low Medicaid payment rates in any 

12 State contributes to limits in access to pe13 diatric subspecialty services in such State; 

14 and 

15 ‘‘(v) recommendations to ameliorate 

16 any problems found with such payment 

17 rates or with access to such services.’’. 

18 (c) ADDITIONAL AMENDMENTS.— 

19 (1) COMMISSION STATUS.—Section 1900(a) of 

20 the Social Security Act is amended by inserting ‘‘as 

21 an agency of Congress’’ after ‘‘established’’. 

22 (2) EXPANSION OF SCOPE.—Section 

23 1900(b)(1)(A) of the Social Security Act is amended 

24 by striking ‘‘children’s access’’ and inserting ‘‘access 
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1 by low-income children and other eligible individ2 uals’’. 

3 (3) CHANGE IN REPORT DEADLINES.—Subpara4 graphs (C) and (D) of section 1900(b)(1) of such 

5 Act are amended by striking ‘‘2010’’ and inserting 

6 ‘‘2011’’ each place it appears. 

7 (4) REPORT IN HEALTH REFORM.—Section 

8 1900(b)(2) of such Act is amended— 

9 (A) in subparagraph (A)(i), by striking 

10 ‘‘skilled’’; 

11 (B) by striking subparagraph (B); 

12 (C) by redesignating subparagraph (C) as 

13 subparagraph (B); and 

14 (D) by adding at the end the following new 

15 subparagraph: 

16 ‘‘(C) IMPLEMENTATION OF HEALTH RE17 FORM.—The implementation of the provisions 

18 of the Affordable Health Care for America Act 

19 that relate to Medicaid or CHIP by the Sec20 retary, the Health Choices Commissioner, and 

21 the States, including the effect of such imple22 mentation on the access to needed health care 

23 items and services by low-income individuals 

24 and families.’’. 
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1 (5) CLARIFICATION OF MEMBERSHIP.—Section 

2 1900(c)(2)(B) of such Act is amended by striking 

3 ‘‘consumers’’ and inserting ‘‘individuals’’. 

4 (6) AUTHORIZATION OF APPROPRIATIONS.— 

5 (A) CURRENT AUTHORIZATION.—Section 

6 1900(f)(2) of such Act is amended— 

7 (i) in the heading, by inserting ‘‘OF

8 APPROPRIATIONS PRIOR TO 2010’’ after 

9 ‘‘AUTHORIZATION’’; and 

10 (ii) by striking ‘‘There are’’ and in11 serting ‘‘Prior to January 1, 2010, there 

12 are’’ 

13 (B) FUTURE AUTHORIZATION.—Section 

14 1900(f) of such Act is further amended by add15 ing at the end the following new paragraph: 

16 after the period the following: 

17 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS FOR

18 2010.—Beginning on January 1, 2010, there is au19 thorized to be appropriated $11,800,000 to carry 

20 out the provisions of this section. Such funds shall 

21 remain available until expended.’’. 

22 SEC. 1785. OUTREACH AND ENROLLMENT OF MEDICAID 

23 AND CHIP ELIGIBLE INDIVIDUALS. 

24 (a) IN GENERAL.—Not later than 12 months after 

25 date of enactment of this Act, the Secretary of Health and 
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1 Human Services shall issue guidance regarding standards 

2 and best practices for conducting outreach to inform eligi3 ble individuals about healthcare coverage under Medicaid 

4 under title XIX of the Social Security Act or for child 

5 health assistance under CHIP under title XXI of such 

6 Act, providing assistance to such individuals for enroll7 ment in applicable programs, and establishing methods or 

8 procedures for eliminating application and enrollment bar9 riers. Such guidance shall include provisions to ensure 

10 that outreach, enrollment assistance, and administrative 

11 simplification efforts are targeted specifically to vulnerable 

12 populations such as children, unaccompanied homeless 

13 youth, victims of abuse or trauma, individuals with mental 

14 health or substance related disorders, and individuals with 

15 HIV/AIDS. Guidance issued pursuant to this section re16 lating to methods to increase outreach and enrollment pro17 vided for under titles XIX and XXI of the Social Security 

18 Act shall specifically target such vulnerable and under19 served populations and shall include, but not be limited 

20 to, guidance on outstationing of eligibility workers, express 

21 lane eligibility, residence requirements, documentation of 

22 income and assets, presumptive eligibility, continuous eli23 gibility, and automatic renewal. 

24 (b) IMPLEMENTATION.—In implementing the re25 quirements under subsection (a), the Secretary may use 
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1 such authorities as are available under law and may work 

2 with such entities as the Secretary deems appropriate to 

3 facilitate effective implementation of such programs. Not 

4 later than 2 years after the enactment of this Act and 

5 annually thereafter, the Secretary shall review and report 

6 to Congress on progress in implementing targeted out7 reach, application and enrollment assistance, and adminis8 trative simplification methods for such vulnerable and un9 derserved populations as are specified in subsection (a). 

10 SEC. 1786. PROHIBITIONS ON FEDERAL MEDICAID AND 

11 CHIP PAYMENT FOR UNDOCUMENTED 

12 ALIENS. 

13 Nothing in this title shall change current prohibitions 

14 against Federal Medicaid and CHIP payments under titles 

15 XIX and XXI of the Social Security Act on behalf of indi16 viduals who are not lawfully present in the United States. 

17 SEC. 1787. DEMONSTRATION PROJECT FOR STABILIZATION 

18 OF EMERGENCY MEDICAL CONDITIONS BY 

19 INSTITUTIONS FOR MENTAL DISEASES. 

20 (a) AUTHORITY TO CONDUCT DEMONSTRATION

21 PROJECT.—The Secretary of Health and Human Services 

22 (in this section referred to as the ‘‘Secretary’’) shall estab23 lish a demonstration project under which an eligible State 

24 (as described in subsection (c)) shall provide reimburse25 ment under the State Medicaid plan under title XIX of 
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1 the Social Security Act to an institution for mental dis2 eases that is subject to the requirements of section 1867 

3 of the Social Security Act (42 U.S.C. 1395dd) for the pro4 vision of medical assistance available under such plan to 

5 an individual who— 

6 (1) has attained age 21, but has not attained 

7 age 65; 

8 (2) is eligible for medical assistance under such 

9 plan; and 

10 (3) requires such medical assistance to stabilize 

11 an emergency medical condition. 

12 (b) IN-STAY REVIEW.—The Secretary shall establish 

13 a mechanism for in-stay review to determine whether or 

14 not the patient has been stabilized (as defined in sub15 section (h)(5)). This mechanism shall commence before 

16 the third day of the inpatient stay. States participating 

17 in the demonstration project may manage the provision 

18 of these benefits under the project through utilization re19 view, authorization, or management practices, or the ap20 plication of medical necessity and appropriateness criteria 

21 applicable to behavioral health. 

22 (c) ELIGIBLE STATE DEFINED.— 

23 (1) APPLICATION.—Upon approval of an appli24 cation submitted by a State described in paragraph 

25 (2), the State shall be an eligible State for purposes 
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1 of conducting a demonstration project under this 

2 section. 

3 (2) STATE DESCRIBED.—States shall be se4 lected by the Secretary in a manner so as to provide 

5 geographic diversity on the basis of the application 

6 to conduct a demonstration project under this sec7 tion submitted by such States. 

8 (d) LENGTH OF DEMONSTRATION PROJECT.—The 

9 demonstration project established under this section shall 

10 be conducted for a period of 3 consecutive years. 

11 (e) LIMITATIONS ON FEDERAL FUNDING.— 

12 (1) APPROPRIATION.— 

13 (A) IN GENERAL.—Out of any funds in the 

14 Treasury not otherwise appropriated, there is 

15 appropriated to carry out this section, 

16 $75,000,000 for fiscal year 2010. 

17 (B) BUDGET AUTHORITY.—Subparagraph 

18 (A) constitutes budget authority in advance of 

19 appropriations Act and represents the obliga20 tion of the Federal Government to provide for 

21 the payment of the amounts appropriated under 

22 that subparagraph. 

23 (2) 3-YEAR AVAILABILITY.—Funds appro24 priated under paragraph (1) shall remain available 

25 for obligation through December 31, 2012. 
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1 (3) LIMITATION ON PAYMENTS.—In no case 

2 may— 

3 (A) the aggregate amount of payments 

4 made by the Secretary to eligible States under 

5 this section exceed $75,000,000; or 

6 (B) payments be provided by the Secretary 

7 under this section after December 31, 2012. 

8 (4) FUNDS ALLOCATED TO STATES.—The Sec9 retary shall allocate funds to eligible States based on 

10 their applications and the availability of funds. 

11 (5) PAYMENTS TO STATES.—The Secretary 

12 shall pay to each eligible State, from its allocation 

13 under paragraph (4), an amount each quarter equal 

14 to the Federal medical assistance percentage of ex15 penditures in the quarter for medical assistance de16 scribed in subsection (a). 

17 (f) REPORTS.— 

18 (1) ANNUAL PROGRESS REPORTS.—The Sec19 retary shall submit annual reports to Congress on 

20 the progress of the demonstration project conducted 

21 under this section. 

22 (2) FINAL REPORT AND RECOMMENDATION.— 

23 An evaluation shall be conducted of the demonstra24 tion project’s impact on the functioning of the health 

25 and mental health service system and on individuals 
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1 enrolled in the Medicaid program. This evaluation 

2 shall include collection of baseline data for one-year 

3 prior to the initiation of the demonstration project 

4 as well as collection of data from matched compari5 son states not participating in the demonstration. 

6 The evaluation measures shall include the following: 

7 (A) A determination, by State, as to 

8 whether the demonstration project resulted in 

9 increased access to inpatient mental health 

10 services under the Medicaid program and 

11 whether average length of stays were longer (or 

12 shorter) for individuals admitted under the 

13 demonstration project compared with individ14 uals otherwise admitted in comparison sites. 

15 (B) An analysis, by State, regarding 

16 whether the demonstration project produced a 

17 significant reduction in emergency room visits 

18 for individuals eligible for assistance under the 

19 Medicaid program or in the duration of emer20 gency room lengths of stay. 

21 (C) An assessment of discharge planning 

22 by participating hospitals that ensures access to 

23 further (non-emergency) inpatient or residential 

24 care as well as continuity of care for those dis25 charged to outpatient care. 
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1 (D) An assessment of the impact of the 

2 demonstration project on the costs of the full 

3 range of mental health services (including inpa4 tient, emergency and ambulatory care) under 

5 the plan as contrasted with the comparison 

6 areas. 

7 (E) Data on the percentage of consumers 

8 with Medicaid coverage who are admitted to in9 patient facilities as a result of the demonstra10 tion project as compared to those admitted to 

11 these same facilities through other means. 

12 (F) A recommendation regarding whether 

13 the demonstration project should be continued 

14 after December 31, 2012, and expanded on a 

15 national basis. 

16 (g) WAIVER AUTHORITY.— 

17 (1) IN GENERAL.—The Secretary shall waive 

18 the limitation of subdivision (B) following paragraph 

19 (28) of section 1905(a) of the Social Security Act 

20 (42 U.S.C. 1396d(a)) (relating to limitations on pay21 ments for care or services for individuals under 65 

22 years of age who are patients in an institution for 

23 mental diseases) for purposes of carrying out the 

24 demonstration project under this section. 
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1 (2) LIMITED OTHER WAIVER AUTHORITY.—The 

2 Secretary may waive other requirements of title XIX 

3 of the Social Security Act (including the require4 ments of sections 1902(a)(1) (relating to 

5 statewideness) and 1902(1)(10)(B) (relating to com6 parability)) only to extent necessary to carry out the 

7 demonstration project under this section. 

8 (h) DEFINITIONS.—In this section: 

9 (1) EMERGENCY MEDICAL CONDITION.—The 

10 term ‘‘emergency medical condition’’ means, with re11 spect to an individual, an individual who expresses 

12 suicidal or homicidal thoughts or gestures, if deter13 mined dangerous to self or others. 

14 (2) FEDERAL MEDICAL ASSISTANCE PERCENT15 AGE.—The term ‘‘Federal medical assistance per16 centage’’ has the meaning given that term with re17 spect to a State under section 1905(b) of the Social 

18 Security Act (42 U.S.C. 1396d(b)). 

19 (3) INSTITUTION FOR MENTAL DISEASES.—The 

20 term ‘‘institution for mental diseases’’ has the mean21 ing given to that term in section 1905(i) of the So22 cial Security Act (42 U.S.C. 1396d(i)). 

23 (4) MEDICAL ASSISTANCE.—The term ‘‘medical 

24 assistance’’ has the meaning given to that term in 
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1 section 1905(a) of the Social Security Act (42 

2 U.S.C. 1396d(a)). 

3 (5) STABILIZED.—The term ‘‘stabilized’’ 

4 means, with respect to an individual, that the emer5 gency medical condition no longer exists with respect 

6 to the individual and the individual is no longer dan7 gerous to self or others. 

8 (6) STATE.—The term ‘‘State’’ has the mean9 ing given that term for purposes of title XIX of the 

10 Social Security Act (42 U.S.C. 1396 et seq.). 

11 SEC. 1788. APPLICATION OF MEDICAID IMPROVEMENT 

12 FUND. 

13 Section 1941(b)(1) of the Social Security Act (42 

14 U.S.C. 1396w–1(b)(1)) is amended by striking ‘‘from the 

15 Fund’’ and all that follows and inserting ‘‘from the Fund, 

16 only such amounts as may be appropriated or otherwise 

17 made available by law.’’. 

18 SEC. 1789. TREATMENT OF CERTAIN MEDICAID BROKERS. 

19 Section 1903(b)(4) of the Social Security Act (42 

20 U.S.C. 1396b(b)(4)) is amended— 

21 (1) in the matter before subparagraph (A), by 

22 inserting after ‘‘respect to the broker’’ the following: 

23 ‘‘(or, in the case of subparagraph (A) and subpara24 graph (B)(i), if the Inspector General of Department 

25 of Health and Human Services finds that the broker 
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1 has established and maintains procedures to ensure 

2 the independence of its enrollment activities from 

3 the interests of any managed care entity or pro4 vider)’’; and 

5 (2) in subparagraph (B)— 

6 (A) by inserting ‘‘(i)’’ after ‘‘either’’; and 

7 (B) by inserting ‘‘(ii)’’ after ‘‘health care 

8 provider or’’. 

9 SEC. 1790. RULE FOR CHANGES REQUIRING STATE LEGIS10 LATION. 

11 In the case of a State plan for medical assistance 

12 under title XIX of the Social Security Act which the Sec13 retary of Health and Human Services determines requires 

14 State legislation (other than legislation appropriating 

15 funds) in order for the plan to meet an additional require16 ment imposed by an amendment made by this title, the 

17 State plan shall not be regarded as failing to comply with 

18 the requirements of such title XIX solely on the basis of 

19 its failure to meet this additional requirement before the 

20 first day of the first calendar quarter beginning after the 

21 close of the first regular session of the State legislature 

22 that begins after the date of the enactment of this Act. 

23 For purposes of the previous sentence, in the case of a 

24 State that has a 2-year legislative session, each year of 
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1 such session shall be deemed to be a separate regular ses2 sion of the State legislature. 

3 TITLE VIII—REVENUE-RELATED 

4 PROVISIONS 

5 SEC. 1801. DISCLOSURES TO FACILITATE IDENTIFICATION 

6 OF INDIVIDUALS LIKELY TO BE INELIGIBLE 

7 FOR THE LOW-INCOME ASSISTANCE UNDER 

8 THE MEDICARE PRESCRIPTION DRUG PRO9 GRAM TO ASSIST SOCIAL SECURITY ADMINIS10 TRATION’S OUTREACH TO ELIGIBLE INDIVID11 UALS. 

12 (a) IN GENERAL.—Paragraph (19) of section 6103(l) 

13 of the Internal Revenue Code of 1986 is amended to read 

14 as follows: 

15 ‘‘(19) DISCLOSURES TO FACILITATE IDENTI16 FICATION OF INDIVIDUALS LIKELY TO BE INELI17 GIBLE FOR LOW-INCOME SUBSIDIES UNDER MEDI18 CARE PRESCRIPTION DRUG PROGRAM TO ASSIST SO19 CIAL SECURITY ADMINISTRATION’S OUTREACH TO

20 ELIGIBLE INDIVIDUALS.— 

21 ‘‘(A) IN GENERAL.—Upon written request 

22 from the Commissioner of Social Security, the 

23 following return information (including such in24 formation disclosed to the Social Security Ad25 ministration under paragraph (1) or (5)) shall 
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1 be disclosed to officers and employees of the So2 cial Security Administration, with respect to 

3 any taxpayer identified by the Commissioner of 

4 Social Security— 

5 ‘‘(i) return information for the appli6 cable year from returns with respect to 

7 wages (as defined in section 3121(a) or 

8 3401(a)) and payments of retirement in9 come (as described in paragraph (1) of this 

10 subsection), 

11 ‘‘(ii) unearned income information 

12 and income information of the taxpayer 

13 from partnerships, trusts, estates, and sub14 chapter S corporations for the applicable 

15 year, 

16 ‘‘(iii) if the individual filed an income 

17 tax return for the applicable year, the fil18 ing status, number of dependents, income 

19 from farming, and income from self-em20 ployment, on such return, 

21 ‘‘(iv) if the individual is a married in22 dividual filing a separate return for the ap23 plicable year, the social security number (if 

24 reasonably available) of the spouse on such 

25 return, 
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1 ‘‘(v) if the individual files a joint re2 turn for the applicable year, the social se3 curity number, unearned income informa4 tion, and income information from partner5 ships, trusts, estates, and subchapter S 

6 corporations of the individual’s spouse on 

7 such return, and 

8 ‘‘(vi) such other return information 

9 relating to the individual (or the individ10 ual’s spouse in the case of a joint return) 

11 as is prescribed by the Secretary by regula12 tion as might indicate that the individual 

13 is likely to be ineligible for a low-income 

14 prescription drug subsidy under section 

15 1860D–14 of the Social Security Act. 

16 ‘‘(B) APPLICABLE YEAR.—For the pur17 poses of this paragraph, the term ‘applicable 

18 year’ means the most recent taxable year for 

19 which information is available in the Internal 

20 Revenue Service’s taxpayer information records. 

21 ‘‘(C) RESTRICTION ON INDIVIDUALS FOR

22 WHOM DISCLOSURE MAY BE REQUESTED.—The 

23 Commissioner of Social Security shall request 

24 information under this paragraph only with re25 spect to— 
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1 ‘‘(i) individuals the Social Security 

2 Administration has identified, using all 

3 other reasonably available information, as 

4 likely to be eligible for a low-income pre5 scription drug subsidy under section 

6 1860D–14 of the Social Security Act and 

7 who have not applied for such subsidy, and 

8 ‘‘(ii) any individual the Social Security 

9 Administration has identified as a spouse 

10 of an individual described in clause (i). 

11 ‘‘(D) RESTRICTION ON USE OF DISCLOSED

12 INFORMATION.—Return information disclosed 

13 under this paragraph may be used only by offi14 cers and employees of the Social Security Ad15 ministration solely for purposes of identifying 

16 individuals likely to be ineligible for a low-in17 come prescription drug subsidy under section 

18 1860D–14 of the Social Security Act for use in 

19 outreach efforts under section 1144 of the So20 cial Security Act.’’. 

21 (b) SAFEGUARDS.—Paragraph (4) of section 6103(p) 

22 of such Code is amended— 

23 (1) by striking ‘‘(19),’’ each place it appears, 

24 and 
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1 (2) by striking ‘‘or (17)’’ each place it appears 

2 and inserting ‘‘(17), or (19)’’. 

3 (c) CONFORMING AMENDMENT.—Paragraph (3) of 

4 section 6103(a) of such Code is amended by striking 

5 ‘‘(19),’’. 

6 (d) EFFECTIVE DATE.—The amendments made by 

7 this section shall apply to disclosures made after the date 

8 which is 12 months after the date of the enactment of 

9 this Act. 

10 SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH 

11 TRUST FUND; FINANCING FOR TRUST FUND. 

12 (a) ESTABLISHMENT OF TRUST FUND.— 

13 (1) IN GENERAL.—Subchapter A of chapter 98 

14 of the Internal Revenue Code of 1986 (relating to 

15 trust fund code) is amended by adding at the end 

16 the following new section: 

17 ‘‘SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS 

18 RESEARCH TRUST FUND. 

19 ‘‘(a) CREATION OF TRUST FUND.—There is estab20 lished in the Treasury of the United States a trust fund 

21 to be known as the ‘Health Care Comparative Effective22 ness Research Trust Fund’ (hereinafter in this section re23 ferred to as the ‘CERTF’), consisting of such amounts 

24 as may be appropriated or credited to such Trust Fund 

25 as provided in this section and section 9602(b). 
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1 ‘‘(b) TRANSFERS TO FUND.— 

2 ‘‘(1) IN GENERAL.—There are hereby appro3 priated to the Trust Fund the following: 

4 ‘‘(A) For fiscal year 2010, $90,000,000. 

5 ‘‘(B) For fiscal year 2011, $100,000,000. 

6 ‘‘(C) For fiscal year 2012, $110,000,000. 

7 ‘‘(D) For each fiscal year beginning with 

8 fiscal year 2013— 

9 ‘‘(i) an amount equivalent to the net 

10 revenues received in the Treasury from the 

11 fees imposed under subchapter B of chap12 ter 34 (relating to fees on health insurance 

13 and self-insured plans) for such fiscal year; 

14 and 

15 ‘‘(ii) subject to subsection (c)(2), 

16 amounts determined by the Secretary of 

17 Health and Human Services to be equiva18 lent to the fair share per capita amount 

19 computed under subsection (c)(1) for the 

20 fiscal year multiplied by the average num21 ber of individuals entitled to benefits under 

22 part A, or enrolled under part B, of title 

23 XVIII of the Social Security Act during 

24 such fiscal year. 

25 ‘‘(2) ADMINISTRATIVE PROVISIONS.— 
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1 ‘‘(A) TRANSFERS FROM OTHER TRUST

2 FUNDS.—The amounts appropriated by sub3 paragraphs (A), (B), (C), and (D)(ii) of para4 graph (1) shall be transferred from the Federal 

5 Hospital Insurance Trust Fund and from the 

6 Federal Supplementary Medical Insurance 

7 Trust Fund (established under section 1841 of 

8 such Act), and from the Medicare Prescription 

9 Drug Account within such Trust Fund, in pro10 portion (as estimated by the Secretary) to the 

11 total expenditures during such fiscal year that 

12 are made under title XVIII of such Act from 

13 the respective trust fund or account. 

14 ‘‘(B) APPROPRIATIONS NOT SUBJECT TO

15 FISCAL YEAR LIMITATION.—The amounts ap16 propriated by paragraph (1) shall not be sub17 ject to any fiscal year limitation. 

18 ‘‘(C) PERIODIC TRANSFERS, ESTIMATES, 

19 AND ADJUSTMENTS.—Except as provided in 

20 subparagraph (A), the provisions of section 

21 9601 shall apply to the amounts appropriated 

22 by paragraph (1). 

23 ‘‘(c) FAIR SHARE PER CAPITA AMOUNT.— 

24 ‘‘(1) COMPUTATION.— 
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1 ‘‘(A) IN GENERAL.—Subject to subpara2 graph (B), the fair share per capita amount 

3 under this paragraph for a fiscal year (begin4 ning with fiscal year 2013) is an amount com5 puted by the Secretary of Health and Human 

6 Services for such fiscal year that, when applied 

7 under this section and subchapter B of chapter 

8 34 of the Internal Revenue Code of 1986, will 

9 result in revenues to the CERTF of 

10 $375,000,000 for the fiscal year. 

11 ‘‘(B) ALTERNATIVE COMPUTATION.— 

12 ‘‘(i) IN GENERAL.—If the Secretary is 

13 unable to compute the fair share per capita 

14 amount under subparagraph (A) for a fis15 cal year, the fair share per capita amount 

16 under this paragraph for the fiscal year 

17 shall be the default amount determined 

18 under clause (ii) for the fiscal year. 

19 ‘‘(ii) DEFAULT AMOUNT.—The default 

20 amount under this clause for— 

21 ‘‘(I) fiscal year 2013 is equal to 

22 $2; or 

23 ‘‘(II) a subsequent year is equal 

24 to the default amount under this 

25 clause for the preceding fiscal year in-
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1 creased by the annual percentage in2 crease in the medical care component 

3 of the consumer price index (United 

4 States city average) for the 12-month 

5 period ending with April of the pre6 ceding fiscal year. 

7 Any amount determined under subclause 

8 (II) shall be rounded to the nearest penny. 

9 ‘‘(2) LIMITATION ON MEDICARE FUNDING.—In 

10 no case shall the amount transferred under sub11 section (b)(4)(B) for any fiscal year exceed 

12 $90,000,000. 

13 ‘‘(d) EXPENDITURES FROM FUND.— 

14 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

15 amounts in the CERTF are available, without the 

16 need for further appropriations and without fiscal 

17 year limitation, to the Secretary of Health and 

18 Human Services to carry out section 1181 of the So19 cial Security Act. 

20 ‘‘(2) ALLOCATION FOR COMMISSION.—The fol21 lowing amounts in the CERTF shall be available, 

22 without the need for further appropriations and 

23 without fiscal year limitation, to the Commission to 

24 carry out the activities of the Comparative Effective-
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1 ness Research Commission established under section 

2 1181(b) of the Social Security Act: 

3 ‘‘(A) For fiscal year 2010, $7,000,000. 

4 ‘‘(B) For fiscal year 2011, $9,000,000. 

5 ‘‘(C) For each fiscal year beginning with 

6 2012, 2.6 percent of the total amount appro7 priated to the CERTF under subsection (b) for 

8 the fiscal year. 

9 ‘‘(e) NET REVENUES.—For purposes of this section, 

10 the term ‘net revenues’ means the amount estimated by 

11 the Secretary based on the excess of— 

12 ‘‘(1) the fees received in the Treasury under 

13 subchapter B of chapter 34, over 

14 ‘‘(2) the decrease in the tax imposed by chapter 

15 1 resulting from the fees imposed by such sub16 chapter.’’. 

17 (2) CLERICAL AMENDMENT.—The table of sec18 tions for such subchapter A is amended by adding 

19 at the end thereof the following new item: 

‘‘Sec. 9511. Health Care Comparative Effectiveness Research Trust Fund.’’. 

20 (b) FINANCING FOR FUND FROM FEES ON INSURED

21 AND SELF-INSURED HEALTH PLANS.— 

22 (1) GENERAL RULE.—Chapter 34 of the Inter23 nal Revenue Code of 1986 is amended by adding at 

24 the end the following new subchapter: 
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1 ‘‘Subchapter B—Insured and Self-Insured 

2 Health Plans 

‘‘Sec. 4375. Health insurance. 

‘‘Sec. 4376. Self-insured health plans. 

‘‘Sec. 4377. Definitions and special rules. 

3 ‘‘SEC. 4375. HEALTH INSURANCE. 

4 ‘‘(a) IMPOSITION OF FEE.—There is hereby imposed 

5 on each specified health insurance policy for each policy 

6 year a fee equal to the fair share per capita amount deter7 mined under section 9511(c)(1) multiplied by the average 

8 number of lives covered under the policy. 

9 ‘‘(b) LIABILITY FOR FEE.—The fee imposed by sub10 section (a) shall be paid by the issuer of the policy. 

11 ‘‘(c) SPECIFIED HEALTH INSURANCE POLICY.—For 

12 purposes of this section: 

13 ‘‘(1) IN GENERAL.—Except as otherwise pro14 vided in this section, the term ‘specified health in15 surance policy’ means any accident or health insur16 ance policy issued with respect to individuals resid17 ing in the United States. 

18 ‘‘(2) EXEMPTION FOR CERTAIN POLICIES.—The 

19 term ‘specified health insurance policy’ does not in20 clude any insurance if substantially all of its cov21 erage is of excepted benefits described in section 

22 9832(c). 

23 ‘‘(3) TREATMENT OF PREPAID HEALTH COV24 ERAGE ARRANGEMENTS.— 
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1 ‘‘(A) IN GENERAL.—In the case of any ar2 rangement described in subparagraph (B)— 

3 ‘‘(i) such arrangement shall be treated 

4 as a specified health insurance policy, and 

5 ‘‘(ii) the person referred to in such 

6 subparagraph shall be treated as the 

7 issuer. 

8 ‘‘(B) DESCRIPTION OF ARRANGEMENTS.— 

9 An arrangement is described in this subpara10 graph if under such arrangement fixed pay11 ments or premiums are received as consider12 ation for any person’s agreement to provide or 

13 arrange for the provision of accident or health 

14 coverage to residents of the United States, re15 gardless of how such coverage is provided or ar16 ranged to be provided. 

17 ‘‘SEC. 4376. SELF-INSURED HEALTH PLANS. 

18 ‘‘(a) IMPOSITION OF FEE.—In the case of any appli19 cable self-insured health plan for each plan year, there is 

20 hereby imposed a fee equal to the fair share per capita 

21 amount determined under section 9511(c)(1) multiplied by 

22 the average number of lives covered under the plan. 

23 ‘‘(b) LIABILITY FOR FEE.— 

24 ‘‘(1) IN GENERAL.—The fee imposed by sub25 section (a) shall be paid by the plan sponsor. 
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1 ‘‘(2) PLAN SPONSOR.—For purposes of para2 graph (1) the term ‘plan sponsor’ means— 

3 ‘‘(A) the employer in the case of a plan es4 tablished or maintained by a single employer, 

5 ‘‘(B) the employee organization in the case 

6 of a plan established or maintained by an em7 ployee organization, 

8 ‘‘(C) in the case of— 

9 ‘‘(i) a plan established or maintained 

10 by 2 or more employers or jointly by 1 or 

11 more employers and 1 or more employee 

12 organizations, 

13 ‘‘(ii) a multiple employer welfare ar14 rangement, or 

15 ‘‘(iii) a voluntary employees’ bene16 ficiary association described in section 

17 501(c)(9), 

18 the association, committee, joint board of trust19 ees, or other similar group of representatives of 

20 the parties who establish or maintain the plan, 

21 or 

22 ‘‘(D) the cooperative or association de23 scribed in subsection (c)(2)(F) in the case of a 

24 plan established or maintained by such a coop25 erative or association. 
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1 ‘‘(c) APPLICABLE SELF-INSURED HEALTH PLAN.— 

2 For purposes of this section, the term ‘applicable self-in3 sured health plan’ means any plan for providing accident 

4 or health coverage if— 

5 ‘‘(1) any portion of such coverage is provided 

6 other than through an insurance policy, and 

7 ‘‘(2) such plan is established or maintained— 

8 ‘‘(A) by one or more employers for the 

9 benefit of their employees or former employees, 

10 ‘‘(B) by one or more employee organiza11 tions for the benefit of their members or former 

12 members, 

13 ‘‘(C) jointly by 1 or more employers and 1 

14 or more employee organizations for the benefit 

15 of employees or former employees, 

16 ‘‘(D) by a voluntary employees’ beneficiary 

17 association described in section 501(c)(9), 

18 ‘‘(E) by any organization described in sec19 tion 501(c)(6), or 

20 ‘‘(F) in the case of a plan not described in 

21 the preceding subparagraphs, by a multiple em22 ployer welfare arrangement (as defined in sec23 tion 3(40) of Employee Retirement Income Se24 curity Act of 1974), a rural electric cooperative 

25 (as defined in section 3(40)(B)(iv) of such Act), 
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1 or a rural telephone cooperative association (as 

2 defined in section 3(40)(B)(v) of such Act). 

3 ‘‘SEC. 4377. DEFINITIONS AND SPECIAL RULES. 

4 ‘‘(a) DEFINITIONS.—For purposes of this sub5 chapter— 

6 ‘‘(1) ACCIDENT AND HEALTH COVERAGE.—The 

7 term ‘accident and health coverage’ means any cov8 erage which, if provided by an insurance policy, 

9 would cause such policy to be a specified health in10 surance policy (as defined in section 4375(c)). 

11 ‘‘(2) INSURANCE POLICY.—The term ‘insurance 

12 policy’ means any policy or other instrument where13 by a contract of insurance is issued, renewed, or ex14 tended. 

15 ‘‘(3) UNITED STATES.—The term ‘United 

16 States’ includes any possession of the United States. 

17 ‘‘(b) TREATMENT OF GOVERNMENTAL ENTITIES.— 

18 ‘‘(1) IN GENERAL.—For purposes of this sub19 chapter— 

20 ‘‘(A) the term ‘person’ includes any gov21 ernmental entity, and 

22 ‘‘(B) notwithstanding any other law or rule 

23 of law, governmental entities shall not be ex24 empt from the fees imposed by this subchapter 

25 except as provided in paragraph (2). 
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1 ‘‘(2) TREATMENT OF EXEMPT GOVERNMENTAL

2 PROGRAMS.—In the case of an exempt governmental 

3 program, no fee shall be imposed under section 4375 

4 or section 4376 on any covered life under such pro5 gram. 

6 ‘‘(3) EXEMPT GOVERNMENTAL PROGRAM DE7 FINED.—For purposes of this subchapter, the term 

8 ‘exempt governmental program’ means— 

9 ‘‘(A) any insurance program established 

10 under title XVIII of the Social Security Act, 

11 ‘‘(B) the medical assistance program es12 tablished by title XIX or XXI of the Social Se13 curity Act, 

14 ‘‘(C) any program established by Federal 

15 law for providing medical care (other than 

16 through insurance policies) to individuals (or 

17 the spouses and dependents thereof) by reason 

18 of such individuals being— 

19 ‘‘(i) members of the Armed Forces of 

20 the United States, or 

21 ‘‘(ii) veterans, and 

22 ‘‘(D) any program established by Federal 

23 law for providing medical care (other than 

24 through insurance policies) to members of In-
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1 dian tribes (as defined in section 4(d) of the In2 dian Health Care Improvement Act). 

3 ‘‘(c) TREATMENT AS TAX.—For purposes of subtitle 

4 F, the fees imposed by this subchapter shall be treated 

5 as if they were taxes. 

6 ‘‘(d) NO COVER OVER TO POSSESSIONS.—Notwith7 standing any other provision of law, no amount collected 

8 under this subchapter shall be covered over to any posses9 sion of the United States.’’. 

10 (2) CLERICAL AMENDMENTS.— 

11 (A) Chapter 34 of such Code is amended 

12 by striking the chapter heading and inserting 

13 the following: 

14 ‘‘CHAPTER 34—TAXES ON CERTAIN 

15 INSURANCE POLICIES 

‘‘SUBCHAPTER A. POLICIES ISSUED BY FOREIGN INSURERS

‘‘SUBCHAPTER B. INSURED AND SELF-INSURED HEALTH PLANS

16 ‘‘Subchapter A—Policies Issued By Foreign 

17 Insurers’’. 

18 (B) The table of chapters for subtitle D of 

19 such Code is amended by striking the item re20 lating to chapter 34 and inserting the following 

21 new item: 

‘‘CHAPTER 34—TAXES ON CERTAIN INSURANCE POLICIES’’. 

22 (3) EFFECTIVE DATE.—The amendments made 

23 by this subsection shall apply with respect to policies 
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1 and plans for portions of policy or plan years begin2 ning on or after October 1, 2012. 

3 TITLE IX—MISCELLANEOUS 

4 PROVISIONS 

5 SEC. 1901. REPEAL OF TRIGGER PROVISION. 

6 Subtitle A of title VIII of the Medicare Prescription 

7 Drug, Improvement, and Modernization Act of 2003 (Pub8 lic Law 108–173) is repealed and the provisions of law 

9 amended by such subtitle are restored as if such subtitle 

10 had never been enacted. 

11 SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT 

12 (CCA) PROGRAM. 

13 Section 1860C–1 of the Social Security Act (42 

14 U.S.C. 1395w–29), as added by section 241(a) of the 

15 Medicare Prescription Drug, Improvement, and Mod16 ernization Act of 2003 (Public Law 108–173), is repealed. 

17 SEC. 1903. EXTENSION OF GAINSHARING DEMONSTRATION. 

18 (a) IN GENERAL.—Subsection (d)(3) of section 5007 

19 of the Deficit Reduction Act of 2005 (Public Law 109– 

20 171) is amended by inserting ‘‘(or September 30, 2011, 

21 in the case of a demonstration project in operation as of 

22 October 1, 2008)’’ after ‘‘December 31, 2009’’. 

23 (b) FUNDING.— 
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1 (1) IN GENERAL.—Subsection (f)(1) of such 

2 section is amended by inserting ‘‘and for fiscal year 

3 2010, $1,600,000,’’ after ‘‘$6,000,000,’’. 

4 (2) AVAILABILITY.—Subsection (f)(2) of such 

5 section is amended by striking ‘‘2010’’ and inserting 

6 ‘‘2014 or until expended’’. 

7 (c) REPORTS.— 

8 (1) QUALITY IMPROVEMENT AND SAVINGS.— 

9 Subsection (e)(3) of such section is amended by 

10 striking ‘‘December 1, 2008’’ and inserting ‘‘March 

11 31, 2011’’. 

12 (2) FINAL REPORT.—Subsection (e)(4) of such 

13 section is amended by striking ‘‘May 1, 2010’’ and 

14 inserting ‘‘March 31, 2013’’. 

15 SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITA16 TION PROGRAMS FOR FAMILIES WITH YOUNG 

17 CHILDREN AND FAMILIES EXPECTING CHIL18 DREN. 

19 Part B of title IV of the Social Security Act (42 

20 U.S.C. 621–629i) is amended by adding at the end the 

21 following: 
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1 ‘‘Subpart 3—Support for Quality Home Visitation 

2 Programs 

3 ‘‘SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES 

4 WITH YOUNG CHILDREN AND FAMILIES EX5 PECTING CHILDREN. 

6 ‘‘(a) PURPOSE.—The purpose of this section is to im7 prove the well-being, health, and development of children 

8 by enabling the establishment and expansion of high qual9 ity programs providing voluntary home visitation for fami10 lies with young children and families expecting children. 

11 ‘‘(b) GRANT APPLICATION.—A State that desires to 

12 receive a grant under this section shall submit to the Sec13 retary for approval, at such time and in such manner as 

14 the Secretary may require, an application for the grant 

15 that includes the following: 

16 ‘‘(1) DESCRIPTION OF HOME VISITATION PRO17 GRAMS.—A description of the high quality programs 

18 of home visitation for families with young children 

19 and families expecting children that will be sup20 ported by a grant made to the State under this sec21 tion, the outcomes the programs are intended to 

22 achieve, and the evidence supporting the effective23 ness of the programs. 

24 ‘‘(2) RESULTS OF NEEDS ASSESSMENT.—The 

25 results of a statewide needs assessment that de26 scribes— 
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1 ‘‘(A) the number, quality, and capacity of 

2 home visitation programs for families with 

3 young children and families expecting children 

4 in the State; 

5 ‘‘(B) the number and types of families who 

6 are receiving services under the programs; 

7 ‘‘(C) the sources and amount of funding 

8 provided to the programs; 

9 ‘‘(D) the gaps in home visitation in the 

10 State, including identification of communities 

11 that are in high need of the services; and 

12 ‘‘(E) training and technical assistance ac13 tivities designed to achieve or support the goals 

14 of the programs. 

15 ‘‘(3) ASSURANCES.—Assurances from the State 

16 that— 

17 ‘‘(A) in supporting home visitation pro18 grams using funds provided under this section, 

19 the State shall identify and prioritize serving 

20 communities that are in high need of such serv21 ices, especially communities with a high propor22 tion of low-income families or a high incidence 

23 of child maltreatment; 

24 ‘‘(B) the State will reserve 5 percent of the 

25 grant funds for training and technical assist-
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1 ance to the home visitation programs using 

2 such funds; 

3 ‘‘(C) in supporting home visitation pro4 grams using funds provided under this section, 

5 the State will promote coordination and collabo6 ration with other home visitation programs (in7 cluding programs funded under title XIX) and 

8 with other child and family services, health 

9 services, income supports, and other related as10 sistance; 

11 ‘‘(D) home visitation programs supported 

12 using such funds will, when appropriate, pro13 vide referrals to other programs serving chil14 dren and families; and 

15 ‘‘(E) the State will comply with subsection 

16 (i), and cooperate with any evaluation con17 ducted under subsection (j). 

18 ‘‘(4) OTHER INFORMATION.—Such other infor19 mation as the Secretary may require. 

20 ‘‘(c) ALLOTMENTS.— 

21 ‘‘(1) INDIAN TRIBES.—From the amount re22 served under subsection (l)(2) for a fiscal year, the 

23 Secretary shall allot to each Indian tribe that meets 

24 the requirement of subsection (d), if applicable, for 

25 the fiscal year the amount that bears the same ratio 
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1 to the amount so reserved as the number of children 

2 in the Indian tribe whose families have income that 

3 does not exceed 200 percent of the poverty line bears 

4 to the total number of children in such Indian tribes 

5 whose families have income that does not exceed 200 

6 percent of the poverty line. 

7 ‘‘(2) STATES AND TERRITORIES.—From the 

8 amount appropriated under subsection (m) for a fis9 cal year that remains after making the reservations 

10 required by subsection (l), the Secretary shall allot 

11 to each State that is not an Indian tribe and that 

12 meets the requirement of subsection (d), if applica13 ble, for the fiscal year the amount that bears the 

14 same ratio to the remainder of the amount so appro15 priated as the number of children in the State whose 

16 families have income that does not exceed 200 per17 cent of the poverty line bears to the total number of 

18 children in such States whose families have income 

19 that does not exceed 200 percent of the poverty line. 

20 ‘‘(3) REALLOTMENTS.—The amount of any al21 lotment to a State under a paragraph of this sub22 section for any fiscal year that the State certifies to 

23 the Secretary will not be expended by the State pur24 suant to this section shall be available for reallot25 ment using the allotment methodology specified in 
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1 that paragraph. Any amount so reallotted to a State 

2 is deemed part of the allotment of the State under 

3 this subsection. 

4 ‘‘(d) MAINTENANCE OF EFFORT.—Beginning with 

5 fiscal year 2011, a State meets the requirement of this 

6 subsection for a fiscal year if the Secretary finds that the 

7 aggregate expenditures by the State from State and local 

8 sources for programs of home visitation for families with 

9 young children and families expecting children for the then 

10 preceding fiscal year was not less than 100 percent of such 

11 aggregate expenditures for the then 2nd preceding fiscal 

12 year. 

13 ‘‘(e) PAYMENT OF GRANT.— 

14 ‘‘(1) IN GENERAL.—The Secretary shall make a 

15 grant to each State that meets the requirements of 

16 subsections (b) and (d), if applicable, for a fiscal 

17 year for which funds are appropriated under sub18 section (m), in an amount equal to the reimbursable 

19 percentage of the eligible expenditures of the State 

20 for the fiscal year, but not more than the amount 

21 allotted to the State under subsection (c) for the fis22 cal year. 

23 ‘‘(2) REIMBURSABLE PERCENTAGE DEFINED.— 

24 In paragraph (1), the term ‘reimbursable percent25 age’ means, with respect to a fiscal year— 
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1 ‘‘(A) 85 percent, in the case of fiscal year 

2 2010; 

3 ‘‘(B) 80 percent, in the case of fiscal year 

4 2011; or 

5 ‘‘(C) 75 percent, in the case of fiscal year 

6 2012 and any succeeding fiscal year. 

7 ‘‘(f) ELIGIBLE EXPENDITURES.— 

8 ‘‘(1) IN GENERAL.—In this section, the term 

9 ‘eligible expenditures’— 

10 ‘‘(A) means expenditures to provide vol11 untary home visitation for as many families 

12 with young children (under the age of school 

13 entry) and families expecting children as prac14 ticable, through the implementation or expan15 sion of high quality home visitation programs 

16 that— 

17 ‘‘(i) adhere to clear evidence-based 

18 models of home visitation that have dem19 onstrated positive effects on important pro20 gram-determined child and parenting out21 comes, such as reducing abuse and neglect 

22 and improving child health and develop23 ment; 

24 ‘‘(ii) employ well-trained and com25 petent staff, maintain high quality super-
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1 vision, provide for ongoing training and 

2 professional development, and show strong 

3 organizational capacity to implement such 

4 a program; 

5 ‘‘(iii) establish appropriate linkages 

6 and referrals to other community resources 

7 and supports; 

8 ‘‘(iv) monitor fidelity of program im9 plementation to ensure that services are 

10 delivered according to the specified model; 

11 and 

12 ‘‘(v) provide parents with— 

13 ‘‘(I) knowledge of age-appro14 priate child development in cognitive, 

15 language, social, emotional, and motor 

16 domains (including knowledge of sec17 ond language acquisition, in the case 

18 of English language learners); 

19 ‘‘(II) knowledge of realistic ex20 pectations of age-appropriate child be21 haviors; 

22 ‘‘(III) knowledge of health and 

23 wellness issues for children and par24 ents; 
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1 ‘‘(IV) modeling, consulting, and 

2 coaching on parenting practices; 

3 ‘‘(V) skills to interact with their 

4 child to enhance age-appropriate de5 velopment; 

6 ‘‘(VI) skills to recognize and seek 

7 help for issues related to health, devel8 opmental delays, and social, emo9 tional, and behavioral skills; and 

10 ‘‘(VII) activities designed to help 

11 parents become full partners in the 

12 education of their children; 

13 ‘‘(B) includes expenditures for training, 

14 technical assistance, and evaluations related to 

15 the programs; and 

16 ‘‘(C) does not include any expenditure with 

17 respect to which a State has submitted a claim 

18 for payment under any other provision of Fed19 eral law. 

20 ‘‘(2) PRIORITY FUNDING FOR PROGRAMS WITH

21 STRONGEST EVIDENCE.— 

22 ‘‘(A) IN GENERAL.—The expenditures, de23 scribed in paragraph (1), of a State for a fiscal 

24 year that are attributable to the cost of pro25 grams that do not adhere to a model of home 
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1 visitation with the strongest evidence of effec2 tiveness shall not be considered eligible expendi3 tures for the fiscal year to the extent that the 

4 total of the expenditures exceeds the applicable 

5 percentage for the fiscal year of the allotment 

6 of the State under subsection (c) for the fiscal 

7 year. 

8 ‘‘(B) APPLICABLE PERCENTAGE DE9 FINED.—In subparagraph (A), the term ‘appli10 cable percentage’ means, with respect to a fiscal 

11 year— 

12 ‘‘(i) 60 percent for fiscal year 2010; 

13 ‘‘(ii) 55 percent for fiscal year 2011; 

14 ‘‘(iii) 50 percent for fiscal year 2012; 

15 ‘‘(iv) 45 percent for fiscal year 2013; 

16 or 

17 ‘‘(v) 40 percent for fiscal year 2014. 

18 ‘‘(g) NO USE OF OTHER FEDERAL FUNDS FOR

19 STATE MATCH.—A State to which a grant is made under 

20 this section may not expend any Federal funds to meet 

21 the State share of the cost of an eligible expenditure for 

22 which the State receives a payment under this section. 

23 ‘‘(h) WAIVER AUTHORITY.— 

24 ‘‘(1) IN GENERAL.—The Secretary may waive 

25 or modify the application of any provision of this 
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1 section, other than subsection (b) or (f), to an In2 dian tribe if the failure to do so would impose an 

3 undue burden on the Indian tribe. 

4 ‘‘(2) SPECIAL RULE.—An Indian tribe is 

5 deemed to meet the requirement of subsection (d) 

6 for purposes of subsections (c) and (e) if— 

7 ‘‘(A) the Secretary waives the requirement; 

8 or 

9 ‘‘(B) the Secretary modifies the require10 ment, and the Indian tribe meets the modified 

11 requirement. 

12 ‘‘(i) STATE REPORTS.—Each State to which a grant 

13 is made under this section shall submit to the Secretary 

14 an annual report on the progress made by the State in 

15 addressing the purposes of this section. Each such report 

16 shall include a description of— 

17 ‘‘(1) the services delivered by the programs that 

18 received funds from the grant; 

19 ‘‘(2) the characteristics of each such program, 

20 including information on the service model used by 

21 the program and the performance of the program; 

22 ‘‘(3) the characteristics of the providers of serv23 ices through the program, including staff qualifica24 tions, work experience, and demographic characteris25 tics; 
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1 ‘‘(4) the characteristics of the recipients of serv2 ices provided through the program, including the 

3 number of the recipients, the demographic charac4 teristics of the recipients, and family retention; 

5 ‘‘(5) the annual cost of implementing the pro6 gram, including the cost per family served under the 

7 program; 

8 ‘‘(6) the outcomes experienced by recipients of 

9 services through the program; 

10 ‘‘(7) the training and technical assistance pro11 vided to aid implementation of the program, and 

12 how the training and technical assistance contrib13 uted to the outcomes achieved through the program; 

14 ‘‘(8) the indicators and methods used to mon15 itor whether the program is being implemented as 

16 designed; and 

17 ‘‘(9) other information as determined necessary 

18 by the Secretary. 

19 ‘‘(j) EVALUATION.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall, by 

21 grant or contract, provide for the conduct of an 

22 independent evaluation of the effectiveness of home 

23 visitation programs receiving funds provided under 

24 this section, which shall examine the following: 
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1 ‘‘(A) The effect of home visitation pro2 grams on child and parent outcomes, including 

3 child maltreatment, child health and develop4 ment, school readiness, and links to community 

5 services. 

6 ‘‘(B) The effectiveness of home visitation 

7 programs on different populations, including 

8 the extent to which the ability of programs to 

9 improve outcomes varies across programs and 

10 populations. 

11 ‘‘(2) REPORTS TO THE CONGRESS.— 

12 ‘‘(A) INTERIM REPORT.—Within 3 years 

13 after the date of the enactment of this section, 

14 the Secretary shall submit to the Congress an 

15 interim report on the evaluation conducted pur16 suant to paragraph (1). 

17 ‘‘(B) FINAL REPORT.—Within 5 years 

18 after the date of the enactment of this section, 

19 the Secretary shall submit to the Congress a 

20 final report on the evaluation conducted pursu21 ant to paragraph (1). 

22 ‘‘(k) ANNUAL REPORTS TO THE CONGRESS.—The 

23 Secretary shall submit annually to the Congress a report 

24 on the activities carried out using funds made available 
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1 under this section, which shall include a description of the 

2 following: 

3 ‘‘(1) The high need communities targeted by 

4 States for programs carried out under this section. 

5 ‘‘(2) The service delivery models used in the 

6 programs receiving funds provided under this sec7 tion. 

8 ‘‘(3) The characteristics of the programs, in9 cluding— 

10 ‘‘(A) the qualifications and demographic 

11 characteristics of program staff; and 

12 ‘‘(B) recipient characteristics including the 

13 number of families served, the demographic 

14 characteristics of the families served, and fam15 ily retention and duration of services. 

16 ‘‘(4) The outcomes reported by the programs. 

17 ‘‘(5) The research-based instruction, materials, 

18 and activities being used in the activities funded 

19 under the grant. 

20 ‘‘(6) The training and technical activities, in21 cluding on-going professional development, provided 

22 to the programs. 

23 ‘‘(7) The annual costs of implementing the pro24 grams, including the cost per family served under 

25 the programs. 
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1 ‘‘(8) The indicators and methods used by States 

2 to monitor whether the programs are being been im3 plemented as designed. 

4 ‘‘(l) RESERVATIONS OF FUNDS.—From the amounts 

5 appropriated for a fiscal year under subsection (m), the 

6 Secretary shall reserve— 

7 ‘‘(1) an amount equal to 5 percent of the 

8 amounts to pay the cost of the evaluation provided 

9 for in subsection (j), and the provision to States of 

10 training and technical assistance, including the dis11 semination of best practices in early childhood home 

12 visitation; and 

13 ‘‘(2) after making the reservation required by 

14 paragraph (1), an amount equal to 3 percent of the 

15 amount so appropriated, to pay for grants to Indian 

16 tribes under this section. 

17 ‘‘(m) APPROPRIATIONS.—Out of any money in the 

18 Treasury of the United States not otherwise appropriated, 

19 there is appropriated to the Secretary to carry out this 

20 section— 

21 ‘‘(1) $50,000,000 for fiscal year 2010; 

22 ‘‘(2) $100,000,000 for fiscal year 2011; 

23 ‘‘(3) $150,000,000 for fiscal year 2012; 

24 ‘‘(4) $200,000,000 for fiscal year 2013; and 

25 ‘‘(5) $250,000,000 for fiscal year 2014. 
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1 ‘‘(n) INDIAN TRIBES TREATED AS STATES.—In this 

2 section, paragraphs (4), (5), and (6) of section 431(a) 

3 shall apply.’’. 

4 SEC. 1905. IMPROVED COORDINATION AND PROTECTION 

5 FOR DUAL ELIGIBLES. 

6 Title XI of the Social Security Act is amended by 

7 inserting after section 1150 the following new section: 

8 ‘‘IMPROVED COORDINATION AND PROTECTION FOR DUAL

9 ELIGIBLES

10 ‘‘SEC. 1150A. (a) IN GENERAL.—The Secretary shall 

11 provide, through an identifiable office or program within 

12 the Centers for Medicare & Medicaid Services, for a fo13 cused effort to provide for improved coordination between 

14 Medicare and Medicaid and protection in the case of dual 

15 eligibles (as defined in subsection (g)). The office or pro16 gram shall— 

17 ‘‘(1) review Medicare and Medicaid policies re18 lated to enrollment, benefits, service delivery, pay19 ment, and grievance and appeals processes under 

20 parts A and B of title XVIII, under the Medicare 

21 Advantage program under part C of such title, and 

22 under title XIX; 

23 ‘‘(2) identify areas of such policies where better 

24 coordination and protection could improve care and 

25 costs; and 
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1 ‘‘(3) issue guidance to States regarding improv2 ing such coordination and protection. 

3 ‘‘(b) ELEMENTS.—The improved coordination and 

4 protection under this section shall include efforts— 

5 ‘‘(1) to simplify access of dual eligibles to bene6 fits and services under Medicare and Medicaid; 

7 ‘‘(2) to improve care continuity for dual eligi8 bles and ensure safe and effective care transitions; 

9 ‘‘(3) to harmonize regulatory conflicts between 

10 Medicare and Medicaid rules with regard to dual eli11 gibles; and 

12 ‘‘(4) to improve total cost and quality perform13 ance under Medicare and Medicaid for dual eligibles. 

14 ‘‘(c) RESPONSIBILITIES.—In carrying out this sec15 tion, the Secretary shall provide for the following: 

16 ‘‘(1) An examination of Medicare and Medicaid 

17 payment systems to develop strategies to foster more 

18 integrated and higher quality care. 

19 ‘‘(2) Development of methods to facilitate ac20 cess to post-acute and community-based services and 

21 to identify actions that could lead to better coordina22 tion of community-based care. 

23 ‘‘(3) A study of enrollment of dual eligibles in 

24 the Medicare Savings Program (as defined in section 

25 1144(c)(7)), under Medicaid, and in the low-income 
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1 subsidy program under section 1860D–14 to identify 

2 methods to more efficiently and effectively reach and 

3 enroll dual eligibles. 

4 ‘‘(4) An assessment of communication strate5 gies for dual eligibles to determine whether addi6 tional informational materials or outreach is needed, 

7 including an assessment of the Medicare website, 1– 

8 800–MEDICARE, and the Medicare handbook. 

9 ‘‘(5) Research and evaluation of areas where 

10 service utilization, quality, and access to cost sharing 

11 protection could be improved and an assessment of 

12 factors related to enrollee satisfaction with services 

13 and care delivery. 

14 ‘‘(6) Collection (and making available to the 

15 public) of data and a database that describe the eli16 gibility, benefit and cost-sharing assistance available 

17 to dual eligibles by State. 

18 ‘‘(7) Support for coordination of State and Fed19 eral contracting and oversight for dual coordination 

20 programs supportive of the goals described in sub21 section (b). 

22 ‘‘(8) Support for State Medicaid agencies 

23 through the provision of technical assistance for 

24 Medicare and Medicaid coordination initiatives de-
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1 signed to improve acute and long-term care for dual 

2 eligibles. 

3 ‘‘(9) Monitoring total combined Medicare and 

4 Medicaid program costs in serving dual eligibles and 

5 making recommendations for optimizing total quality 

6 and cost performance across both programs. 

7 ‘‘(10) Coordination of activities relating to 

8 Medicare Advantage plans under 1859(b)(6)(B)(ii) 

9 and Medicaid. 

10 ‘‘(d) REPORTING.—The Office or program shall work 

11 with relevant State agencies and any appropriate quality 

12 measurement entities to improve and coordinate reporting 

13 requirements for Medicare and Medicaid. In addition, the 

14 Office or program shall seek to minimize duplication in 

15 reporting requirements, where appropriate, and to identify 

16 opportunities to combine assessment requirements, where 

17 appropriate. The Office or program shall seek to identify 

18 quality metrics and assessment requirements that facili19 tate comparisons of the quality of care received by bene20 ficiaries enrolled in or entitled to benefits under fee-for21 service Medicare, the Medicare Advantage program, fee22 for-service Medicaid, and Medicaid managed care, and 

23 combinations thereof (including integrated Medicare-Med24 icaid programs for dual eligibles). 
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1 ‘‘(e) ENDORSEMENT.—The Secretary shall seek en2 dorsement by the entity with a contract under section 

3 1890(a) of quality measures and benchmarks developed 

4 under this section. 

5 ‘‘(f) CONSULTATION WITH STAKEHOLDERS.—The 

6 Office or program shall consult with relevant stakeholders, 

7 including dual eligible beneficiaries representatives for 

8 dual eligible beneficiaries, health plans, providers, and rel9 evant State agencies, in the development of policies related 

10 to integrated Medicare-Medicaid programs for dual eligi11 bles. 

12 ‘‘(g) PERIODIC REPORTS.—Not later than 1 year 

13 after the date of the enactment of this section and every 

14 3 years thereafter the Secretary shall submit to Congress 

15 a report on progress in activities conducted under this sec16 tion. 

17 ‘‘(h) DEFINITIONS.—In this section: 

18 ‘‘(1) DUAL ELIGIBLE.—The term ‘dual eligible’ 

19 means an individual who is dually eligible for bene20 fits under title XVIII, and medical assistance under 

21 title XIX, including such individuals who are eligible 

22 for benefits under the Medicare Savings Program 

23 (as defined in section 1144(c)(7)). 
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1 ‘‘(2) MEDICARE; MEDICAID.—The terms ‘Medi2 care’ and ‘Medicaid’ mean the programs under titles 

3 XVIII and XIX, respectively.’’. 

4 SEC. 1906. ASSESSMENT OF MEDICARE COST-INTENSIVE 

5 DISEASES AND CONDITIONS. 

6 (a) INITIAL ASSESSMENT.— 

7 (1) IN GENERAL.—The Secretary of Health and 

8 Human Services shall conduct an assessment of the 

9 diseases and conditions that are the most cost-inten10 sive for the Medicare program and, to the extent 

11 possible, assess the diseases and conditions that 

12 could become cost-intensive for Medicare in the fu13 ture. In conducting the assessment, the Secretary 

14 shall include the input of relevant research agencies, 

15 including the National Institutes of Health, the 

16 Agency for Healthcare Research and Quality, the 

17 Food and Drug Administration, and the Centers for 

18 Medicare & Medicaid Services. 

19 (2) REPORT.—Not later than January 1, 2011, 

20 the Secretary shall transmit a report to the Commit21 tees on Energy and Commerce, Ways and Means, 

22 and Appropriations of the House of Representatives 

23 and the Committees on Health, Education, Labor 

24 and Pensions, Finance, and Appropriations of the 
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1 Senate on the assessment conducted under para2 graph (1). Such report shall— 

3 (A) include the assessment of current and 

4 future trends of cost-intensive diseases and con5 ditions described in such paragraph; 

6 (B) address whether current research pri7 orities are appropriately addressing current and 

8 future cost-intensive conditions so identified; 

9 and 

10 (C) include recommendations concerning 

11 research in the Department of Health and 

12 Human Services that should be funded to im13 prove the prevention, treatment, or cure of such 

14 cost-intensive diseases and conditions. 

15 (b) UPDATES OF ASSESSMENT.—Not later than Jan16 uary 1, 2013, and biennially thereafter, the Secretary 

17 shall— 

18 (1) review and update the assessment and rec19 ommendations described in subsection (a)(1); and 

20 (2) submit a report described in subsection 

21 (a)(2) to the Committees specified in subsection 

22 (a)(2) on such updated assessment and rec23 ommendations. 
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1 SEC. 1907. ESTABLISHMENT OF CENTER FOR MEDICARE 

2 AND MEDICAID INNOVATION WITHIN CMS. 

3 (a) IN GENERAL.—Title XI of the Social Security Act 

4 is amended by inserting after section 1115 the following 

5 new section: 

6 ‘‘CENTER FOR MEDICARE AND MEDICAID INNOVATION

7 ‘‘SEC. 1115A. (a) CENTER FOR MEDICARE AND

8 MEDICAID INNOVATION ESTABLISHED.— 

9 ‘‘(1) IN GENERAL.—There is created within the 

10 Centers for Medicare & Medicaid Services a Center 

11 for Medicare and Medicaid Innovation (in this sec12 tion referred to as the ‘CMI’) to carry out the duties 

13 described in this section. The purpose of the CMI is 

14 to test innovative payment and service delivery mod15 els to improve the coordination, quality, and effi16 ciency of health care services provided to applicable 

17 individuals defined in paragraph (4)(A). 

18 ‘‘(2) DEADLINE.—The Secretary shall ensure 

19 that the CMI is carrying out the duties described in 

20 this section by not later than January 1, 2011. 

21 ‘‘(3) CONSULTATION.—In carrying out the du22 ties under this section, the CMI shall consult rep23 resentatives of relevant Federal agencies, clinical 

24 and analytical experts with expertise in medicine and 

25 health care management, and States. The CMI shall 
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1 use open door forums or other mechanisms to seek 

2 input from interested parties. 

3 ‘‘(4) DEFINITIONS.—In this section: 

4 ‘‘(A) APPLICABLE INDIVIDUAL.—The term 

5 ‘applicable individual’ means— 

6 ‘‘(i) an individual who is enrolled 

7 under part B and entitled to benefits 

8 under part A of title XVIII; 

9 ‘‘(ii) an individual who is eligible for 

10 medical assistance under title XIX; or 

11 ‘‘(iii) an individual who meets the cri12 teria of both clauses (i) and (ii). 

13 ‘‘(B) APPLICABLE TITLE.—The term ‘ap14 plicable title’ means title XVIII, title XIX, or 

15 both. 

16 ‘‘(b) TESTING OF MODELS (PHASE I).— 

17 ‘‘(1) IN GENERAL.—The CMI shall test pay18 ment and service delivery models in accordance with 

19 selection criteria under paragraph (2) to determine 

20 the effect of applying such models under the applica21 ble title (as defined in subsection (a)(4)(B)) on pro22 gram expenditures under such titles and the quality 

23 of care received by individuals receiving benefits 

24 under such title. 

25 ‘‘(2) SELECTION OF MODELS TO BE TESTED.— 
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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 give preference to testing models for which, as 

3 determined by the Administrator of the Centers 

4 for Medicare & Medicaid Services and using 

5 such input from outside the Centers as the Ad6 ministrator determines appropriate, there is evi7 dence that the model addresses a defined popu8 lation for which there are deficits in care lead9 ing to poor clinical outcomes or potentially 

10 avoidable expenditures. The Administrator shall 

11 focus on models expected to reduce program 

12 costs under the applicable title while preserving 

13 or enhancing the quality of care received by in14 dividuals receiving benefits under such title. 

15 ‘‘(B) APPLICATION TO OTHER DEM16 ONSTRATIONS.—The Secretary shall operate the 

17 demonstration programs under sections 1222 

18 and 1236 of the Affordable Health Care for 

19 America Act through the CMI in accordance 

20 with the rules applicable under this section, in21 cluding those relating to evaluations, termi22 nations, and expansions. 

23 ‘‘(3) BUDGET NEUTRALITY.— 

24 ‘‘(A) INITIAL PERIOD.—The Secretary 

25 shall not require, as a condition for testing a 
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1 model under paragraph (1), that the design of 

2 such model ensure that such model is budget 

3 neutral initially with respect to expenditures 

4 under the applicable title. 

5 ‘‘(B) TERMINATION.—The Secretary shall 

6 terminate or modify the design and implemen7 tation of a model unless the Secretary deter8 mines (and the Chief Actuary of the Centers for 

9 Medicare & Medicaid Services, with respect to 

10 spending under the applicable title, certifies), 

11 after testing has begun, that the model is ex12 pected to— 

13 ‘‘(i) improve the quality of care (as 

14 determined by the Administrator of the 

15 Centers for Medicare & Medicaid Services) 

16 without increasing spending under such 

17 title; 

18 ‘‘(ii) reduce spending under such titles 

19 without reducing the quality of care; or 

20 ‘‘(iii) do both. 

21 Such termination may occur at any time after 

22 such testing has begun and before completion of 

23 the testing. 

24 ‘‘(4) EVALUATION.— 
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1 ‘‘(A) IN GENERAL.—The Secretary shall 

2 conduct an evaluation of each model tested 

3 under this subsection. Such evaluation shall in4 clude an analysis of— 

5 ‘‘(i) the quality of care furnished 

6 under the model, including through the use 

7 of patient-level outcomes measures; and 

8 ‘‘(ii) the changes in spending under 

9 the applicable titles by reason of the 

10 model. 

11 The Secretary shall make the results of each 

12 evaluation under this paragraph available to the 

13 public in a timely fashion. 

14 ‘‘(B) MEASURE SELECTION.—To the ex15 tent feasible, the Secretary shall select meas16 ures under this paragraph that reflect national 

17 priorities for quality improvement and patient18 centered care consistent with the measures de19 veloped under section 1192(c)(1). 

20 ‘‘(5) TESTING PERIOD.—In no case shall a 

21 model be tested under this subsection for more than 

22 a 7-year period. 

23 ‘‘(c) EXPANSION OF MODELS (PHASE II).—The Sec24 retary may expand the duration and the scope of a model 

25 that is being tested under subsection (b) (including imple-
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1 mentation on a nationwide basis), to the extent deter2 mined appropriate by the Secretary, if— 

3 ‘‘(1) the Secretary determines that such expan4 sion is expected— 

5 ‘‘(A) to improve the quality of patient care 

6 without increasing spending under the applica7 ble titles; 

8 ‘‘(B) to reduce spending under applicable 

9 titles without reducing the quality of care; or 

10 ‘‘(C) to do both; 

11 ‘‘(2) the Chief Actuary of the Centers for Medi12 care & Medicaid Services certifies that such expan13 sion would reduce (or not result in any increase in) 

14 net program spending under applicable titles; and 

15 ‘‘(3) the Secretary determines that such expan16 sion would not deny or limit the coverage or provi17 sion of benefits under the applicable title for applica18 ble individuals. 

19 ‘‘(d) IMPLEMENTATION.— 

20 ‘‘(1) WAIVER AUTHORITY.—The Secretary may 

21 waive such requirements of titles XI and XVIII and 

22 of sections 1902 and 1903(m) as may be necessary 

23 solely for purposes of carrying out this section with 

24 respect to testing models described in subsection (b). 
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1 ‘‘(2) LIMITATIONS ON REVIEW.—There shall be 

2 no administrative or judicial review under section 

3 1869, section 1878, or otherwise of— 

4 ‘‘(A) the selection of models for testing or 

5 expansion under this section; 

6 ‘‘(B) the elements, parameters, scope, and 

7 duration of such models for testing or dissemi8 nation; 

9 ‘‘(C) the termination or modification of the 

10 design and implementation of a model under 

11 subsection (b)(3)(B); and 

12 ‘‘(D) determinations about expansion of 

13 the duration and scope of a model under sub14 section (c) including the determination that a 

15 model is not expected to meet criteria described 

16 in paragraphs (1) or (2) of such subsection. 

17 ‘‘(3) ADMINISTRATION.—Chapter 35 of title 44, 

18 United States Code, shall not apply to the testing 

19 and evaluation of models or expansion of such mod20 els under this section. 

21 ‘‘(4) FUNDING FOR TESTING ITEMS AND SERV22 ICES AND ADMINISTRATIVE COSTS.— 

23 ‘‘(A) ADDITIONAL BENEFITS.—There shall 

24 be available until expended, equally divided 

25 from the Federal Supplementary Hospital In-
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1 surance Trust Fund and Federal Supple2 mentary Medical Insurance Trust Fund for 

3 payments for additional benefits for items and 

4 services under models tested under subsection 

5 (b) not otherwise covered under this title and 

6 applicable to benefits under this title, and for 

7 researching, designing, implementing, and eval8 uating such models, $350,000,000 for fiscal 

9 year 2010, $440,000,000 for fiscal year 2011, 

10 $550,000,000 for fiscal year 2012, and, for a 

11 subsequent fiscal year, the amount determined 

12 under this subparagraph for the preceding fis13 cal year increased by the annual percentage 

14 rate of increase in total expenditures under this 

15 title for the subsequent fiscal year as estimated 

16 in the latest available Annual Report of the 

17 Board of Trustees as described in section 

18 1841(b)(2). 

19 ‘‘(B) MEDICAID.—For administrative costs 

20 of the Centers for Medicare & Medicaid Serv21 ices for administering this section with respect 

22 to title XIX, from any amounts in the Treasury 

23 not otherwise appropriated there are appro24 priated to the Secretary for the Centers for 

25 Medicare & Medicaid Services Program Man-
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1 agement Account $25,000,000 for each fiscal 

2 year beginning with fiscal year 2010. Amounts 

3 appropriated under this subparagraph for a fis4 cal year shall be available until expended. 

5 ‘‘(e) REPORT TO CONGRESS.—Beginning in 2012, 

6 and not less than once every other year thereafter, the 

7 Secretary shall submit to Congress a report on activities 

8 under this section. Each such report shall describe the 

9 payment models tested under subsection (b), including the 

10 number of individuals described in subsection (a)(4)(A)(i) 

11 and of individuals described in subsection (a)(4)(A)(ii) 

12 participating in such models and payments made under 

13 applicable titles for services on behalf of such individuals, 

14 any models chosen for expansion under subsection (c), and 

15 the results from evaluations under subsection (b)(4). In 

16 addition, each such report shall provide such recommenda17 tions as the Secretary believes are appropriate for legisla18 tive action to facilitate the development and expansion of 

19 successful payment models.’’. 

20 (b) MEDICAID CONFORMING AMENDMENT.—Section 

21 1902(a) of the Social Security Act (42 U.S.C. 1396a(a)), 

22 as amended by sections 1631(b), 1703(a), 1729, 1753, 

23 1757(a), and 1759(a), is amended— 

24 (1) in paragraph (78), by striking ‘‘and’’ at the 

25 end; 
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1 (2) in paragraph (79), by striking the period at 

2 the end and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (79) the fol4 lowing new paragraph: 

5 ‘‘(80) provide for implementation of the pay6 ment models specified by the Secretary under section 

7 1115A(c) for implementation on a nationwide basis 

8 unless the State demonstrates to the satisfaction of 

9 the Secretary that implementation would not be ad10 ministratively feasible or appropriate to the health 

11 care delivery system of the State.’’. 

12 SEC. 1908. APPLICATION OF EMERGENCY SERVICES LAWS. 

13 Nothing in this Act shall be construed to relieve any 

14 health care provider from providing emergency services as 

15 required by State or Federal law, including section 1867 

16 of the Social Security Act (popularly known as 

17 ‘‘EMTALA’’). 

18 SEC. 1909. DISREGARD UNDER THE SUPPLEMENTAL SECU19 RITY INCOME PROGRAM OF COMPENSATION 

20 FOR PARTICIPATION IN CLINICAL TRIALS 

21 FOR RARE DISEASES OR CONDITIONS. 

22 (a) INCOME DISREGARD.—Section 1612(b) of the So23 cial Security Act (42 U.S.C. 1382a(b)) is amended— 

24 (1) by striking ‘‘and’’ at the end of paragraph 

25 (24); 
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1 (2) by striking the period at the end of para2 graph (25) and inserting ‘‘; and’’; and 

3 (3) by adding at the end the following: 

4 ‘‘(26) The first $2,000 per year received by 

5 such individual (or such spouse) for participation in 

6 a clinical trial to test a treatment for a rare disease 

7 or condition (within the meaning of section 5(b)(2) 

8 of the Orphan Drug Act (Public Law 97–414)), 

9 that— 

10 ‘‘(A) has been reviewed and approved by 

11 an institutional review board that— 

12 ‘‘(i) is established to protect the rights 

13 and welfare of human subjects partici14 pating in research; and 

15 ‘‘(ii) meet the standards for such bod16 ies set forth in part 46 of title 45, Code of 

17 Federal Regulations; and 

18 ‘‘(B) meets the standards for protection of 

19 human subjects for clinical research (as set 

20 forth in such part).’’. 

21 (b) RESOURCE DISREGARD.—Section 1613(a) of 

22 such Act (42 U.S.C. 1382b(a)) is amended— 

23 (1) by striking ‘‘and’’ at the end of paragraph 

24 (15); 
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1 (2) by striking the period at the end of para2 graph (16) and inserting ‘‘; and’’; and 

3 (3) by inserting after paragraph (16) the fol4 lowing: 

5 ‘‘(17) the first $2,000 per year received by such 

6 individual (or such spouse) for participation in a 

7 clinical trial, as described in section 1612(b)(26).’’. 

8 (c) EFFECTIVE DATE.—The amendments made by 

9 this section shall apply to benefits payable for calendar 

10 months beginning after the earlier of— 

11 (1) the date the Commissioner of Social Secu12 rity promulgates regulations to carry out the amend13 ments; or 

14 (2) the 180-day period that begins with the 

15 date of the enactment of this Act. 

16 DIVISION C—PUBLIC HEALTH 

17 AND WORKFORCE DEVELOP18 MENT 

19 SEC. 2001. TABLE OF CONTENTS; REFERENCES. 

20 (a) TABLE OF CONTENTS.—The table of contents of 

21 this division is as follows: 

Sec. 2001. Table of contents; references. 

Sec. 2002. Public Health Investment Fund. 

Sec. 2003. Deficit neutrality. 

TITLE I—COMMUNITY HEALTH CENTERS 

Sec. 2101. Increased funding. 

TITLE II—WORKFORCE 
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Subtitle A—Primary Care Workforce 

PART 1—NATIONAL HEALTH SERVICE CORPS

Sec. 2201. National Health Service Corps. 

Sec. 2202. Authorizations of appropriations. 

PART 2—PROMOTION OF PRIMARY CARE AND DENTISTRY

Sec. 2211. Frontline health providers. 

‘‘SUBPART XI—HEALTH PROFESSIONAL NEEDS AREAS

‘‘Sec. 340H. In general. 

‘‘Sec. 340I. Loan repayments. 

‘‘Sec. 340J. Report. 

‘‘Sec. 340K. Allocation. 

Sec. 2212. Primary care student loan funds. 

Sec. 2213. Training in family medicine, general internal medicine, general pediatrics, geriatrics, and physician assistants. 

Sec. 2214. Training of medical residents in community-based settings. 

Sec. 2215. Training for general, pediatric, and public health dentists and dental 

hygienists. 

Sec. 2216. Authorization of appropriations. 

Sec. 2217. Study on effectiveness of scholarships and loan repayments. 

Subtitle B—Nursing Workforce 

Sec. 2221. Amendments to Public Health Service Act. 

Subtitle C—Public Health Workforce 

Sec. 2231. Public Health Workforce Corps. 

‘‘SUBPART XII—PUBLIC HEALTH WORKFORCE

‘‘Sec. 340L. Public Health Workforce Corps. 

‘‘Sec. 340M. Public Health Workforce Scholarship Program. 

‘‘Sec. 340N. Public Health Workforce Loan Repayment Program. 

Sec. 2232. Enhancing the public health workforce. 

Sec. 2233. Public health training centers. 

Sec. 2234. Preventive medicine and public health training grant program. 

Sec. 2235. Authorization of appropriations. 

Subtitle D—Adapting Workforce to Evolving Health System Needs 

PART 1—HEALTH PROFESSIONS TRAINING FOR DIVERSITY

Sec. 2241. Scholarships for disadvantaged students, loan repayments and fellowships regarding faculty positions, and educational assistance 

in the health professions regarding individuals from disadvantaged backgrounds. 

Sec. 2242. Nursing workforce diversity grants. 

Sec. 2243. Coordination of diversity and cultural competency programs. 

PART 2—INTERDISCIPLINARY TRAINING PROGRAMS

Sec. 2251. Cultural and linguistic competency training for health professionals. 

Sec. 2252. Innovations in interdisciplinary care training. 
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PART 3—ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND

ASSESSMENT

Sec. 2261. Health workforce evaluation and assessment. 

PART 4—HEALTH WORKFORCE ASSESSMENT

Sec. 2271. Health workforce assessment. 

PART 5—AUTHORIZATION OF APPROPRIATIONS

Sec. 2281. Authorization of appropriations. 

TITLE III—PREVENTION AND WELLNESS 

Sec. 2301. Prevention and wellness. 

‘‘TITLE XXXI—PREVENTION AND WELLNESS 

‘‘Subtitle A—Prevention and Wellness Trust 

‘‘Sec. 3111. Prevention and Wellness Trust. 

‘‘Subtitle B—National Prevention and Wellness Strategy 

‘‘Sec. 3121. National Prevention and Wellness Strategy. 

‘‘Subtitle C—Prevention Task Forces 

‘‘Sec. 3131. Task Force on Clinical Preventive Services. 

‘‘Sec. 3132. Task Force on Community Preventive Services. 

‘‘Subtitle D—Prevention and Wellness Research 

‘‘Sec. 3141. Prevention and wellness research activity coordination. 

‘‘Sec. 3142. Community prevention and wellness research grants. 

‘‘Sec. 3143. Research on subsidies and rewards to encourage wellness and 

healthy behaviors. 

‘‘Subtitle E—Delivery of Community Prevention and Wellness Services 

‘‘Sec. 3151. Community prevention and wellness services grants. 

‘‘Subtitle F—Core Public Health Infrastructure 

‘‘Sec. 3161. Core public health infrastructure for State, local, and tribal 

health departments. 

‘‘Sec. 3162. Core public health infrastructure and activities for CDC. 

‘‘Subtitle G—General Provisions 

‘‘Sec. 3171. Definitions. 

TITLE IV—QUALITY AND SURVEILLANCE 

Sec. 2401. Implementation of best practices in the delivery of health care. 

Sec. 2402. Assistant Secretary for Health Information. 

Sec. 2403. Authorization of appropriations. 

TITLE V—OTHER PROVISIONS 
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Subtitle A—Drug Discount for Rural and Other Hospitals; 340B Program 

Integrity 

Sec. 2501. Expanded participation in 340B program. 

Sec. 2502. Improvements to 340B program integrity. 

Sec. 2503. Effective date. 

Subtitle B—Programs 

PART 1—GRANTS FOR CLINICS AND CENTERS

Sec. 2511. School-based health clinics. 

Sec. 2512. Nurse-Managed health centers. 

Sec. 2513. Federally qualified behavioral health centers. 

PART 2—OTHER GRANT PROGRAMS

Sec. 2521. Comprehensive programs to provide education to nurses and create 

a pipeline to nursing. 

Sec. 2522. Mental and behavioral health training. 

Sec. 2523. Reauthorization of telehealth and telemedicine grant programs. 

Sec. 2524. No child left unimmunized against influenza: demonstration program using elementary and secondary schools as influenza vaccination centers. 

Sec. 2525. Extension of Wisewoman Program. 

Sec. 2526. Healthy teen initiative to prevent teen pregnancy. 

Sec. 2527. National training initiatives on autism spectrum disorders. 

Sec. 2528. Implementation of medication management services in treatment of 

chronic diseases. 

Sec. 2529. Postpartum depression. 

Sec. 2530. Grants to promote positive health behaviors and outcomes. 

Sec. 2531. Medical liability alternatives. 

Sec. 2532. Infant mortality pilot programs. 

Sec. 2533. Secondary school health sciences training program. 

Sec. 2534. Community-based collaborative care networks. 

Sec. 2535. Community-based overweight and obesity prevention program. 

Sec. 2536. Reducing student-to-school nurse ratios. 

Sec. 2537. Medical-legal partnerships. 

Sec. 2538. Screening, brief intervention, referral, and treatment for mental 

health and substance abuse disorders. 

Sec. 2539. Grants to assist in developing medical schools in federally-designated 

health professional shortage areas. 

PART 3—EMERGENCY CARE-RELATED PROGRAMS

Sec. 2551. Trauma care centers. 

Sec. 2552. Emergency care coordination. 

Sec. 2553. Pilot programs to improve emergency medical care. 

Sec. 2554. Assisting veterans with military emergency medical training to become State-licensed or certified emergency medical technicians 

(EMTs). 

Sec. 2555. Dental emergency responders: public health and medical response. 

Sec. 2556. Dental emergency responders: homeland security. 

PART 4—PAIN CARE AND MANAGEMENT PROGRAMS

Sec. 2561. Institute of Medicine Conference on Pain. 
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Sec. 2562. Pain research at National Institutes of Health. 

Sec. 2563. Public awareness campaign on pain management. 

Subtitle C—Food and Drug Administration 

PART 1—IN GENERAL

Sec. 2571. National medical device registry. 

Sec. 2572. Nutrition labeling of standard menu items at chain restaurants and 

of articles of food sold from vending machines. 

Sec. 2573. Protecting consumer access to generic drugs. 

PART 2—BIOSIMILARS

Sec. 2575. Licensure pathway for biosimilar biological products. 

Sec. 2576. Fees relating to biosimilar biological products. 

Sec. 2577. Amendments to certain patent provisions. 

Subtitle D—Community Living Assistance Services and Supports 

Sec. 2581. Establishment of national voluntary insurance program for purchasing community living assistance services and support 

(CLASS program). 

‘‘TITLE XXXII—COMMUNITY LIVING ASSISTANCE SERVICES AND 

SUPPORTS 

‘‘Sec. 3201. Purpose. 

‘‘Sec. 3202. Definitions. 

‘‘Sec. 3203. CLASS Independence Benefit Plan. 

‘‘Sec. 3204. Enrollment and disenrollment requirements. 

‘‘Sec. 3205. Benefits. 

‘‘Sec. 3206. CLASS Independence Fund. 

‘‘Sec. 3207. CLASS Independence Advisory Council. 

‘‘Sec. 3208. Regulations; annual report. 

‘‘Sec. 3209. Inspector General’s report. 

Subtitle E—Miscellaneous 

Sec. 2585. States failing to adhere to certain employment obligations. 

Sec. 2586. Health centers under Public Health Service Act; liability protections 

for volunteer practitioners. 

Sec. 2587. Report to Congress on the current state of parasitic diseases that 

have been overlooked among the poorest Americans. 

Sec. 2588. Office of Women’s Health. 

Sec. 2588A. Offices of Minority Health. 

Sec. 2589. Long-Term Care and Family Caregiver Support. 

Sec. 2590. Web site on health care labor market and related educational and 

training opportunities. 

Sec. 2591. Online health workforce training programs. 

Sec. 2592. Access for individuals with disabilities. 

Sec. 2593. Duplicative grant programs. 

Sec. 2594. Diabetes screening collaboration and outreach program. 

Sec. 2595. Improvement of vital statistics collection. 

Sec. 2596. National Health Services Corps demonstration on incentive payments. 
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1 (b) REFERENCES.—Except as otherwise specified, 

2 whenever in this division an amendment is expressed in 

3 terms of an amendment to a section or other provision, 

4 the reference shall be considered to be made to a section 

5 or other provision of the Public Health Service Act (42 

6 U.S.C. 201 et seq.). 

7 SEC. 2002. PUBLIC HEALTH INVESTMENT FUND. 

8 (a) ESTABLISHMENT OF FUNDS.— 

9 (1) IN GENERAL.—Subject to section 2003, 

10 there is hereby established in the Treasury a sepa11 rate account to be known as the ‘‘Public Health In12 vestment Fund’’ (referred to in this section and sec13 tion 2003 as the ‘‘Fund’’). 

14 (2) FUNDING.— 

15 (A) There shall be deposited into the 

16 Fund— 

17 (i) for fiscal year 2011, 

18 $4,600,000,000; 

19 (ii) for fiscal year 2012, 

20 $5,600,000,000; 

21 (iii) for fiscal year 2013, 

22 $6,900,000,000; 

23 (iv) for fiscal year 2014, 

24 $7,800,000,000; and 
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1 (v) for fiscal year 2015, 

2 $9,000,000,000. 

3 (B) Amounts deposited into the Fund shall 

4 be derived from general revenues of the Treas5 ury only for the fiscal years set forth in this 

6 section, and amounts appropriated from the 

7 Fund shall remain available until expended. 

8 (b) AUTHORIZATION OF APPROPRIATIONS FROM THE

9 FUND.— 

10 (1) NEW FUNDING.— 

11 (A) IN GENERAL.—Subject to section 

12 2003, amounts in the Fund are authorized to 

13 be appropriated for carrying out activities 

14 under designated public health provisions. 

15 (B) DESIGNATED PROVISIONS.—For pur16 poses of this paragraph, the term ‘‘designated 

17 public health provisions’’ means the provisions 

18 for which amounts are authorized to be appro19 priated under section 330(s), 338(c), 338H–1, 

20 799C, 872, or 3111 of the Public Health Serv21 ice Act, as added by this division. 

22 (2) BASELINE FUNDING.— 

23 (A) IN GENERAL.—Amounts in the Fund 

24 are authorized to be appropriated (as described 

25 in paragraph (1)) for a fiscal year only if (ex-
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1 cluding any amounts in or appropriated from 

2 the Fund) the amounts specified in subpara3 graph (B) for the fiscal year involved are equal 

4 to or greater than the amounts specified in sub5 paragraph (B) for fiscal year 2008. 

6 (B) AMOUNTS SPECIFIED.—The amounts 

7 specified in this subparagraph, with respect to 

8 a fiscal year, are the amounts appropriated (ex9 cluding any amounts in or appropriated from 

10 the Fund) for the following: 

11 (i) Community health centers (includ12 ing funds appropriated under the authority 

13 of section 330 of the Public Health Service 

14 Act (42 U.S.C. 254b)). 

15 (ii) The National Health Service 

16 Corps Program (including funds appro17 priated under the authority of section 338 

18 of such Act (42 U.S.C. 254k)). 

19 (iii) The National Health Service 

20 Corps Scholarship and Loan Repayment 

21 Programs (including funds appropriated 

22 under the authority of section 338H of 

23 such Act (42 U.S.C. 254q)). 

24 (iv) Primary care education programs 

25 (including funds appropriated under the 
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1 authority of sections 736, 740, 741, and 

2 747 of such Act (42 U.S.C. 293, 293d, 

3 and 293k)). 

4 (v) Sections 761 and 770 of such Act 

5 (42 U.S.C. 294n and 295e). 

6 (vi) Nursing workforce development 

7 (including funds appropriated under the 

8 authority of title VIII of such Act (42 

9 U.S.C. 296 et seq.)). 

10 (vii) The National Center for Health 

11 Statistics (including funds appropriated 

12 under the authority of sections 304, 306, 

13 307, and 308 of such Act (42 U.S.C. 

14 242b, 242k, 242l, and 242m)). 

15 (viii) The Agency for Healthcare Re16 search and Quality (including funds made 

17 available under the authority of title IX of 

18 such Act (42 U.S.C. 299 et seq.)). 

19 SEC. 2003. DEFICIT NEUTRALITY. 

20 (a) AVAILABILITY.—Funds appropriated or made 

21 available pursuant to sections 330(s), 338(c), 338H–1, 

22 799C, 872, or 3111 of the Public Health Service Act, as 

23 added by this division, are only available for the purposes 

24 set forth in this Act. Appropriations shall not be available 

25 and are precluded from obligation for any other purpose. 
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1 (b) ESTIMATION OF BUDGETARY IMPACT.—For the 

2 purposes of estimating the spending effects of this Act, 

3 the authorization of appropriations from the Fund, to the 

4 extent amounts in the Fund are derived from the general 

5 revenues of the Treasury, shall be treated as new direct 

6 spending and attributed to this Act. 

7 (c) BUDGETARY TREATMENT.—For the purposes of 

8 section 257 of the Balanced Budget and Emergency Def9 icit Control Act of 1985, the Fund, to the extent amounts 

10 in the Fund are derived from the general revenues of the 

11 Treasury, and not in excess of amounts subsequently ap12 propriated from the Fund, shall be deemed to be included 

13 on the list of appropriations referenced under section 

14 250(c)(17) of that Act. 

15 TITLE I—COMMUNITY HEALTH 

16 CENTERS 

17 SEC. 2101. INCREASED FUNDING. 

18 Section 330 of the Public Health Service Act (42 

19 U.S.C. 254b) is amended— 

20 (1) in subsection (r)(1)— 

21 (A) in subparagraph (D), by striking 

22 ‘‘and’’ at the end; 

23 (B) in subparagraph (E), by striking the 

24 period at the end and inserting ‘‘; and’’; and 

25 (C) by inserting at the end the following: 
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1 ‘‘(F) such sums as may be necessary for 

2 each of fiscal years 2013 through 2015.’’; and 

3 (2) by inserting after subsection (r) the fol4 lowing: 

5 ‘‘(s) ADDITIONAL FUNDING.—For the purpose of 

6 carrying out this section, in addition to any other amounts 

7 authorized to be appropriated for such purpose, there are 

8 authorized to be appropriated, out of any monies in the 

9 Public Health Investment Fund, the following: 

10 ‘‘(1) For fiscal year 2011, $1,000,000,000. 

11 ‘‘(2) For fiscal year 2012, $1,500,000,000. 

12 ‘‘(3) For fiscal year 2013, $2,500,000,000. 

13 ‘‘(4) For fiscal year 2014, $3,000,000,000. 

14 ‘‘(5) For fiscal year 2015, $4,000,000,000.’’. 

15 TITLE II—WORKFORCE 

16 Subtitle A—Primary Care 

17 Workforce 

18 PART 1—NATIONAL HEALTH SERVICE CORPS 

19 SEC. 2201. NATIONAL HEALTH SERVICE CORPS. 

20 (a) FULFILLMENT OF OBLIGATED SERVICE RE21 QUIREMENT THROUGH HALF-TIME SERVICE.— 

22 (1) WAIVERS.—Subsection (i) of section 331 

23 (42 U.S.C. 254d) is amended— 

24 (A) in paragraph (1), by striking ‘‘In car25 rying out subpart III’’ and all that follows 
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1 through the period and inserting ‘‘In carrying 

2 out subpart III, the Secretary may, in accord3 ance with this subsection, issue waivers to indi4 viduals who have entered into a contract for ob5 ligated service under the Scholarship Program 

6 or the Loan Repayment Program under which 

7 the individuals are authorized to satisfy the re8 quirement of obligated service through pro9 viding clinical practice that is half-time.’’; 

10 (B) in paragraph (2)— 

11 (i) in subparagraphs (A)(ii) and (B), 

12 by striking ‘‘less than full time’’ each place 

13 it appears and inserting ‘‘half time’’; 

14 (ii) in subparagraphs (C) and (F), by 

15 striking ‘‘less than full-time service’’ each 

16 place it appears and inserting ‘‘half-time 

17 service’’; and 

18 (iii) by amending subparagraphs (D) 

19 and (E) to read as follows: 

20 ‘‘(D) the entity and the Corps member agree in 

21 writing that the Corps member will perform half22 time clinical practice; 

23 ‘‘(E) the Corps member agrees in writing to 

24 fulfill all of the service obligations under section 
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1 338C through half-time clinical practice and ei2 ther— 

3 ‘‘(i) double the period of obligated service 

4 that would otherwise be required; or 

5 ‘‘(ii) in the case of contracts entered into 

6 under section 338B, accept a minimum service 

7 obligation of 2 years with an award amount 

8 equal to 50 percent of the amount that would 

9 otherwise be payable for full-time service; and’’; 

10 and 

11 (C) in paragraph (3), by striking ‘‘In eval12 uating a demonstration project described in 

13 paragraph (1)’’ and inserting ‘‘In evaluating 

14 waivers issued under paragraph (1)’’. 

15 (2) DEFINITIONS.—Subsection (j) of section 

16 331 (42 U.S.C. 254d) is amended by adding at the 

17 end the following: 

18 ‘‘(5) The terms ‘full time’ and ‘full-time’ mean 

19 a minimum of 40 hours per week in a clinical prac20 tice, for a minimum of 45 weeks per year. 

21 ‘‘(6) The terms ‘half time’ and ‘half-time’ mean 

22 a minimum of 20 hours per week (not to exceed 39 

23 hours per week) in a clinical practice, for a min24 imum of 45 weeks per year.’’. 
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1 (b) REAPPOINTMENT TO NATIONAL ADVISORY COUN2 CIL.—Section 337(b)(1) (42 U.S.C. 254j(b)(1)) is amend3 ed by striking ‘‘Members may not be reappointed to the 

4 Council.’’. 

5 (c) LOAN REPAYMENT AMOUNT.—Section 

6 338B(g)(2)(A) (42 U.S.C. 254l–1(g)(2)(A)) is amended 

7 by striking ‘‘$35,000’’ and inserting ‘‘$50,000, plus, be8 ginning with fiscal year 2012, an amount determined by 

9 the Secretary on an annual basis to reflect inflation,’’. 

10 (d) TREATMENT OF TEACHING AS OBLIGATED SERV11 ICE.—Subsection (a) of section 338C (42 U.S.C. 254m) 

12 is amended by adding at the end the following: ‘‘The Sec13 retary may treat teaching as clinical practice for up to 

14 20 percent of such period of obligated service.’’. 

15 SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS. 

16 (a) NATIONAL HEALTH SERVICE CORPS PRO17 GRAM.—Section 338 (42 U.S.C. 254k) is amended— 

18 (1) in subsection (a), by striking ‘‘2012’’ and 

19 inserting ‘‘2015’’; and 

20 (2) by adding at the end the following: 

21 ‘‘(c) For the purpose of carrying out this subpart, 

22 in addition to any other amounts authorized to be appro23 priated for such purpose, there are authorized to be appro24 priated, out of any monies in the Public Health Invest25 ment Fund, the following: 
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1 ‘‘(1) $63,000,000 for fiscal year 2011. 

2 ‘‘(2) $66,000,000 for fiscal year 2012. 

3 ‘‘(3) $70,000,000 for fiscal year 2013. 

4 ‘‘(4) $73,000,000 for fiscal year 2014. 

5 ‘‘(5) $77,000,000 for fiscal year 2015.’’. 

6 (b) SCHOLARSHIP AND LOAN REPAYMENT PRO7 GRAMS.—Subpart III of part D of title III of the Public 

8 Health Service Act (42 U.S.C. 254l et seq.) is amended— 

9 (1) in section 338H(a)— 

10 (A) in paragraph (4), by striking ‘‘and’’ at 

11 the end; 

12 (B) in paragraph (5), by striking the pe13 riod at the end and inserting ‘‘; and’’; and 

14 (C) by adding at the end the following: 

15 ‘‘(6) for each of fiscal years 2013 through 

16 2015, such sums as may be necessary.’’; and 

17 (2) by inserting after section 338H the fol18 lowing: 

19 ‘‘SEC. 338H–1. ADDITIONAL FUNDING. 

20 ‘‘For the purpose of carrying out this subpart, in ad21 dition to any other amounts authorized to be appropriated 

22 for such purpose, there are authorized to be appropriated, 

23 out of any monies in the Public Health Investment Fund, 

24 the following: 

25 ‘‘(1) $254,000,000 for fiscal year 2011. 
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1 ‘‘(2) $266,000,000 for fiscal year 2012. 

2 ‘‘(3) $278,000,000 for fiscal year 2013. 

3 ‘‘(4) $292,000,000 for fiscal year 2014. 

4 ‘‘(5) $306,000,000 for fiscal year 2015.’’. 

5 PART 2—PROMOTION OF PRIMARY CARE AND 

6 DENTISTRY 

7 SEC. 2211. FRONTLINE HEALTH PROVIDERS. 

8 Part D of title III (42 U.S.C. 254b et seq.) is amend9 ed by adding at the end the following: 

10 ‘‘Subpart XI—Health Professional Needs Areas 

11 ‘‘SEC. 340H. IN GENERAL. 

12 ‘‘(a) PROGRAM.—The Secretary, acting through the 

13 Administrator of the Health Resources and Services Ad14 ministration, shall establish a program, to be known as 

15 the Frontline Health Providers Loan Repayment Pro16 gram, to address unmet health care needs in health profes17 sional needs areas through loan repayments under section 

18 340I. 

19 ‘‘(b) DESIGNATION OF HEALTH PROFESSIONAL

20 NEEDS AREAS.— 

21 ‘‘(1) IN GENERAL.—In this subpart, the term 

22 ‘health professional needs area’ means an area, pop23 ulation, or facility that is designated by the Sec24 retary in accordance with paragraph (2). 
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1 ‘‘(2) DESIGNATION.—To be designated by the 

2 Secretary as a health professional needs area under 

3 this subpart: 

4 ‘‘(A) In the case of an area, the area must 

5 be a rational area for the delivery of health 

6 services. 

7 ‘‘(B) The area, population, or facility must 

8 have, in one or more health disciplines, special9 ties, or subspecialties for the population served, 

10 as determined by the Secretary— 

11 ‘‘(i) insufficient capacity of health 

12 professionals; or 

13 ‘‘(ii) high needs for health services, in14 cluding services to address health dispari15 ties. 

16 ‘‘(C) With respect to the delivery of pri17 mary health services, the area, population, or 

18 facility must not include a health professional 

19 shortage area (as designated under section 

20 332), except that the area, population, or facil21 ity may include such a health professional 

22 shortage area in which there is an unmet need 

23 for such services. 

24 ‘‘(c) ELIGIBILITY.—To be eligible to participate in 

25 the Program, an individual shall— 
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1 ‘‘(1) hold a degree in a course of study or pro2 gram (approved by the Secretary) from a school de3 fined in section 799B(1)(A) (other than a school of 

4 public health); 

5 ‘‘(2) hold a degree in a course of study or pro6 gram (approved by the Secretary) from a school or 

7 program defined in subparagraph (C), (D), or 

8 (E)(4) of section 799B(1), as designated by the Sec9 retary; 

10 ‘‘(3) be enrolled as a full-time student— 

11 ‘‘(A) in a school or program defined in 

12 subparagraph (C), (D), or (E)(4) of section 

13 799B(1), as designated by the Secretary, or a 

14 school described in paragraph (1); and 

15 ‘‘(B) in the final year of a course of study 

16 or program, offered by such school or program 

17 and approved by the Secretary, leading to a de18 gree in a discipline referred to in subparagraph 

19 (A) (other than a graduate degree in public 

20 health), (C), (D), or (E)(4) of section 799B(1); 

21 ‘‘(4) be a practitioner described in section 

22 1842(b)(18)(C) or 1848(k)(3)(B)(iii) or (iv) of the 

23 Social Security Act; or 
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1 ‘‘(5) be a practitioner in the field of respiratory 

2 therapy, medical technology, or radiologic tech3 nology. 

4 ‘‘(d) DEFINITIONS.—In this subpart: 

5 ‘‘(1) The term ‘health disparities’ has the 

6 meaning given to the term in section 3171. 

7 ‘‘(2) The term ‘primary health services’ has the 

8 meaning given to such term in section 331(a)(3)(D). 

9 ‘‘SEC. 340I. LOAN REPAYMENTS. 

10 ‘‘(a) LOAN REPAYMENTS.—The Secretary, acting 

11 through the Administrator of the Health Resources and 

12 Services Administration, shall enter into contracts with in13 dividuals under which— 

14 ‘‘(1) the individual agrees— 

15 ‘‘(A) to serve as a full-time primary health 

16 services provider or as a full-time or part-time 

17 provider of other health services for a period of 

18 time equal to 2 years or such longer period as 

19 the individual may agree to; 

20 ‘‘(B) to serve in a health professional 

21 needs area in a health discipline, specialty, or a 

22 subspecialty for which the area, population, or 

23 facility is designated as a health professional 

24 needs area under section 340H; and 
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1 ‘‘(C) in the case of an individual described 

2 in section 340H(c)(3) who is in the final year 

3 of study and who has accepted employment as 

4 a primary health services provider or provider 

5 of other health services in accordance with sub6 paragraphs (A) and (B), to complete the edu7 cation or training and maintain an acceptable 

8 level of academic standing (as determined by 

9 the educational institution offering the course 

10 of study or training); and 

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

12 of such service, an amount on the principal and in13 terest of the undergraduate or graduate educational 

14 loans (or both) of the individual that is not more 

15 than 50 percent of the average award made under 

16 the National Health Service Corps Loan Repayment 

17 Program under subpart III in that year. 

18 ‘‘(b) PRACTICE SETTING.—A contract entered into 

19 under this section shall allow the individual receiving the 

20 loan repayment to satisfy the service requirement de21 scribed in subsection (a)(1) through employment in a solo 

22 or group practice, a clinic, an accredited public or private 

23 nonprofit hospital, or any other health care entity, as 

24 deemed appropriate by the Secretary. 
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1 ‘‘(c) APPLICATION OF CERTAIN PROVISIONS.—The 

2 provisions of subpart III of part D shall, except as incon3 sistent with this section, apply to the loan repayment pro4 gram under this subpart in the same manner and to the 

5 same extent as such provisions apply to the National 

6 Health Service Corps Loan Repayment Program estab7 lished under section 338B. 

8 ‘‘(d) INSUFFICIENT NUMBER OF APPLICANTS.—If 

9 there are an insufficient number of applicants for loan re10 payments under this section to obligate all appropriated 

11 funds, the Secretary shall transfer the unobligated funds 

12 to the National Health Service Corps for the purpose of 

13 recruiting applicants and entering into contracts with indi14 viduals so as to ensure a sufficient number of participants 

15 in the National Health Service Corps for the following 

16 year. 

17 ‘‘SEC. 340J. REPORT. 

18 ‘‘The Secretary shall submit to the Congress an an19 nual report on the program carried out under this subpart. 

20 ‘‘SEC. 340K. ALLOCATION. 

21 ‘‘Of the amount of funds obligated under this subpart 

22 each fiscal year for loan repayments— 

23 ‘‘(1) 90 percent shall be for physicians and 

24 other health professionals providing primary health 

25 services; and 
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1 ‘‘(2) 10 percent shall be for health professionals 

2 not described in paragraph (1).’’. 

3 SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS. 

4 (a) IN GENERAL.—Section 735 (42 U.S.C. 292y) is 

5 amended— 

6 (1) by redesignating subsection (f) as sub7 section (g); and 

8 (2) by inserting after subsection (e) the fol9 lowing: 

10 ‘‘(f) DETERMINATION OF FINANCIAL NEED.—The 

11 Secretary— 

12 ‘‘(1) may require, or authorize a school or other 

13 entity to require, the submission of financial infor14 mation to determine the financial resources available 

15 to any individual seeking assistance under this sub16 part; and 

17 ‘‘(2) shall take into account the extent to which 

18 such individual is financially independent in deter19 mining whether to require or authorize the submis20 sion of such information regarding such individual’s 

21 family members.’’. 

22 (b) REVISED GUIDELINES.—The Secretary of Health 

23 and Human Services shall— 
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1 (1) strike the second sentence of section 

2 57.206(b)(1) of title 42, Code of Federal Regula3 tions; and 

4 (2) make such other revisions to guidelines and 

5 regulations in effect as of the date of the enactment 

6 of this Act as may be necessary for consistency with 

7 the amendments made by paragraph (1). 

8 SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL IN9 TERNAL MEDICINE, GENERAL PEDIATRICS, 

10 GERIATRICS, AND PHYSICIAN ASSISTANTS. 

11 Section 747 (42 U.S.C. 293k) is amended— 

12 (1) by amending the section heading to read as 

13 follows: ‘‘PRIMARY CARE TRAINING AND EN14 HANCEMENT’’; 

15 (2) by redesignating subsection (e) as sub16 section (g); and 

17 (3) by striking subsections (a) through (d) and 

18 inserting the following: 

19 ‘‘(a) PROGRAM.—The Secretary shall establish a pri20 mary care training and capacity building program con21 sisting of awarding grants and contracts under sub22 sections (b) and (c). 

23 ‘‘(b) SUPPORT AND DEVELOPMENT OF PRIMARY

24 CARE TRAINING PROGRAMS.— 
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1 ‘‘(1) IN GENERAL.—The Secretary shall make 

2 grants to, or enter into contracts with, eligible enti3 ties— 

4 ‘‘(A) to plan, develop, operate, or partici5 pate in an accredited professional training pro6 gram, including an accredited residency or in7 ternship program, in the field of family medi8 cine, general internal medicine, general pediat9 rics, or geriatrics for medical students, interns, 

10 residents, or practicing physicians; 

11 ‘‘(B) to provide financial assistance in the 

12 form of traineeships and fellowships to medical 

13 students, interns, residents, or practicing physi14 cians, who are participants in any such pro15 gram, and who plan to specialize or work in 

16 family medicine, general internal medicine, gen17 eral pediatrics, or geriatrics; 

18 ‘‘(C) to plan, develop, operate, or partici19 pate in an accredited program for the training 

20 of physicians who plan to teach in family medi21 cine, general internal medicine, general pediat22 rics, or geriatrics training programs including 

23 in community-based settings; 

24 ‘‘(D) to provide financial assistance in the 

25 form of traineeships and fellowships to prac-
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1 ticing physicians who are participants in any 

2 such programs and who plan to teach in a fam3 ily medicine, general internal medicine, general 

4 pediatrics, or geriatrics training program; and 

5 ‘‘(E) to plan, develop, operate, or partici6 pate in an accredited program for physician as7 sistant education, and for the training of indi8 viduals who plan to teach in programs to pro9 vide such training. 

10 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

11 or contract under paragraph (1), an entity shall 

12 be— 

13 ‘‘(A) an accredited school of medicine or 

14 osteopathic medicine, public or nonprofit private 

15 hospital, or physician assistant training pro16 gram; 

17 ‘‘(B) a public or private nonprofit entity; 

18 or 

19 ‘‘(C) a consortium of 2 or more entities de20 scribed in subparagraphs (A) and (B). 

21 ‘‘(c) CAPACITY BUILDING IN PRIMARY CARE.— 

22 ‘‘(1) IN GENERAL.—The Secretary shall make 

23 grants to or enter into contracts with eligible entities 

24 to establish, maintain, or improve— 
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1 ‘‘(A) academic administrative units (in2 cluding departments, divisions, or other appro3 priate units) in the specialties of family medi4 cine, general internal medicine, general pediat5 rics, or geriatrics; or 

6 ‘‘(B) programs that improve clinical teach7 ing in such specialties. 

8 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

9 or contract under paragraph (1), an entity shall be 

10 an accredited school of medicine or osteopathic med11 icine. 

12 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

13 under this section, the Secretary shall give preference to 

14 entities that have a demonstrated record of at least one 

15 of the following: 

16 ‘‘(1) Training a high or significantly improved 

17 percentage of health professionals who provide pri18 mary care. 

19 ‘‘(2) Training individuals who are from dis20 advantaged backgrounds (including racial and ethnic 

21 minorities underrepresented among primary care 

22 professionals). 

23 ‘‘(3) A high rate of placing graduates in prac24 tice settings having the principal focus of serving in 

25 underserved areas or populations experiencing health 
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1 disparities (including serving patients eligible for 

2 medical assistance under title XIX of the Social Se3 curity Act or for child health assistance under title 

4 XXI of such Act or those with special health care 

5 needs). 

6 ‘‘(4) Supporting teaching programs that ad7 dress the health care needs of vulnerable popu8 lations. 

9 ‘‘(e) REPORT.—The Secretary shall submit to the 

10 Congress an annual report on the program carried out 

11 under this section. 

12 ‘‘(f) DEFINITION.—In this section, the term ‘health 

13 disparities’ has the meaning given the term in section 

14 3171.’’. 

15 SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMU16 NITY-BASED SETTINGS. 

17 Title VII (42 U.S.C. 292 et seq.) is amended— 

18 (1) by redesignating section 748 as 749A; and 

19 (2) by inserting after section 747 the following: 

20 ‘‘SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMU21 NITY-BASED SETTINGS. 

22 ‘‘(a) PROGRAM.—The Secretary shall establish a pro23 gram for the training of medical residents in community24 based settings consisting of awarding grants and contracts 

25 under this section. 
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1 ‘‘(b) DEVELOPMENT AND OPERATION OF COMMU2 NITY-BASED PROGRAMS.—The Secretary shall make 

3 grants to, or enter into contracts with, eligible entities— 

4 ‘‘(1) to plan and develop a new primary care 

5 residency training program, which may include— 

6 ‘‘(A) planning and developing curricula; 

7 ‘‘(B) recruiting and training residents and 

8 faculty; and 

9 ‘‘(C) other activities designated to result in 

10 accreditation of such a program; or 

11 ‘‘(2) to operate or participate in an established 

12 primary care residency training program, which may 

13 include— 

14 ‘‘(A) planning and developing curricula; 

15 ‘‘(B) recruitment and training of residents; 

16 and 

17 ‘‘(C) retention of faculty. 

18 ‘‘(c) ELIGIBLE ENTITY.—To be eligible to receive a 

19 grant or contract under subsection (b), an entity shall— 

20 ‘‘(1) be designated as a recipient of payment 

21 for the direct costs of medical education under sec22 tion 1886(k) of the Social Security Act; 

23 ‘‘(2) be designated as an approved teaching 

24 health center under section 1502(d) of the Afford25 able Health Care for America Act and continuing to 
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1 participate in the demonstration project under such 

2 section; 

3 ‘‘(3) be an applicant for designation described 

4 in paragraph (1) or (2) and have demonstrated to 

5 the Secretary appropriate involvement of an accred6 ited teaching hospital to carry out the inpatient re7 sponsibilities associated with a primary care resi8 dency training program; or 

9 ‘‘(4) be eligible to be designated as described in 

10 paragraph (1) or (2), not be an applicant as de11 scribed in paragraph (3), and have demonstrated ap12 propriate involvement of an accredited teaching hos13 pital to carry out the inpatient responsibilities asso14 ciated with a primary care residency training pro15 gram. 

16 ‘‘(d) PREFERENCES.—In awarding grants and con17 tracts under paragraph (1) or (2) of subsection (b), the 

18 Secretary shall give preference to entities that— 

19 ‘‘(1) support teaching programs that address 

20 the health care needs of vulnerable populations; or 

21 ‘‘(2) are a Federally qualified health center (as 

22 defined in section 1861(aa)(4) of the Social Security 

23 Act) or a rural health clinic (as defined in section 

24 1861(aa)(2) of such Act). 
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1 ‘‘(e) ADDITIONAL PREFERENCES FOR ESTABLISHED

2 PROGRAMS.—In awarding grants and contracts under 

3 subsection (b)(2), the Secretary shall give preference to 

4 entities that have a demonstrated record of training— 

5 ‘‘(1) a high or significantly improved percentage 

6 of health professionals who provide primary care; 

7 ‘‘(2) individuals who are from disadvantaged 

8 backgrounds (including racial and ethnic minorities 

9 underrepresented among primary care professionals); 

10 or 

11 ‘‘(3) individuals who practice in settings having 

12 the principal focus of serving underserved areas or 

13 populations experiencing health disparities (including 

14 serving patients eligible for medical assistance under 

15 title XIX of the Social Security Act or for child 

16 health assistance under title XXI of such Act or 

17 those with special health care needs). 

18 ‘‘(f) PERIOD OF AWARDS.— 

19 ‘‘(1) IN GENERAL.—The period of a grant or 

20 contract under this section— 

21 ‘‘(A) shall not exceed 3 years for awards 

22 under subsection (b)(1); and 

23 ‘‘(B) shall not exceed 5 years for awards 

24 under subsection (b)(2). 

25 ‘‘(2) SPECIAL RULES.— 
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1 ‘‘(A) An award of a grant or contract 

2 under subsection (b)(1) shall not be renewed. 

3 ‘‘(B) The period of a grant or contract 

4 awarded to an entity under subsection (b)(2) 

5 shall not overlap with the period of any grant 

6 or contact awarded to the same entity under 

7 subsection (b)(1). 

8 ‘‘(g) REPORT.—The Secretary shall submit to the 

9 Congress an annual report on the program carried out 

10 under this section. 

11 ‘‘(h) DEFINITIONS.—In this section: 

12 ‘‘(1) HEALTH DISPARITIES.—The term ‘health 

13 disparities’ has the meaning given the term in sec14 tion 3171. 

15 ‘‘(2) PRIMARY CARE RESIDENT.—The term ‘pri16 mary care resident’ has the meaning given the term 

17 in section 1886(h)(5)(H) of the Social Security Act. 

18 ‘‘(3) PRIMARY CARE RESIDENCY TRAINING PRO19 GRAM.—The term ‘primary care residency training 

20 program’ means an approved medical residency 

21 training program described in section 1886(h)(5)(A) 

22 of the Social Security Act for primary care residents 

23 that is— 

24 ‘‘(A) in the case of entities seeking awards 

25 under subsection (b)(1), actively applying to be 
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1 accredited by the Accreditation Council for 

2 Graduate Medical Education or the American 

3 Osteopathic Association; or 

4 ‘‘(B) in the case of entities seeking awards 

5 under subsection (b)(2), so accredited. 

6 ‘‘(i) ALLOCATION OF FUNDS.—Of the amount appro7 priated pursuant to section 799C(a) for a fiscal year, not 

8 more than 17 percent of such amount shall be made avail9 able to carry out this section.’’. 

10 SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUB11 LIC HEALTH DENTISTS AND DENTAL HYGIEN12 ISTS. 

13 Title VII (42 U.S.C. 292 et seq.) is amended— 

14 (1) in section 791(a)(1), by striking ‘‘747 and 

15 750’’ and inserting ‘‘747, 749, and 750’’; and 

16 (2) by inserting after section 748, as added, the 

17 following: 

18 ‘‘SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUB19 LIC HEALTH DENTISTS AND DENTAL HYGIEN20 ISTS. 

21 ‘‘(a) PROGRAM.—The Secretary shall establish a 

22 training program for oral health professionals consisting 

23 of awarding grants and contracts under this section. 

24 ‘‘(b) SUPPORT AND DEVELOPMENT OF ORAL

25 HEALTH TRAINING PROGRAMS.—The Secretary shall 
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1 make grants to, or enter into contracts with, eligible enti2 ties— 

3 ‘‘(1) to plan, develop, operate, or participate in 

4 an accredited professional training program for oral 

5 health professionals; 

6 ‘‘(2) to provide financial assistance to oral 

7 health professionals who are in need thereof, who 

8 are participants in any such program, and who plan 

9 to work in general, pediatric, or public health den10 tistry, or dental hygiene; 

11 ‘‘(3) to plan, develop, operate, or participate in 

12 a program for the training of oral health profes13 sionals who plan to teach in general, pediatric, or 

14 public health dentistry, or dental hygiene; 

15 ‘‘(4) to provide financial assistance in the form 

16 of traineeships and fellowships to oral health profes17 sionals who plan to teach in general, pediatric, or 

18 public health dentistry or dental hygiene; 

19 ‘‘(5) to establish, maintain, or improve— 

20 ‘‘(A) academic administrative units (in21 cluding departments, divisions, or other appro22 priate units) in the specialties of general, pedi23 atric, or public health dentistry; or 

24 ‘‘(B) programs that improve clinical teach25 ing in such specialties; 
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1 ‘‘(6) to plan, develop, operate, or participate in 

2 predoctoral and postdoctoral training in general, pe3 diatric, or public health dentistry programs; 

4 ‘‘(7) to plan, develop, operate, or participate in 

5 a loan repayment program for full-time faculty in a 

6 program of general, pediatric, or public health den7 tistry; and 

8 ‘‘(8) to provide technical assistance to pediatric 

9 dental training programs in developing and imple10 menting instruction regarding the oral health status, 

11 dental care needs, and risk-based clinical disease 

12 management of all pediatric populations with an em13 phasis on underserved children. 

14 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con15 tract under this section, an entity shall be— 

16 ‘‘(1) an accredited school of dentistry, training 

17 program in dental hygiene, or public or nonprofit 

18 private hospital; 

19 ‘‘(2) a training program in dental hygiene at an 

20 accredited institution of higher education; 

21 ‘‘(3) a public or private nonprofit entity; or 

22 ‘‘(4) a consortium of— 

23 ‘‘(A) 1 or more of the entities described in 

24 paragraphs (1) through (3); and 

25 ‘‘(B) an accredited school of public health. 
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1 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

2 under this section, the Secretary shall give preference to 

3 entities that have a demonstrated record of at least one 

4 of the following: 

5 ‘‘(1) Training a high or significantly improved 

6 percentage of oral health professionals who practice 

7 general, pediatric, or public health dentistry. 

8 ‘‘(2) Training individuals who are from dis9 advantaged backgrounds (including racial and ethnic 

10 minorities underrepresented among oral health pro11 fessionals). 

12 ‘‘(3) A high rate of placing graduates in prac13 tice settings having the principal focus of serving in 

14 underserved areas or populations experiencing health 

15 disparities (including serving patients eligible for 

16 medical assistance under title XIX of the Social Se17 curity Act or for child health assistance under title 

18 XXI of such Act or those with special health care 

19 needs). 

20 ‘‘(4) Supporting teaching programs that ad21 dress the oral health needs of vulnerable popu22 lations. 

23 ‘‘(5) Providing instruction regarding the oral 

24 health status, oral health care needs, and risk-based 
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1 clinical disease management of all pediatric popu2 lations with an emphasis on underserved children. 

3 ‘‘(e) REPORT.—The Secretary shall submit to the 

4 Congress an annual report on the program carried out 

5 under this section. 

6 ‘‘(f) DEFINITIONS.—In this section: 

7 ‘‘(1) The term ‘health disparities’ has the 

8 meaning given the term in section 3171. 

9 ‘‘(2) The term ‘oral health professional’ means 

10 an individual training or practicing— 

11 ‘‘(A) in general dentistry, pediatric den12 tistry, public health dentistry, or dental hy13 giene; or 

14 ‘‘(B) another oral health specialty, as 

15 deemed appropriate by the Secretary.’’. 

16 SEC. 2216. AUTHORIZATION OF APPROPRIATIONS. 

17 (a) IN GENERAL.—Part F of title VII (42 U.S.C. 

18 295j et seq.) is amended by adding at the end the fol19 lowing: 

20 ‘‘SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVEST21 MENT FUND. 

22 ‘‘(a) PROMOTION OF PRIMARY CARE AND DEN23 TISTRY.—For the purpose of carrying out subpart XI of 

24 part D of title III and sections 747, 748, and 749, in addi25 tion to any other amounts authorized to be appropriated 
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1 for such purpose, there are authorized to be appropriated, 

2 out of any monies in the Public Health Investment Fund, 

3 the following: 

4 ‘‘(1) $240,000,000 for fiscal year 2011. 

5 ‘‘(2) $253,000,000 for fiscal year 2012. 

6 ‘‘(3) $265,000,000 for fiscal year 2013. 

7 ‘‘(4) $278,000,000 for fiscal year 2014. 

8 ‘‘(5) $292,000,000 for fiscal year 2015.’’. 

9 (b) EXISTING AUTHORIZATION OF APPROPRIA10 TIONS.—Subsection (g)(1), as so redesignated, of section 

11 747 (42 U.S.C. 293k) is amended by striking ‘‘2002’’ and 

12 inserting ‘‘2015’’. 

13 SEC. 2217. STUDY ON EFFECTIVENESS OF SCHOLARSHIPS 

14 AND LOAN REPAYMENTS. 

15 (a) STUDY.—The Comptroller General of the United 

16 States shall conduct a study to determine the effectiveness 

17 of scholarship and loan repayment programs under sub18 parts III and XI of part D of title III of the Public Health 

19 Service Act, as amended or added by sections 2201 and 

20 2211, including whether scholarships or loan repayments 

21 are more effective in— 

22 (1) incentivizing physicians, and other pro23 viders, to pursue careers in primary care specialties; 

24 (2) retaining such primary care providers; and 
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1 (3) encouraging such primary care providers to 

2 practice in underserved areas. 

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

4 date of the enactment of this Act, the Comptroller General 

5 shall submit to the Congress a report on the results of 

6 the study under subsection (a). 

7 Subtitle B—Nursing Workforce 

8 SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT. 

9 (a) DEFINITIONS.—Section 801 (42 U.S.C. 296 et 

10 seq.) is amended— 

11 (1) in paragraph (1), by inserting ‘‘nurse-man12 aged health centers,’’ after ‘‘nursing centers,’’; and 

13 (2) by adding at the end the following: 

14 ‘‘(16) NURSE-MANAGED HEALTH CENTER.— 

15 The term ‘nurse-managed health center’— 

16 ‘‘(A) means a nurse-practice arrangement, 

17 managed by one or more advanced practice 

18 nurses, that provides primary care or wellness 

19 services to underserved or vulnerable popu20 lations and is associated with an accredited 

21 school of nursing, Federally qualified health 

22 center, or independent nonprofit health or social 

23 services agency; and 

24 ‘‘(B) shall not be construed as changing 

25 State law requirements applicable to an ad-
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1 vanced practice nurse or the authorized scope of 

2 practice of such a nurse.’’. 

3 (b) GRANTS FOR HEALTH PROFESSIONS EDU4 CATION.—Title VIII (42 U.S.C. 296 et seq.) is amended 

5 by striking section 807. 

6 (c) REPORTS.—Part A of title VIII (42 U.S.C. 296 

7 et seq.) is amended by adding at the end the following: 

8 ‘‘SEC. 809. REPORTS. 

9 ‘‘The Secretary shall submit to the Congress a sepa10 rate annual report on the activities carried out under each 

11 of sections 811, 821, 836, 846A, and 861.’’. 

12 (d) ADVANCED EDUCATION NURSING GRANTS.—Sec13 tion 811(f) (42 U.S.C. 296j(f)) is amended— 

14 (1) by striking paragraph (2); 

15 (2) by redesignating paragraph (3) as para16 graph (2); and 

17 (3) in paragraph (2), as so redesignated, by 

18 striking ‘‘that agrees’’ and all that follows through 

19 the end and inserting: ‘‘that agrees to expend the 

20 award— 

21 ‘‘(A) to train advanced education nurses 

22 who will practice in health professional shortage 

23 areas designated under section 332; or 

24 ‘‘(B) to increase diversity among advanced 

25 education nurses.’’. 
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1 (e) NURSE EDUCATION, PRACTICE, AND RETENTION

2 GRANTS.—Section 831 (42 U.S.C. 296p) is amended— 

3 (1) in subsection (b), by amending paragraph 

4 (3) to read as follows: 

5 ‘‘(3) providing coordinated care, quality care, 

6 and other skills needed to practice nursing; or’’; and 

7 (2) by striking subsection (e) and redesignating 

8 subsections (f) through (h) as subsections (e) 

9 through (g), respectively. 

10 (f) STUDENT LOANS.—Subsection (a) of section 836 

11 (42 U.S.C. 297b) is amended— 

12 (1) by striking ‘‘$2,500’’ and inserting 

13 ‘‘$3,300’’; 

14 (2) by striking ‘‘$4,000’’ and inserting 

15 ‘‘$5,200’’; 

16 (3) by striking ‘‘$13,000’’ and inserting 

17 ‘‘$17,000’’; and 

18 (4) by adding at the end the following: ‘‘Begin19 ning with fiscal year 2012, the dollar amounts speci20 fied in this subsection shall be adjusted by an 

21 amount determined by the Secretary on an annual 

22 basis to reflect inflation.’’. 

23 (g) LOAN REPAYMENT.—Section 846 (42 U.S.C. 

24 297n) is amended— 
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1 (1) in subsection (a), by amending paragraph 

2 (3) to read as follows: 

3 ‘‘(3) who enters into an agreement with the 

4 Secretary to serve for a period of not less than 2 

5 years— 

6 ‘‘(A) as a nurse at a health care facility 

7 with a critical shortage of nurses; or 

8 ‘‘(B) as a faculty member at an accredited 

9 school of nursing;’’; and 

10 (2) in subsection (g)(1), by striking ‘‘to provide 

11 health services’’ each place it appears and inserting 

12 ‘‘to provide health services or serve as a faculty 

13 member’’. 

14 (h) NURSE FACULTY LOAN PROGRAM.—Paragraph 

15 (2) of section 846A(c) (42 U.S.C. 297n–1(c)) is amended 

16 by striking ‘‘$30,000’’ and all that follows through the 

17 semicolon and inserting ‘‘$35,000, plus, beginning with 

18 fiscal year 2012, an amount determined by the Secretary 

19 on an annual basis to reflect inflation;’’. 

20 (i) PUBLIC SERVICE ANNOUNCEMENTS.—Title VIII 

21 (42 U.S.C. 296 et seq.) is amended by striking part H. 

22 (j) TECHNICAL AND CONFORMING AMENDMENTS.— 

23 Title VIII (42 U.S.C. 296 et seq.) is amended— 

24 (1) by moving section 810 (relating to prohibi25 tion against discrimination by schools on the basis of 
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1 sex) so that it follows section 809, as added by sub2 section (c); 

3 (2) in sections 835, 836, 838, 840, and 842, by 

4 striking the term ‘‘this subpart’’ each place it ap5 pears and inserting ‘‘this part’’; 

6 (3) in section 836(h), by striking the last sen7 tence; 

8 (4) in section 836, by redesignating subsection 

9 (l) as subsection (k); 

10 (5) in section 839, by striking ‘‘839’’ and all 

11 that follows through ‘‘(a)’’ and inserting ‘‘839. (a)’’; 

12 (6) in section 835(b), by striking ‘‘841’’ each 

13 place it appears and inserting ‘‘871’’; 

14 (7) by redesignating section 841 as section 871, 

15 moving part F to the end of the title, and redesig16 nating such part as part H; 

17 (8) in part G— 

18 (A) by redesignating section 845 as section 

19 851; and 

20 (B) by redesignating part G as part F; and 

21 (9) in part I— 

22 (A) by redesignating section 855 as section 

23 861; and 

24 (B) by redesignating part I as part G. 

25 (k) FUNDING.— 
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1 (1) IN GENERAL.—Part H, as redesignated, of 

2 title VIII is amended by adding at the end the fol3 lowing: 

4 ‘‘SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVEST5 MENT FUND. 

6 ‘‘For the purpose of carrying out this title, in addi7 tion to any other amounts authorized to be appropriated 

8 for such purpose, there are authorized to be appropriated, 

9 out of any monies in the Public Health Investment Fund, 

10 the following: 

11 ‘‘(1) $115,000,000 for fiscal year 2011. 

12 ‘‘(2) $122,000,000 for fiscal year 2012. 

13 ‘‘(3) $127,000,000 for fiscal year 2013. 

14 ‘‘(4) $134,000,000 for fiscal year 2014. 

15 ‘‘(5) $140,000,000 for fiscal year 2015.’’. 

16 (2) EXISTING AUTHORIZATIONS OF APPROPRIA17 TIONS.— 

18 (A) SECTIONS 831, 846, 846A, AND 861.— 

19 Sections 831(g) (as so redesignated), 846(i)(1) 

20 (42 U.S.C. 297n(i)(1)), 846A(f) (42 U.S.C. 

21 297n–1(f)), and 861(e) (as so redesignated) are 

22 amended by striking ‘‘2007’’ each place it ap23 pears and inserting ‘‘2015’’. 
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1 (B) SECTION 871.—Section 871, as so re2 designated by subsection (j), is amended to read 

3 as follows: 

4 ‘‘SEC. 871. FUNDING. 

5 ‘‘For the purpose of carrying out parts B, C, and D 

6 (subject to section 851(g)), there are authorized to be ap7 propriated such sums as may be necessary for each fiscal 

8 year through fiscal year 2015.’’. 

9 Subtitle C—Public Health 

10 Workforce 

11 SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS. 

12 Part D of title III (42 U.S.C. 254b et seq.), as 

13 amended by section 2211, is amended by adding at the 

14 end the following: 

15 ‘‘Subpart XII—Public Health Workforce 

16 ‘‘SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS. 

17 ‘‘(a) ESTABLISHMENT.—There is established, within 

18 the Service, the Public Health Workforce Corps (in this 

19 subpart referred to as the ‘Corps’), for the purpose of en20 suring an adequate supply of public health professionals 

21 throughout the Nation. The Corps shall consist of— 

22 ‘‘(1) such officers of the Regular and Reserve 

23 Corps of the Service as the Secretary may designate; 

24 ‘‘(2) such civilian employees of the United 

25 States as the Secretary may appoint; and 
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1 ‘‘(3) such other individuals who are not employ2 ees of the United States. 

3 ‘‘(b) ADMINISTRATION.—Except as provided in sub4 section (c), the Secretary shall carry out this subpart act5 ing through the Administrator of the Health Resources 

6 and Services Administration. 

7 ‘‘(c) PLACEMENT AND ASSIGNMENT.—The Secretary, 

8 acting through the Director of the Centers for Disease 

9 Control and Prevention, shall develop a methodology for 

10 placing and assigning Corps participants as public health 

11 professionals. Such methodology may allow for placing and 

12 assigning such participants in State, local, and tribal 

13 health departments and Federally qualified health centers 

14 (as defined in section 1861(aa)(4) of the Social Security 

15 Act). 

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

17 provisions of subpart II shall, except as inconsistent with 

18 this subpart, apply to the Public Health Workforce Corps 

19 in the same manner and to the same extent as such provi20 sions apply to the National Health Service Corps estab21 lished under section 331. 

22 ‘‘(e) REPORT.—The Secretary shall submit to the 

23 Congress an annual report on the programs carried out 

24 under this subpart. 
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1 ‘‘SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP 

2 PROGRAM. 

3 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab4 lish the Public Health Workforce Scholarship Program 

5 (referred to in this section as the ‘Program’) for the pur6 pose described in section 340L(a). 

7 ‘‘(b) ELIGIBILITY.—To be eligible to participate in 

8 the Program, an individual shall— 

9 ‘‘(1)(A) be accepted for enrollment, or be en10 rolled, as a full-time or part-time student in a course 

11 of study or program (approved by the Secretary) at 

12 an accredited graduate school or program of public 

13 health; or 

14 ‘‘(B) have demonstrated expertise in public 

15 health and be accepted for enrollment, or be en16 rolled, as a full-time or part-time student in a course 

17 of study or program (approved by the Secretary) 

18 at— 

19 ‘‘(i) an accredited graduate school or pro20 gram of nursing; health administration, man21 agement, or policy; preventive medicine; labora22 tory science; veterinary medicine; or dental 

23 medicine; or 

24 ‘‘(ii) another accredited graduate school or 

25 program, as deemed appropriate by the Sec26 retary; 
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1 ‘‘(2) be eligible for, or hold, an appointment as 

2 a commissioned officer in the Regular or Reserve 

3 Corps of the Service or be eligible for selection for 

4 civilian service in the Corps; and 

5 ‘‘(3) sign and submit to the Secretary a written 

6 contract (described in subsection (c)) to serve full7 time as a public health professional, upon the com8 pletion of the course of study or program involved, 

9 for the period of obligated service described in sub10 section (c)(2)(E). 

11 ‘‘(c) CONTRACT.—The written contract between the 

12 Secretary and an individual under subsection (b)(3) shall 

13 contain— 

14 ‘‘(1) an agreement on the part of the Secretary 

15 that the Secretary will— 

16 ‘‘(A) provide the individual with a scholar17 ship for a period of years (not to exceed 4 aca18 demic years) during which the individual shall 

19 pursue an approved course of study or program 

20 to prepare the individual to serve in the public 

21 health workforce; and 

22 ‘‘(B) accept (subject to the availability of 

23 appropriated funds) the individual into the 

24 Corps; 
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1 ‘‘(2) an agreement on the part of the individual 

2 that the individual will— 

3 ‘‘(A) accept provision of such scholarship 

4 to the individual; 

5 ‘‘(B) maintain full-time or part-time enroll6 ment in the approved course of study or pro7 gram described in subsection (b)(1) until the in8 dividual completes that course of study or pro9 gram; 

10 ‘‘(C) while enrolled in the approved course 

11 of study or program, maintain an acceptable 

12 level of academic standing (as determined by 

13 the educational institution offering such course 

14 of study or program); 

15 ‘‘(D) if applicable, complete a residency or 

16 internship; and 

17 ‘‘(E) serve full-time as a public health pro18 fessional for a period of time equal to the great19 er of— 

20 ‘‘(i) 1 year for each academic year for 

21 which the individual was provided a schol22 arship under the Program; or 

23 ‘‘(ii) 2 years; and 
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1 ‘‘(3) an agreement by both parties as to the na2 ture and extent of the scholarship assistance, which 

3 may include— 

4 ‘‘(A) payment of reasonable educational ex5 penses of the individual, including tuition, fees, 

6 books, equipment, and laboratory expenses; and 

7 ‘‘(B) payment of a stipend of not more 

8 than $1,269 (plus, beginning with fiscal year 

9 2012, an amount determined by the Secretary 

10 on an annual basis to reflect inflation) per 

11 month for each month of the academic year in12 volved, with the dollar amount of such a stipend 

13 determined by the Secretary taking into consid14 eration whether the individual is enrolled full15 time or part-time. 

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

17 provisions of subpart III shall, except as inconsistent with 

18 this subpart, apply to the scholarship program under this 

19 section in the same manner and to the same extent as 

20 such provisions apply to the National Health Service 

21 Corps Scholarship Program established under section 

22 338A. 
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1 ‘‘SEC. 340N. PUBLIC HEALTH WORKFORCE LOAN REPAY2 MENT PROGRAM. 

3 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab4 lish the Public Health Workforce Loan Repayment Pro5 gram (referred to in this section as the ‘Program’) for the 

6 purpose described in section 340L(a). 

7 ‘‘(b) ELIGIBILITY.—To be eligible to participate in 

8 the Program, an individual shall— 

9 ‘‘(1)(A) have a graduate degree from an accred10 ited school or program of public health; 

11 ‘‘(B) have demonstrated expertise in public 

12 health and have a graduate degree in a course of 

13 study or program (approved by the Secretary) 

14 from— 

15 ‘‘(i) an accredited school or program of 

16 nursing; health administration, management, or 

17 policy; preventive medicine; laboratory science; 

18 veterinary medicine; or dental medicine; or 

19 ‘‘(ii) another accredited school or program 

20 approved by the Secretary; or 

21 ‘‘(C) be enrolled as a full-time or part-time stu22 dent in the final year of a course of study or pro23 gram (approved by the Secretary) offered by a 

24 school or program described in subparagraph (A) or 

25 (B), leading to a graduate degree; 
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1 ‘‘(2) be eligible for, or hold, an appointment as 

2 a commissioned officer in the Regular or Reserve 

3 Corps of the Service or be eligible for selection for 

4 civilian service in the Corps; 

5 ‘‘(3) if applicable, complete a residency or in6 ternship; and 

7 ‘‘(4) sign and submit to the Secretary a written 

8 contract (described in subsection (c)) to serve full9 time as a public health professional for the period of 

10 obligated service described in subsection (c)(2). 

11 ‘‘(c) CONTRACT.—The written contract between the 

12 Secretary and an individual under subsection (b)(4) shall 

13 contain— 

14 ‘‘(1) an agreement by the Secretary to repay on 

15 behalf of the individual loans incurred by the indi16 vidual in the pursuit of the relevant public health 

17 workforce educational degree in accordance with the 

18 terms of the contract; 

19 ‘‘(2) an agreement by the individual to serve 

20 full-time as a public health professional for a period 

21 of time equal to 2 years or such longer period as the 

22 individual may agree to; and 

23 ‘‘(3) in the case of an individual described in 

24 subsection (b)(1)(C) who is in the final year of study 

25 and who has accepted employment as a public health 
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1 professional, in accordance with section 340L(c), an 

2 agreement on the part of the individual to complete 

3 the education or training, maintain an acceptable 

4 level of academic standing (as determined by the 

5 educational institution offering the course of study 

6 or training), and serve the period of obligated service 

7 described in paragraph (2). 

8 ‘‘(d) PAYMENTS.— 

9 ‘‘(1) IN GENERAL.—A loan repayment provided 

10 for an individual under a written contract under the 

11 Program shall consist of payment, in accordance 

12 with paragraph (2), on behalf of the individual of 

13 the principal, interest, and related expenses on gov14 ernment and commercial loans received by the indi15 vidual regarding the undergraduate or graduate edu16 cation of the individual (or both), which loans were 

17 made for reasonable educational expenses, including 

18 tuition, fees, books, equipment, and laboratory ex19 penses, incurred by the individual. 

20 ‘‘(2) PAYMENTS FOR YEARS SERVED.— 

21 ‘‘(A) IN GENERAL.—For each year of obli22 gated service that an individual contracts to 

23 serve under subsection (c), the Secretary may 

24 pay up to $35,000 (plus, beginning with fiscal 

25 year 2012, an amount determined by the Sec-
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1 retary on an annual basis to reflect inflation) 

2 on behalf of the individual for loans described 

3 in paragraph (1). 

4 ‘‘(B) REPAYMENT SCHEDULE.—Any ar5 rangement made by the Secretary for the mak6 ing of loan repayments in accordance with this 

7 subsection shall provide that any repayments 

8 for a year of obligated service shall be made no 

9 later than the end of the fiscal year in which 

10 the individual completes such year of service. 

11 ‘‘(e) APPLICATION OF CERTAIN PROVISIONS.—The 

12 provisions of subpart III shall, except as inconsistent with 

13 this subpart, apply to the loan repayment program under 

14 this section in the same manner and to the same extent 

15 as such provisions apply to the National Health Service 

16 Corps Loan Repayment Program established under sec17 tion 338B.’’. 

18 SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE. 

19 Section 765 (42 U.S.C. 295) is amended to read as 

20 follows: 

21 ‘‘SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE. 

22 ‘‘(a) PROGRAM.—The Secretary, acting through the 

23 Administrator of the Health Resources and Services Ad24 ministration and in consultation with the Director of the 

25 Centers for Disease Control and Prevention, shall estab-
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1 lish a public health workforce training and enhancement 

2 program consisting of awarding grants and contracts 

3 under subsection (b). 

4 ‘‘(b) GRANTS AND CONTRACTS.—The Secretary shall 

5 award grants to, or enter into contracts with, eligible enti6 ties— 

7 ‘‘(1) to plan, develop, operate, or participate in, 

8 an accredited professional training program in the 

9 field of public health (including such a program in 

10 nursing; health administration, management, or pol11 icy; preventive medicine; laboratory science; veteri12 nary medicine; or dental medicine) for members of 

13 the public health workforce, including midcareer pro14 fessionals; 

15 ‘‘(2) to provide financial assistance in the form 

16 of traineeships and fellowships to students who are 

17 participants in any such program and who plan to 

18 specialize or work in the field of public health; 

19 ‘‘(3) to plan, develop, operate, or participate in 

20 a program for the training of public health profes21 sionals who plan to teach in any program described 

22 in paragraph (1); and 

23 ‘‘(4) to provide financial assistance in the form 

24 of traineeships and fellowships to public health pro25 fessionals who are participants in any program de-
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1 scribed in paragraph (1) and who plan to teach in 

2 the field of public health, including nursing; health 

3 administration, management, or policy; preventive 

4 medicine; laboratory science; veterinary medicine; or 

5 dental medicine. 

6 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con7 tract under this section, an entity shall be— 

8 ‘‘(1) an accredited health professions school, in9 cluding an accredited school or program of public 

10 health; nursing; health administration, management, 

11 or policy; preventive medicine; laboratory science; 

12 veterinary medicine; or dental medicine; 

13 ‘‘(2) a State, local, or tribal health department; 

14 ‘‘(3) a public or private nonprofit entity; or 

15 ‘‘(4) a consortium of 2 or more entities de16 scribed in paragraphs (1) through (3). 

17 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

18 under this section, the Secretary shall give preference to 

19 entities that have a demonstrated record of at least one 

20 of the following: 

21 ‘‘(1) Training a high or significantly improved 

22 percentage of public health professionals who serve 

23 in underserved communities. 

24 ‘‘(2) Training individuals who are from dis25 advantaged backgrounds (including racial and ethnic 
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1 minorities underrepresented among public health 

2 professionals). 

3 ‘‘(3) Training individuals in public health spe4 cialties experiencing a significant shortage of public 

5 health professionals (as determined by the Sec6 retary). 

7 ‘‘(4) Training a high or significantly improved 

8 percentage of public health professionals serving in 

9 the Federal Government or a State, local, or tribal 

10 government. 

11 ‘‘(e) REPORT.—The Secretary shall submit to the 

12 Congress an annual report on the program carried out 

13 under this section.’’. 

14 SEC. 2233. PUBLIC HEALTH TRAINING CENTERS. 

15 Section 766 (42 U.S.C. 295a) is amended— 

16 (1) in subsection (b)(1), by striking ‘‘in further17 ance of the goals established by the Secretary for 

18 the year 2000’’ and inserting ‘‘in furtherance of the 

19 goals established by the Secretary in the national 

20 prevention and wellness strategy under section 

21 3121’’; and 

22 (2) by adding at the end the following: 

23 ‘‘(d) REPORT.—The Secretary shall submit to the 

24 Congress an annual report on the program carried out 

25 under this section.’’. 
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1 SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH 

2 TRAINING GRANT PROGRAM. 

3 Section 768 (42 U.S.C. 295c) is amended to read as 

4 follows: 

5 ‘‘SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH 

6 TRAINING GRANT PROGRAM. 

7 ‘‘(a) GRANTS.—The Secretary, acting through the 

8 Administrator of the Health Resources and Services Ad9 ministration and in consultation with the Director of the 

10 Centers for Disease Control and Prevention, shall award 

11 grants to, or enter into contracts with, eligible entities to 

12 provide training to graduate medical residents in preven13 tive medicine specialties. 

14 ‘‘(b) ELIGIBILITY.—To be eligible for a grant or con15 tract under subsection (a), an entity shall be— 

16 ‘‘(1) an accredited school of public health or 

17 school of medicine or osteopathic medicine; 

18 ‘‘(2) an accredited public or private nonprofit 

19 hospital; 

20 ‘‘(3) a State, local, or tribal health department; 

21 or 

22 ‘‘(4) a consortium of 2 or more entities de23 scribed in paragraphs (1) through (3). 

24 ‘‘(c) USE OF FUNDS.—Amounts received under a 

25 grant or contract under this section shall be used to— 
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1 ‘‘(1) plan, develop (including the development of 

2 curricula), operate, or participate in an accredited 

3 residency or internship program in preventive medi4 cine or public health; 

5 ‘‘(2) defray the costs of practicum experiences, 

6 as required in such a program; and 

7 ‘‘(3) establish, maintain, or improve— 

8 ‘‘(A) academic administrative units (in9 cluding departments, divisions, or other appro10 priate units) in preventive medicine and public 

11 health; or 

12 ‘‘(B) programs that improve clinical teach13 ing in preventive medicine and public health. 

14 ‘‘(d) REPORT.—The Secretary shall submit to the 

15 Congress an annual report on the program carried out 

16 under this section.’’. 

17 SEC. 2235. AUTHORIZATION OF APPROPRIATIONS. 

18 (a) IN GENERAL.—Section 799C, as added by section 

19 2216 of this Act, is amended by adding at the end the 

20 following: 

21 ‘‘(b) PUBLIC HEALTH WORKFORCE.—For the pur22 pose of carrying out subpart XII of part D of title III 

23 and sections 765, 766, and 768, in addition to any other 

24 amounts authorized to be appropriated for such purpose, 
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1 there are authorized to be appropriated, out of any monies 

2 in the Public Health Investment Fund, the following: 

3 ‘‘(1) $51,000,000 for fiscal year 2011. 

4 ‘‘(2) $54,000,000 for fiscal year 2012. 

5 ‘‘(3) $57,000,000 for fiscal year 2013. 

6 ‘‘(4) $59,000,000 for fiscal year 2014. 

7 ‘‘(5) $62,000,000 for fiscal year 2015.’’. 

8 (b) EXISTING AUTHORIZATION OF APPROPRIA9 TIONS.—Subsection (a) of section 770 (42 U.S.C. 295e) 

10 is amended by striking ‘‘2002’’ and inserting ‘‘2015’’. 

11 Subtitle D—Adapting Workforce to 

12 Evolving Health System Needs 

13 PART 1—HEALTH PROFESSIONS TRAINING FOR 

14 DIVERSITY 

15 SEC. 2241. SCHOLARSHIPS FOR DISADVANTAGED STU16 DENTS, LOAN REPAYMENTS AND FELLOW17 SHIPS REGARDING FACULTY POSITIONS, AND 

18 EDUCATIONAL ASSISTANCE IN THE HEALTH 

19 PROFESSIONS REGARDING INDIVIDUALS 

20 FROM DISADVANTAGED BACKGROUNDS. 

21 Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) 

22 is amended by striking ‘‘not more than $20,000’’ and all 

23 that follows through the end of the paragraph and insert24 ing: ‘‘not more than $35,000 (plus, beginning with fiscal 

25 year 2012, an amount determined by the Secretary on an 
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1 annual basis to reflect inflation) of the principal and inter2 est of the educational loans of such individuals.’’. 

3 SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS. 

4 Subsection (b) of section 821 (42 U.S.C. 296m) is 

5 amended— 

6 (1) in the heading, by striking ‘‘GUIDANCE’’ 

7 and inserting ‘‘CONSULTATION’’; and 

8 (2) by striking ‘‘shall take into consideration’’ 

9 and all that follows through ‘‘consult with nursing 

10 associations’’ and inserting ‘‘shall, as appropriate, 

11 consult with nursing associations’’. 

12 SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL 

13 COMPETENCY PROGRAMS. 

14 (a) IN GENERAL.—Title VII (42 U.S.C. 292 et seq.) 

15 is amended by inserting after section 739 the following: 

16 ‘‘SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL 

17 COMPETENCY PROGRAMS. 

18 ‘‘The Secretary shall, to the extent practicable, co19 ordinate the activities carried out under this part and sec20 tion 821 in order to enhance the effectiveness of such ac21 tivities and avoid duplication of effort.’’. 

22 (b) REPORT.—Section 736 (42 U.S.C. 293) is 

23 amended— 

24 (1) by redesignating subsection (h) as sub25 section (i); and 
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1 (2) by inserting after subsection (g) the fol2 lowing: 

3 ‘‘(h) REPORT.—The Secretary shall submit to the 

4 Congress an annual report on the activities carried out 

5 under this section.’’. 

6 PART 2—INTERDISCIPLINARY TRAINING 

7 PROGRAMS 

8 SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY 

9 TRAINING FOR HEALTH PROFESSIONALS. 

10 Section 741 (42 U.S.C. 293e) is amended— 

11 (1) in the section heading, by striking 

12 ‘‘GRANTS FOR HEALTH PROFESSIONS EDU13 CATION’’ and inserting ‘‘CULTURAL AND LIN14 GUISTIC COMPETENCY TRAINING FOR HEALTH

15 PROFESSIONALS’’; 

16 (2) by redesignating subsection (b) as sub17 section (h); and 

18 (3) by striking subsection (a) and inserting the 

19 following: 

20 ‘‘(a) PROGRAM.—The Secretary shall establish a cul21 tural and linguistic competency training program for 

22 health professionals, including nurse professionals, con23 sisting of awarding grants and contracts under subsection 

24 (b). 
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1 ‘‘(b) CULTURAL AND LINGUISTIC COMPETENCY

2 TRAINING.—The Secretary shall award grants to, or enter 

3 into contracts with, eligible entities— 

4 ‘‘(1) to test, develop, and evaluate models of 

5 cultural and linguistic competency training (includ6 ing continuing education) for health professionals; 

7 and 

8 ‘‘(2) to implement cultural and linguistic com9 petency training programs for health professionals 

10 developed under paragraph (1) or otherwise. 

11 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con12 tract under subsection (b), an entity shall be— 

13 ‘‘(1) an accredited health professions school or 

14 program; 

15 ‘‘(2) an academic health center; 

16 ‘‘(3) a public or private nonprofit entity; or 

17 ‘‘(4) a consortium of 2 or more entities de18 scribed in paragraphs (1) through (3). 

19 ‘‘(d) PREFERENCE.—In awarding grants and con20 tracts under this section, the Secretary shall give pref21 erence to entities that have a demonstrated record of at 

22 least one of the following: 

23 ‘‘(1) Addressing, or partnering with an entity 

24 with experience addressing, the cultural and lin-
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1 guistic competency needs of the population to be 

2 served through the grant or contract. 

3 ‘‘(2) Addressing health disparities. 

4 ‘‘(3) Placing health professionals in regions ex5 periencing significant changes in the cultural and 

6 linguistic demographics of populations, including 

7 communities along the United States-Mexico border. 

8 ‘‘(4) Carrying out activities described in sub9 section (b) with respect to more than one health pro10 fession discipline, specialty, or subspecialty. 

11 ‘‘(e) CONSULTATION.—The Secretary shall carry out 

12 this section in consultation with the heads of appropriate 

13 health agencies and offices in the Department of Health 

14 and Human Services, including the Office of Minority 

15 Health and the National Center on Minority Health and 

16 Health Disparities. 

17 ‘‘(f) DEFINITION.—In this section, the term ‘health 

18 disparities’ has the meaning given to the term in section 

19 3171. 

20 ‘‘(g) REPORT.—The Secretary shall submit to the 

21 Congress an annual report on the program carried out 

22 under this section.’’. 
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1 SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE 

2 TRAINING. 

3 Part D of title VII (42 U.S.C. 294 et seq.) is amend4 ed by adding at the end the following: 

5 ‘‘SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE 

6 TRAINING. 

7 ‘‘(a) PROGRAM.—The Secretary shall establish an in8 novations in interdisciplinary care training program con9 sisting of awarding grants and contracts under subsection 

10 (b). 

11 ‘‘(b) TRAINING PROGRAMS.—The Secretary shall 

12 award grants to, or enter into contracts with, eligible enti13 ties— 

14 ‘‘(1) to test, develop, and evaluate health pro15 fessional training programs (including continuing 

16 education) designed to promote— 

17 ‘‘(A) the delivery of health services through 

18 interdisciplinary and team-based models, which 

19 may include patient-centered medical home 

20 models, medication therapy management mod21 els, and models integrating physical, mental, or 

22 oral health services; and 

23 ‘‘(B) coordination of the delivery of health 

24 care within and across settings, including health 

25 care institutions, community-based settings, 

26 and the patient’s home; and 
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1 ‘‘(2) to implement such training programs de2 veloped under paragraph (1) or otherwise. 

3 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con4 tract under subsection (b), an entity shall be— 

5 ‘‘(1) an accredited health professions school or 

6 program; 

7 ‘‘(2) an academic health center; 

8 ‘‘(3) a public or private nonprofit entity (includ9 ing an area health education center or a geriatric 

10 education center); or 

11 ‘‘(4) a consortium of 2 or more entities de12 scribed in paragraphs (1) through (3). 

13 ‘‘(d) PREFERENCES.—In awarding grants and con14 tracts under this section, the Secretary shall give pref15 erence to entities that have a demonstrated record of at 

16 least one of the following: 

17 ‘‘(1) Training a high or significantly improved 

18 percentage of health professionals who serve in un19 derserved communities. 

20 ‘‘(2) Broad interdisciplinary team-based collabo21 rations. 

22 ‘‘(3) Addressing health disparities. 

23 ‘‘(e) REPORT.—The Secretary shall submit to the 

24 Congress an annual report on the program carried out 

25 under this section. 
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1 ‘‘(f) DEFINITIONS.—In this section: 

2 ‘‘(1) The term ‘health disparities’ has the 

3 meaning given the term in section 3171. 

4 ‘‘(2) The term ‘interdisciplinary’ means collabo5 ration across health professions and specialties, 

6 which may include public health, nursing, allied 

7 health, dietetics or nutrition, and appropriate health 

8 specialties.’’. 

9 PART 3—ADVISORY COMMITTEE ON HEALTH 

10 WORKFORCE EVALUATION AND ASSESSMENT 

11 SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESS12 MENT. 

13 Subpart 1 of part E of title VII (42 U.S.C. 294n 

14 et seq.) is amended by adding at the end the following: 

15 ‘‘SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESS16 MENT. 

17 ‘‘(a) ADVISORY COMMITTEE.—The Secretary, acting 

18 through the Assistant Secretary for Health, shall establish 

19 a permanent advisory committee to be known as the Advi20 sory Committee on Health Workforce Evaluation and As21 sessment (referred to in this section as the ‘Advisory Com22 mittee’) to develop and implement an integrated, coordi23 nated, and strategic national health workforce policy re24 flective of current and evolving health workforce needs. 
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1 ‘‘(b) RESPONSIBILITIES.—The Advisory Committee 

2 shall— 

3 ‘‘(1) not later than 1 year after the date of the 

4 establishment of the Advisory Committee, submit 

5 recommendations to the Secretary on— 

6 ‘‘(A) classifications of the health workforce 

7 to ensure consistency of data collection on the 

8 health workforce; and 

9 ‘‘(B) based on such classifications, stand10 ardized methodologies and procedures to enu11 merate the health workforce; 

12 ‘‘(2) not later than 2 years after the date of the 

13 establishment of the Advisory Committee, submit 

14 recommendations to the Secretary on— 

15 ‘‘(A) the supply, diversity, and geographic 

16 distribution of the health workforce; 

17 ‘‘(B) the retention and expansion of the 

18 health workforce (on a short- and long-term 

19 basis) to ensure quality and adequacy of such 

20 workforce; and 

21 ‘‘(C) policies to carry out the recommenda22 tions made pursuant to subparagraphs (A) and 

23 (B); and 

24 ‘‘(3) not later than 4 years after the date of the 

25 establishment of the Advisory Committee, and every 
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1 2 years thereafter, submit updated recommendations 

2 to the Secretary under paragraphs (1) and (2). 

3 ‘‘(c) ROLE OF AGENCY.—The Secretary shall provide 

4 ongoing administrative, research, and technical support 

5 for the operations of the Advisory Committee, including 

6 coordinating and supporting the dissemination of the rec7 ommendations of the Advisory Committee. 

8 ‘‘(d) MEMBERSHIP.— 

9 ‘‘(1) NUMBER; APPOINTMENT.—The Secretary 

10 shall appoint 15 members to serve on the Advisory 

11 Committee. 

12 ‘‘(2) TERMS.— 

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

14 appoint members of the Advisory Committee for 

15 a term of 3 years and may reappoint such 

16 members, but the Secretary may not appoint 

17 any member to serve more than a total of 6 

18 years. 

19 ‘‘(B) STAGGERED TERMS.—Notwith20 standing subparagraph (A), of the members 

21 first appointed to the Advisory Committee 

22 under paragraph (1)— 

23 ‘‘(i) 5 shall be appointed for a term of 

24 1 year; 
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1 ‘‘(ii) 5 shall be appointed for a term 

2 of 2 years; and 

3 ‘‘(iii) 5 shall be appointed for a term 

4 of 3 years. 

5 ‘‘(3) QUALIFICATIONS.—Members of the Advi6 sory Committee shall be appointed from among indi7 viduals who possess expertise in at least one of the 

8 following areas: 

9 ‘‘(A) Conducting and interpreting health 

10 workforce market analysis, including health 

11 care labor workforce analysis. 

12 ‘‘(B) Conducting and interpreting health 

13 finance and economics research. 

14 ‘‘(C) Delivering and administering health 

15 care services. 

16 ‘‘(D) Delivering and administering health 

17 workforce education and training. 

18 ‘‘(4) REPRESENTATION.—In appointing mem19 bers of the Advisory Committee, the Secretary 

20 shall— 

21 ‘‘(A) include no less than one representa22 tive of each of— 

23 ‘‘(i) health professionals within the 

24 health workforce; 
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1 ‘‘(ii) health care patients and con2 sumers; 

3 ‘‘(iii) employers; 

4 ‘‘(iv) labor unions; and 

5 ‘‘(v) third-party health payors; and 

6 ‘‘(B) ensure that— 

7 ‘‘(i) all areas of expertise described in 

8 paragraph (3) are represented; 

9 ‘‘(ii) the members of the Advisory 

10 Committee include members who, collec11 tively, have significant experience working 

12 with— 

13 ‘‘(I) populations in urban and 

14 federally designated rural and non15 metropolitan areas; and 

16 ‘‘(II) populations who are under17 represented in the health professions, 

18 including underrepresented minority 

19 groups; and 

20 ‘‘(iii) individuals who are directly in21 volved in health professions education or 

22 practice do not constitute a majority of the 

23 members of the Advisory Committee. 

24 ‘‘(5) DISCLOSURE AND CONFLICTS OF INTER25 EST.—Members of the Advisory Committee shall not 
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1 be considered employees of the Federal Government 

2 by reason of service on the Advisory Committee, ex3 cept members of the Advisory Committee shall be 

4 considered to be special Government employees with5 in the meaning of section 107 of the Ethics in Gov6 ernment Act of 1978 (5 U.S.C. App.) and section 

7 208 of title 18, United States Code, for the purposes 

8 of disclosure and management of conflicts of interest 

9 under those sections. 

10 ‘‘(6) NO PAY; RECEIPT OF TRAVEL EX11 PENSES.—Members of the Advisory Committee shall 

12 not receive any pay for service on the Committee, 

13 but may receive travel expenses, including a per 

14 diem, in accordance with applicable provisions of 

15 subchapter I of chapter 57 of title 5, United States 

16 Code. 

17 ‘‘(e) CONSULTATION.—In carrying out this section, 

18 the Secretary shall consult with the Secretary of Edu19 cation and the Secretary of Labor. 

20 ‘‘(f) COLLABORATION.—The Advisory Committee 

21 shall collaborate with the advisory bodies at the Health 

22 Resources and Services Administration, the National Ad23 visory Council (as authorized in section 337), the Advisory 

24 Committee on Training in Primary Care Medicine and 

25 Dentistry (as authorized in section 749A), the Advisory 
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1 Committee on Interdisciplinary, Community-Based Link2 ages (as authorized in section 756), the Advisory Council 

3 on Graduate Medical Education (as authorized in section 

4 762), and the National Advisory Council on Nurse Edu5 cation and Practice (as authorized in section 851). 

6 ‘‘(g) FACA.—The Federal Advisory Committee Act 

7 (5 U.S.C. App.) except for section 14 of such Act shall 

8 apply to the Advisory Committee under this section only 

9 to the extent that the provisions of such Act do not conflict 

10 with the requirements of this section. 

11 ‘‘(h) REPORT.—The Secretary shall submit to the 

12 Congress an annual report on the activities of the Advisory 

13 Committee. 

14 ‘‘(i) DEFINITION.—In this section, the term ‘health 

15 workforce’ includes all health care providers with direct 

16 patient care and support responsibilities, including physi17 cians, nurses, physician assistants, pharmacists, oral 

18 health professionals (as defined in section 749(f)(2)), al19 lied health professionals, mental and behavioral health 

20 professionals (as defined in section 775(f)(2)), and public 

21 health professionals (including veterinarians engaged in 

22 public health practice).’’. 
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1 PART 4—HEALTH WORKFORCE ASSESSMENT 

2 SEC. 2271. HEALTH WORKFORCE ASSESSMENT. 

3 (a) IN GENERAL.—Section 761 (42 U.S.C. 294n) is 

4 amended— 

5 (1) by redesignating subsection (c) as sub6 section (e); and 

7 (2) by striking subsections (a) and (b) and in8 serting the following: 

9 ‘‘(a) IN GENERAL.—The Secretary shall, based upon 

10 the classifications and standardized methodologies and 

11 procedures developed by the Advisory Committee on 

12 Health Workforce Evaluation and Assessment under sec13 tion 764(b)— 

14 ‘‘(1) collect data on the health workforce (as 

15 defined in section 764(i)), disaggregated by field, 

16 discipline, and specialty, with respect to— 

17 ‘‘(A) the supply (including retention) of 

18 health professionals relative to the demand for 

19 such professionals; 

20 ‘‘(B) the diversity of health professionals 

21 (including with respect to race, ethnic back22 ground, and sex); and 

23 ‘‘(C) the geographic distribution of health 

24 professionals; and 

25 ‘‘(2) collect such data on individuals partici26 pating in the programs authorized by subtitles A, B, 
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1 and C and part 1 of subtitle D of title II of division 

2 C of the Affordable Health Care for America Act. 

3 ‘‘(b) GRANTS AND CONTRACTS FOR HEALTH WORK4 FORCE ANALYSIS.— 

5 ‘‘(1) IN GENERAL.—The Secretary may award 

6 grants to, or enter into contracts with, eligible enti7 ties to carry out subsection (a). 

8 ‘‘(2) ELIGIBILITY.—To be eligible for a grant 

9 or contract under this subsection, an entity shall 

10 be— 

11 ‘‘(A) an accredited health professions 

12 school or program; 

13 ‘‘(B) an academic health center; 

14 ‘‘(C) a State, local, or tribal government; 

15 ‘‘(D) a public or private entity; or 

16 ‘‘(E) a consortium of 2 or more entities de17 scribed in subparagraphs (A) through (D). 

18 ‘‘(c) COLLABORATION AND DATA SHARING.—The 

19 Secretary shall collaborate with Federal departments and 

20 agencies, health professions organizations (including 

21 health professions education organizations), and profes22 sional medical societies for the purpose of carrying out 

23 subsection (a). 
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1 ‘‘(d) REPORT.—The Secretary shall submit to the 

2 Congress an annual report on the data collected under 

3 subsection (a).’’. 

4 (b) PERIOD BEFORE COMPLETION OF NATIONAL

5 STRATEGY.—Pending completion of the classifications and 

6 standardized methodologies and procedures developed by 

7 the Advisory Committee on Health Workforce Evaluation 

8 and Assessment under section 764(b) of the Public Health 

9 Service Act, as added by section 2261, the Secretary of 

10 Health and Human Services, acting through the Adminis11 trator of the Health Resources and Services Administra12 tion and in consultation with such Advisory Committee, 

13 may make a judgment about the classifications, meth14 odologies, and procedures to be used for collection of data 

15 under section 761(a) of the Public Health Service Act, as 

16 amended by this section. 

17 PART 5—AUTHORIZATION OF APPROPRIATIONS 

18 SEC. 2281. AUTHORIZATION OF APPROPRIATIONS. 

19 (a) IN GENERAL.—Section 799C, as added and 

20 amended, is further amended by adding at the end the 

21 following: 

22 ‘‘(c) HEALTH PROFESSIONS TRAINING FOR DIVER23 SITY.—For the purpose of carrying out sections 736, 737, 

24 738, 739, and 739A, in addition to any other amounts 

25 authorized to be appropriated for such purpose, there are 
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1 authorized to be appropriated, out of any monies in the 

2 Public Health Investment Fund, the following: 

3 ‘‘(1) $90,000,000 for fiscal year 2011. 

4 ‘‘(2) $97,000,000 for fiscal year 2012. 

5 ‘‘(3) $100,000,000 for fiscal year 2013. 

6 ‘‘(4) $104,000,000 for fiscal year 2014. 

7 ‘‘(5) $110,000,000 for fiscal year 2015. 

8 ‘‘(d) INTERDISCIPLINARY TRAINING PROGRAMS, AD9 VISORY COMMITTEE ON HEALTH WORKFORCE EVALUA10 TION AND ASSESSMENT, AND HEALTH WORKFORCE AS11 SESSMENT.—For the purpose of carrying out sections 

12 741, 759, 761, and 764, in addition to any other amounts 

13 authorized to be appropriated for such purpose, there are 

14 authorized to be appropriated, out of any monies in the 

15 Public Health Investment Fund, the following: 

16 ‘‘(1) $87,000,000 for fiscal year 2011. 

17 ‘‘(2) $97,000,000 for fiscal year 2012. 

18 ‘‘(3) $103,000,000 for fiscal year 2013. 

19 ‘‘(4) $105,000,000 for fiscal year 2014. 

20 ‘‘(5) $113,000,000 for fiscal year 2015.’’. 

21 (b) EXISTING AUTHORIZATIONS OF APPROPRIA22 TIONS.— 

23 (1) SECTION 736.—Paragraph (1) of section 

24 736(i) (42 U.S.C. 293(h)), as redesignated, is 

25 amended by striking ‘‘2002’’ and inserting ‘‘2015’’. 
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1 (2) SECTIONS 737, 738, AND 739.—Subsections 

2 (a), (b), and (c) of section 740 are amended by 

3 striking ‘‘2002’’ each place it appears and inserting 

4 ‘‘2015’’. 

5 (3) SECTION 741.—Subsection (h), as so redes6 ignated, of section 741 is amended— 

7 (A) by striking ‘‘and’’ after ‘‘fiscal year 

8 2003,’’; and 

9 (B) by inserting ‘‘, and such sums as may 

10 be necessary for each subsequent fiscal year 

11 through the end of fiscal year 2015’’ before the 

12 period at the end. 

13 (4) SECTION 761.—Subsection (e)(1), as so re14 designated, of section 761 is amended by striking 

15 ‘‘2002’’ and inserting ‘‘2015’’. 

16 TITLE III—PREVENTION AND 

17 WELLNESS 

18 SEC. 2301. PREVENTION AND WELLNESS. 

19 (a) IN GENERAL.—The Public Health Service Act 

20 (42 U.S.C. 201 et seq.) is amended by inserting after title 

21 XXX the following: 
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1 ‘‘TITLE XXXI—PREVENTION AND 

2 WELLNESS 

3 ‘‘Subtitle A—Prevention and 

4 Wellness Trust 

5 ‘‘SEC. 3111. PREVENTION AND WELLNESS TRUST. 

6 ‘‘(a) DEPOSITS INTO TRUST.—There is established 

7 a Prevention and Wellness Trust. There are authorized 

8 to be appropriated to the Trust, out of any monies in the 

9 Public Health Investment Fund— 

10 ‘‘(1) for fiscal year 2011, $2,400,000,000; 

11 ‘‘(2) for fiscal year 2012, $2,845,000,000; 

12 ‘‘(3) for fiscal year 2013, $3,100,000,000; 

13 ‘‘(4) for fiscal year 2014, $3,455,000,000; and 

14 ‘‘(5) for fiscal year 2015, $3,600,000,000. 

15 ‘‘(b) AVAILABILITY OF FUNDS.—Amounts in the Pre16 vention and Wellness Trust shall be available, as provided 

17 in advance in appropriation Acts, for carrying out this 

18 title. 

19 ‘‘(c) ALLOCATION.—Of the amounts authorized to be 

20 appropriated in subsection (a), there are authorized to be 

21 appropriated— 

22 ‘‘(1) for carrying out subtitle C (Prevention 

23 Task Forces), $30,000,000 for each of fiscal years 

24 2011 through 2015; 
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1 ‘‘(2) for carrying out subtitle D (Prevention 

2 and Wellness Research)— 

3 ‘‘(A) for fiscal year 2011, $155,000,000; 

4 ‘‘(B) for fiscal year 2012, $205,000,000; 

5 ‘‘(C) for fiscal year 2013, $255,000,000; 

6 ‘‘(D) for fiscal year 2014, $305,000,000; 

7 and 

8 ‘‘(E) for fiscal year 2015, $355,000,000; 

9 ‘‘(3) for carrying out subtitle E (Delivery of 

10 Community Preventive and Wellness Services)— 

11 ‘‘(A) for fiscal year 2011, $1,065,000,000; 

12 ‘‘(B) for fiscal year 2012, $1,260,000,000; 

13 ‘‘(C) for fiscal year 2013, $1,365,000,000; 

14 ‘‘(D) for fiscal year 2014, $1,570,000,000; 

15 and 

16 ‘‘(E) for fiscal year 2015, $1,600,000,000; 

17 ‘‘(4) for carrying out section 3161 (Core Public 

18 Health Infrastructure for State, Local, and Tribal 

19 Health Departments)— 

20 ‘‘(A) for fiscal year 2011, $800,000,000; 

21 ‘‘(B) for fiscal year 2012, $1,000,000,000; 

22 ‘‘(C) for fiscal year 2013, $1,100,000,000; 

23 ‘‘(D) for fiscal year 2014, $1,200,000,000; 

24 and 
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1 ‘‘(E) for fiscal year 2015, $1,265,000,000; 

2 and 

3 ‘‘(5) for carrying out section 3162 (Core Public 

4 Health Infrastructure and Activities for CDC), 

5 $350,000,000 for each of fiscal years 2011 through 

6 2015. 

7 ‘‘Subtitle B—National Prevention 

8 and Wellness Strategy 

9 ‘‘SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRAT10 EGY. 

11 ‘‘(a) IN GENERAL.—The Secretary shall submit to 

12 the Congress within one year after the date of the enact13 ment of this section, and at least every 2 years thereafter, 

14 a national strategy that is designed to improve the Na15 tion’s health through evidence-based clinical and commu16 nity prevention and wellness activities (in this section re17 ferred to as ‘prevention and wellness activities’), including 

18 core public health infrastructure improvement activities. 

19 ‘‘(b) CONTENTS.—The strategy under subsection (a) 

20 shall include each of the following: 

21 ‘‘(1) Identification of specific national goals and 

22 objectives in prevention and wellness activities that 

23 take into account appropriate public health measures 

24 and standards, including departmental measures and 
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1 standards (including Healthy People and National 

2 Public Health Performance Standards). 

3 ‘‘(2) Establishment of national priorities for 

4 prevention and wellness, taking into account unmet 

5 prevention and wellness needs. 

6 ‘‘(3) Establishment of national priorities for re7 search on prevention and wellness, taking into ac8 count unanswered research questions on prevention 

9 and wellness. 

10 ‘‘(4) Identification of health disparities in pre11 vention and wellness. 

12 ‘‘(5) Review of prevention payment incentives, 

13 the prevention workforce, and prevention delivery 

14 system capacity. 

15 ‘‘(6) A plan for addressing and implementing 

16 paragraphs (1) through (5). 

17 ‘‘(c) CONSULTATION.—In developing or revising the 

18 strategy under subsection (a), the Secretary shall consult 

19 with the following: 

20 ‘‘(1) The heads of appropriate health agencies 

21 and offices in the Department, including the Office 

22 of the Surgeon General of the Public Health Service, 

23 the Office of Minority Health, the Office on Wom24 en’s Health, and the Substance Abuse and Mental 

25 Health Services Administration. 
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1 ‘‘(2) As appropriate, the heads of other Federal 

2 departments and agencies whose programs have a 

3 significant impact upon health (as determined by the 

4 Secretary). 

5 ‘‘(3) As appropriate, nonprofit and for-profit 

6 entities. 

7 ‘‘(4) The Association of State and Territorial 

8 Health Officials and the National Association of 

9 County and City Health Officials. 

10 ‘‘(5) The Task Force on Community Preventive 

11 Services and the Task Force on Clinical Preventive 

12 Services. 

13 ‘‘Subtitle C—Prevention Task 

14 Forces 

15 ‘‘SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERV16 ICES. 

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

18 the Director of the Agency for Healthcare Research and 

19 Quality, shall establish a permanent task force to be 

20 known as the Task Force on Clinical Preventive Services 

21 (in this section referred to as the ‘Task Force’). 

22 ‘‘(b) RESPONSIBILITIES.—The Task Force shall— 

23 ‘‘(1) identify clinical preventive services for re24 view; 
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1 ‘‘(2) review the scientific evidence related to the 

2 benefits, effectiveness, appropriateness, and costs of 

3 clinical preventive services identified under para4 graph (1) for the purpose of developing, updating, 

5 publishing, and disseminating evidence-based rec6 ommendations on the use of such services; 

7 ‘‘(3) as appropriate, take into account health 

8 disparities in developing, updating, publishing, and 

9 disseminating evidence-based recommendations on 

10 the use of such services; 

11 ‘‘(4) identify gaps in clinical preventive services 

12 research and evaluation and recommend priority 

13 areas for such research and evaluation; 

14 ‘‘(5) pursuant to section 3143(c), determine 

15 whether subsidies and rewards meet the Task 

16 Force’s standards for a grade of A or B; 

17 ‘‘(6) as appropriate, consult with the clinical 

18 prevention stakeholders board in accordance with 

19 subsection (f); 

20 ‘‘(7) consult with the Task Force on Commu21 nity Preventive Services established under section 

22 3132; and 

23 ‘‘(8) as appropriate, in carrying out this sec24 tion, consider the national strategy under section 

25 3121. 
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1 ‘‘(c) ROLE OF AGENCY.—The Secretary shall provide 

2 ongoing administrative, research, and technical support 

3 for the operations of the Task Force, including coordi4 nating and supporting the dissemination of the rec5 ommendations of the Task Force. 

6 ‘‘(d) MEMBERSHIP.— 

7 ‘‘(1) NUMBER; APPOINTMENT.—The Task 

8 Force shall be composed of 30 members, appointed 

9 by the Secretary. 

10 ‘‘(2) TERMS.— 

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

12 appoint members of the Task Force for a term 

13 of 6 years and may reappoint such members, 

14 but the Secretary may not appoint any member 

15 to serve more than a total of 12 years. 

16 ‘‘(B) STAGGERED TERMS.—Notwith17 standing subparagraph (A), of the members 

18 first appointed to serve on the Task Force after 

19 the enactment of this title— 

20 ‘‘(i) 10 shall be appointed for a term 

21 of 2 years; 

22 ‘‘(ii) 10 shall be appointed for a term 

23 of 4 years; and 

24 ‘‘(iii) 10 shall be appointed for a term 

25 of 6 years. 
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1 ‘‘(3) QUALIFICATIONS.—Members of the Task 

2 Force shall be appointed from among individuals 

3 who possess expertise in at least one of the following 

4 areas: 

5 ‘‘(A) Health promotion and disease preven6 tion. 

7 ‘‘(B) Evaluation of research and system8 atic evidence reviews. 

9 ‘‘(C) Application of systematic evidence re10 views to clinical decisionmaking or health pol11 icy. 

12 ‘‘(D) Clinical primary care in child and ad13 olescent health. 

14 ‘‘(E) Clinical primary care in adult health, 

15 including women’s health. 

16 ‘‘(F) Clinical primary care in geriatrics. 

17 ‘‘(G) Clinical counseling and behavioral 

18 services for primary care patients. 

19 ‘‘(4) REPRESENTATION.—In appointing mem20 bers of the Task Force, the Secretary shall ensure 

21 that— 

22 ‘‘(A) all areas of expertise described in 

23 paragraph (3) are represented; and 
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1 ‘‘(B) the members of the Task Force in2 clude individuals with expertise in health dis3 parities. 

4 ‘‘(e) SUBGROUPS.—As appropriate to maximize effi5 ciency, the Task Force may delegate authority for con6 ducting reviews and making recommendations to sub7 groups consisting of Task Force members, subject to final 

8 approval by the Task Force. 

9 ‘‘(f) CLINICAL PREVENTION STAKEHOLDERS

10 BOARD.— 

11 ‘‘(1) IN GENERAL.—The Task Force shall con12 vene a clinical prevention stakeholders board com13 posed of representatives of appropriate public and 

14 private entities with an interest in clinical preventive 

15 services to advise the Task Force on developing, up16 dating, publishing, and disseminating evidence-based 

17 recommendations on the use of clinical preventive 

18 services. 

19 ‘‘(2) MEMBERSHIP.—The members of the clin20 ical prevention stakeholders board shall include rep21 resentatives of the following: 

22 ‘‘(A) Health care consumers and patient 

23 groups. 

24 ‘‘(B) Providers of clinical preventive serv25 ices, including community-based providers. 
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1 ‘‘(C) Federal departments and agencies, 

2 including— 

3 ‘‘(i) appropriate health agencies and 

4 offices in the Department, including the 

5 Office of the Surgeon General of the Pub6 lic Health Service, the Office of Minority 

7 Health, the National Center on Minority 

8 Health and Health Disparities, and the Of9 fice on Women’s Health; and 

10 ‘‘(ii) as appropriate, other Federal de11 partments and agencies whose programs 

12 have a significant impact upon health (as 

13 determined by the Secretary). 

14 ‘‘(D) Private health care payors. 

15 ‘‘(3) RESPONSIBILITIES.—In accordance with 

16 subsection (b)(6), the clinical prevention stake17 holders board shall— 

18 ‘‘(A) recommend clinical preventive serv19 ices for review by the Task Force; 

20 ‘‘(B) suggest scientific evidence for consid21 eration by the Task Force related to reviews 

22 undertaken by the Task Force; 

23 ‘‘(C) provide feedback regarding draft rec24 ommendations by the Task Force; and 
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1 ‘‘(D) assist with efforts regarding dissemi2 nation of recommendations by the Director of 

3 the Agency for Healthcare Research and Qual4 ity. 

5 ‘‘(g) DISCLOSURE AND CONFLICTS OF INTEREST.— 

6 Members of the Task Force or the clinical prevention 

7 stakeholders board shall not be considered employees of 

8 the Federal Government by reason of service on the Task 

9 Force or the clinical prevention stakeholders board, except 

10 members of the Task Force or the clinical prevention 

11 stakeholders board shall be considered to be special Gov12 ernment employees within the meaning of section 107 of 

13 the Ethics in Government Act of 1978 (5 U.S.C. App.) 

14 and section 208 of title 18, United States Code, for the 

15 purposes of disclosure and management of conflicts of in16 terest under those sections. 

17 ‘‘(h) NO PAY; RECEIPT OF TRAVEL EXPENSES.— 

18 Members of the Task Force or the clinical prevention 

19 stakeholders board shall not receive any pay for service 

20 on the Task Force, but may receive travel expenses, in21 cluding a per diem, in accordance with applicable provi22 sions of subchapter I of chapter 57 of title 5, United 

23 States Code. 

24 ‘‘(i) APPLICATION OF FACA.—The Federal Advisory 

25 Committee Act (5 U.S.C. App.) except for section 14 of 
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1 such Act shall apply to the Task Force to the extent that 

2 the provisions of such Act do not conflict with the provi3 sions of this title. 

4 ‘‘(j) REPORT.—The Secretary shall submit to the 

5 Congress an annual report on the Task Force, including 

6 with respect to gaps identified and recommendations made 

7 under subsection (b)(4). 

8 ‘‘SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE 

9 SERVICES. 

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

11 the Director of the Centers for Disease Control and Pre12 vention, shall establish a permanent task force to be 

13 known as the Task Force on Community Preventive Serv14 ices (in this section referred to as the ‘Task Force’). 

15 ‘‘(b) RESPONSIBILITIES.—The Task Force shall— 

16 ‘‘(1) identify community preventive services for 

17 review; 

18 ‘‘(2) review the scientific evidence related to the 

19 benefits, effectiveness, appropriateness, and costs of 

20 community preventive services identified under para21 graph (1) for the purpose of developing, updating, 

22 publishing, and disseminating evidence-based rec23 ommendations on the use of such services; 

24 ‘‘(3) as appropriate, take into account health 

25 disparities in developing, updating, publishing, and 
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1 disseminating evidence-based recommendations on 

2 the use of such services; 

3 ‘‘(4) identify gaps in community preventive 

4 services research and evaluation and recommend pri5 ority areas for such research and evaluation; 

6 ‘‘(5) pursuant to section 3143(d), determine 

7 whether subsidies and rewards are effective; 

8 ‘‘(6) as appropriate, consult with the commu9 nity prevention stakeholders board in accordance 

10 with subsection (f); 

11 ‘‘(7) consult with the Task Force on Clinical 

12 Preventive Services established under section 3131; 

13 and 

14 ‘‘(8) as appropriate, in carrying out this sec15 tion, consider the national strategy under section 

16 3121. 

17 ‘‘(c) ROLE OF AGENCY.—The Secretary shall provide 

18 ongoing administrative, research, and technical support 

19 for the operations of the Task Force, including coordi20 nating and supporting the dissemination of the rec21 ommendations of the Task Force. 

22 ‘‘(d) MEMBERSHIP.— 

23 ‘‘(1) NUMBER; APPOINTMENT.—The Task 

24 Force shall be composed of 30 members, appointed 

25 by the Secretary. 
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1 ‘‘(2) TERMS.— 

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

3 appoint members of the Task Force for a term 

4 of 6 years and may reappoint such members, 

5 but the Secretary may not appoint any member 

6 to serve more than a total of 12 years. 

7 ‘‘(B) STAGGERED TERMS.—Notwith8 standing subparagraph (A), of the members 

9 first appointed to serve on the Task Force after 

10 the enactment of this section— 

11 ‘‘(i) 10 shall be appointed for a term 

12 of 2 years; 

13 ‘‘(ii) 10 shall be appointed for a term 

14 of 4 years; and 

15 ‘‘(iii) 10 shall be appointed for a term 

16 of 6 years. 

17 ‘‘(3) QUALIFICATIONS.—Members of the Task 

18 Force shall be appointed from among individuals 

19 who possess expertise in at least one of the following 

20 areas: 

21 ‘‘(A) Public health. 

22 ‘‘(B) Evaluation of research and system23 atic evidence reviews. 

24 ‘‘(C) Disciplines relevant to community 

25 preventive services, including health promotion; 
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1 disease prevention; chronic disease; worksite 

2 health; school-site health; qualitative and quan3 titative analysis; and health economics, policy, 

4 law, and statistics. 

5 ‘‘(4) REPRESENTATION.—In appointing mem6 bers of the Task Force, the Secretary— 

7 ‘‘(A) shall ensure that all areas of exper8 tise described in paragraph (3) are represented; 

9 ‘‘(B) shall ensure that such members in10 clude sufficient representatives of each of— 

11 ‘‘(i) State health officers; 

12 ‘‘(ii) local health officers; 

13 ‘‘(iii) health care practitioners; and 

14 ‘‘(iv) public health practitioners; and 

15 ‘‘(C) shall appoint individuals who have ex16 pertise in health disparities. 

17 ‘‘(e) SUBGROUPS.—As appropriate to maximize effi18 ciency, the Task Force may delegate authority for con19 ducting reviews and making recommendations to sub20 groups consisting of Task Force members, subject to final 

21 approval by the Task Force. 

22 ‘‘(f) COMMUNITY PREVENTION STAKEHOLDERS

23 BOARD.— 

24 ‘‘(1) IN GENERAL.—The Task Force shall con25 vene a community prevention stakeholders board 
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1 composed of representatives of appropriate public 

2 and private entities with an interest in community 

3 preventive services to advise the Task Force on de4 veloping, updating, publishing, and disseminating 

5 evidence-based recommendations on the use of com6 munity preventive services. 

7 ‘‘(2) MEMBERSHIP.—The members of the com8 munity prevention stakeholders board shall include 

9 representatives of the following: 

10 ‘‘(A) Health care consumers and patient 

11 groups. 

12 ‘‘(B) Providers of community preventive 

13 services, including community-based providers. 

14 ‘‘(C) Federal departments and agencies, 

15 including— 

16 ‘‘(i) appropriate health agencies and 

17 offices in the Department, including the 

18 Office of the Surgeon General of the Pub19 lic Health Service, the Office of Minority 

20 Health, the National Center on Minority 

21 Health and Health Disparities, and the Of22 fice on Women’s Health; and 

23 ‘‘(ii) as appropriate, other Federal de24 partments and agencies whose programs 
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1 have a significant impact upon health (as 

2 determined by the Secretary). 

3 ‘‘(D) Private health care payors. 

4 ‘‘(3) RESPONSIBILITIES.—In accordance with 

5 subsection (b)(6), the community prevention stake6 holders board shall— 

7 ‘‘(A) recommend community preventive 

8 services for review by the Task Force; 

9 ‘‘(B) suggest scientific evidence for consid10 eration by the Task Force related to reviews 

11 undertaken by the Task Force; 

12 ‘‘(C) provide feedback regarding draft rec13 ommendations by the Task Force; and 

14 ‘‘(D) assist with efforts regarding dissemi15 nation of recommendations by the Director of 

16 the Centers for Disease Control and Prevention. 

17 ‘‘(g) DISCLOSURE AND CONFLICTS OF INTEREST.— 

18 Members of the Task Force or the community prevention 

19 stakeholders board shall not be considered employees of 

20 the Federal Government by reason of service on the Task 

21 Force or the community prevention stakeholders board, 

22 except members of the Task Force or the community pre23 vention stakeholders board shall be considered to be spe24 cial Government employees within the meaning of section 

25 107 of the Ethics in Government Act of 1978 (5 U.S.C. 
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1 App.) and section 208 of title 18, United States Code, for 

2 the purposes of disclosure and management of conflicts 

3 of interest under those sections. 

4 ‘‘(h) NO PAY; RECEIPT OF TRAVEL EXPENSES.— 

5 Members of the Task Force or the community prevention 

6 stakeholders board shall not receive any pay for service 

7 on the Task Force, but may receive travel expenses, in8 cluding a per diem, in accordance with applicable provi9 sions of subchapter I of chapter 57 of title 5, United 

10 States Code. 

11 ‘‘(i) APPLICATION OF FACA.—The Federal Advisory 

12 Committee Act (5 U.S.C. App.) except for section 14 of 

13 such Act shall apply to the Task Force to the extent that 

14 the provisions of such Act do not conflict with the provi15 sions of this title. 

16 ‘‘(j) REPORT.—The Secretary shall submit to the 

17 Congress an annual report on the Task Force, including 

18 with respect to gaps identified and recommendations made 

19 under subsection (b)(4). 

20 ‘‘Subtitle D—Prevention and 

21 Wellness Research 

22 ‘‘SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIV23 ITY COORDINATION. 

24 ‘‘In conducting or supporting research on prevention 

25 and wellness, the Director of the Centers for Disease Con-
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1 trol and Prevention, the Director of the National Insti2 tutes of Health, and the heads of other agencies within 

3 the Department of Health and Human Services con4 ducting or supporting such research, shall take into con5 sideration the national strategy under section 3121 and 

6 the recommendations of the Task Force on Clinical Pre7 ventive Services under section 3131 and the Task Force 

8 on Community Preventive Services under section 3132. 

9 ‘‘SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RE10 SEARCH GRANTS. 

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

12 the Director of the Centers for Disease Control and Pre13 vention, shall conduct, or award grants to eligible entities 

14 to conduct, research in priority areas identified by the Sec15 retary in the national strategy under section 3121 or by 

16 the Task Force on Community Preventive Services as re17 quired by section 3132. 

18 ‘‘(b) ELIGIBILITY.—To be eligible for a grant under 

19 this section, an entity shall be— 

20 ‘‘(1) a State, local, or tribal department of 

21 health; 

22 ‘‘(2) a public or private nonprofit entity; or 

23 ‘‘(3) a consortium of 2 or more entities de24 scribed in paragraphs (1) and (2). 
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1 ‘‘(c) REPORT.—The Secretary shall submit to the 

2 Congress an annual report on the program of research 

3 under this section. 

4 ‘‘SEC. 3143. RESEARCH ON SUBSIDIES AND REWARDS TO 

5 ENCOURAGE WELLNESS AND HEALTHY BE6 HAVIORS. 

7 ‘‘(a) RESEARCH AND DEMONSTRATION PROJECTS.— 

8 ‘‘(1) IN GENERAL.—The Secretary shall con9 duct, or award grants to public or nonprofit private 

10 entities to conduct, research and demonstration 

11 projects on the use of financial and in-kind subsidies 

12 and rewards to encourage individuals and commu13 nities to promote wellness, adopt healthy behaviors, 

14 and use evidence-based preventive health services. 

15 ‘‘(2) FOCUS.—Research and demonstration 

16 projects under paragraph (1) shall focus on— 

17 ‘‘(A) tobacco use, obesity, and other pre18 vention and wellness priorities identified by the 

19 Secretary in the national strategy under section 

20 3121; 

21 ‘‘(B) the initiation, maintenance, and long22 term sustainability of wellness promotion; adop23 tion of healthy behaviors; and use of evidence24 based preventive health services; and 
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1 ‘‘(C) populations at high risk of prevent2 able diseases and conditions. 

3 ‘‘(b) FINDINGS; REPORT.— 

4 ‘‘(1) SUBMISSION OF FINDINGS.—The Secretary 

5 shall submit the findings of research and demonstra6 tion projects under subsection (a) to— 

7 ‘‘(A) the Task Force on Clinical Preventive 

8 Services established under section 3131 or the 

9 Task Force on Community Preventive Services 

10 established under section 3132, as appropriate; 

11 and 

12 ‘‘(B) the Health Benefits Advisory Com13 mittee established by section 223 of the Afford14 able Health Care for America Act. 

15 ‘‘(2) REPORT TO CONGRESS.—Not later than 

16 18 months after the initiation of research and dem17 onstration projects under subsection (a), the Sec18 retary shall submit a report to the Congress on the 

19 progress of such research and projects, including 

20 any preliminary findings. 

21 ‘‘(c) INCLUSION IN ESSENTIAL BENEFITS PACK22 AGE.—If, on the basis of the findings of research and dem23 onstration projects under subsection (a) or other sources 

24 consistent with section 3131, the Task Force on Clinical 

25 Preventive Services determines that a subsidy or reward 
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1 meets the Task Force’s standards for a grade A or B, 

2 the Secretary shall ensure that the subsidy or reward is 

3 included in the essential benefits package under section 

4 222. 

5 ‘‘(d) INCLUSION AS ALLOWABLE USE OF COMMUNITY

6 PREVENTION AND WELLNESS SERVICES GRANTS.—If, on 

7 the basis of the findings of research and demonstration 

8 projects under subsection (a) or other sources consistent 

9 with section 3132, the Task Force on Community Preven10 tive Services determines that a subsidy or reward is effec11 tive, the Secretary shall ensure that the subsidy or reward 

12 becomes an allowable use of grant funds under section 

13 3151. 

14 ‘‘(e) NONDISCRIMINATION; NO TIE TO PREMIUM OR

15 COST SHARING.—In carrying out this section, the Sec16 retary shall ensure that any subsidy or reward— 

17 ‘‘(1) does not have a discriminatory effect on 

18 the basis of any personal characteristic extraneous 

19 to the provision of high-quality health care or related 

20 services; and 

21 ‘‘(2) is not tied to the premium or cost sharing 

22 of an individual under any qualified health benefits 

23 plan (as defined in section 100(c)). 
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1 ‘‘Subtitle E—Delivery of Commu2 nity Prevention and Wellness 

3 Services 

4 ‘‘SEC. 3151. COMMUNITY PREVENTION AND WELLNESS 

5 SERVICES GRANTS. 

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

7 the Director of the Centers for Disease Control and Pre8 vention, shall establish a program for the delivery of com9 munity prevention and wellness services consisting of 

10 awarding grants to eligible entities— 

11 ‘‘(1) to provide evidence-based, community pre12 vention and wellness services in priority areas identi13 fied by the Secretary in the national strategy under 

14 section 3121; or 

15 ‘‘(2) to plan such services. 

16 ‘‘(b) ELIGIBILITY.— 

17 ‘‘(1) DEFINITION.—To be eligible for a grant 

18 under this section, an entity shall be— 

19 ‘‘(A) a State, local, or tribal department of 

20 health; 

21 ‘‘(B) a public or private entity; or 

22 ‘‘(C) a consortium that— 

23 ‘‘(i) consists of 2 or more entities de24 scribed in subparagraph (A) or (B); and 
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1 ‘‘(ii) may be a community partnership 

2 representing a Health Empowerment Zone. 

3 ‘‘(2) HEALTH EMPOWERMENT ZONE.—In this 

4 subsection, the term ‘Health Empowerment Zone’ 

5 means an area— 

6 ‘‘(A) in which multiple community preven7 tion and wellness services are implemented in 

8 order to address one or more health disparities, 

9 including those identified by the Secretary in 

10 the national strategy under section 3121; and 

11 ‘‘(B) which is represented by a community 

12 partnership that demonstrates community sup13 port and coordination with State, local, or tribal 

14 health departments and includes— 

15 ‘‘(i) a broad cross section of stake16 holders; 

17 ‘‘(ii) residents of the community; and 

18 ‘‘(iii) representatives of entities that 

19 have a history of working within and serv20 ing the community. 

21 ‘‘(c) PREFERENCES.—In awarding grants under this 

22 section, the Secretary shall give preference to entities 

23 that— 
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1 ‘‘(1) will address one or more goals or objec2 tives identified by the Secretary in the national 

3 strategy under section 3121; 

4 ‘‘(2) will address significant health disparities, 

5 including those identified by the Secretary in the na6 tional strategy under section 3121; 

7 ‘‘(3) will address unmet community prevention 

8 and wellness needs and avoid duplication of effort; 

9 ‘‘(4) have been demonstrated to be effective in 

10 communities comparable to the proposed target com11 munity; 

12 ‘‘(5) will contribute to the evidence base for 

13 community prevention and wellness services; 

14 ‘‘(6) demonstrate that the community preven15 tion and wellness services to be funded will be sus16 tainable; and 

17 ‘‘(7) demonstrate coordination or collaboration 

18 across governmental and nongovernmental partners. 

19 ‘‘(d) HEALTH DISPARITIES.—Of the funds awarded 

20 under this section for a fiscal year, the Secretary shall 

21 award not less than 50 percent for planning or imple22 menting community prevention and wellness services 

23 whose primary purpose is to achieve a measurable reduc24 tion in one or more health disparities, including those 
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1 identified by the Secretary in the national strategy under 

2 section 3121. 

3 ‘‘(e) EMPHASIS ON RECOMMENDED SERVICES.—For 

4 fiscal year 2014 and subsequent fiscal years, the Secretary 

5 shall award grants under this section only for planning 

6 or implementing services recommended by the Task Force 

7 on Community Preventive Services under section 3132 or 

8 deemed effective based on a review of comparable rigor 

9 (as determined by the Director of the Centers for Disease 

10 Control and Prevention). 

11 ‘‘(f) PROHIBITED USES OF FUNDS.—An entity that 

12 receives a grant under this section may not use funds pro13 vided through the grant— 

14 ‘‘(1) to build or acquire real property or for 

15 construction; or 

16 ‘‘(2) for services or planning to the extent that 

17 payment has been made, or can reasonably be ex18 pected to be made— 

19 ‘‘(A) under any insurance policy; 

20 ‘‘(B) under any Federal or State health 

21 benefits program (including titles XIX and XXI 

22 of the Social Security Act); or 

23 ‘‘(C) by an entity which provides health 

24 services on a prepaid basis. 
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1 ‘‘(g) REPORT.—The Secretary shall submit to the 

2 Congress an annual report on the program of grants 

3 awarded under this section. 

4 ‘‘(h) DEFINITIONS.—In this section, the term ‘evi5 dence-based’ means that methodologically sound research 

6 has demonstrated a beneficial health effect, in the judg7 ment of the Director of the Centers for Disease Control 

8 and Prevention. 

9 ‘‘Subtitle F—Core Public Health 

10 Infrastructure 

11 ‘‘SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR 

12 STATE, LOCAL, AND TRIBAL HEALTH DEPART13 MENTS. 

14 ‘‘(a) PROGRAM.—The Secretary, acting through the 

15 Director of the Centers for Disease Control and Preven16 tion, shall establish a core public health infrastructure 

17 program consisting of awarding grants under subsection 

18 (b). 

19 ‘‘(b) GRANTS.— 

20 ‘‘(1) AWARD.—For the purpose of addressing 

21 core public health infrastructure needs, the Sec22 retary— 

23 ‘‘(A) shall award a grant to each State 

24 health department; and 
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1 ‘‘(B) may award grants on a competitive 

2 basis to State, local, or tribal health depart3 ments. 

4 ‘‘(2) ALLOCATION.—Of the total amount of 

5 funds awarded as grants under this subsection for a 

6 fiscal year— 

7 ‘‘(A) not less than 50 percent shall be for 

8 grants to State health departments under para9 graph (1)(A); and 

10 ‘‘(B) not less than 30 percent shall be for 

11 grants to State, local, or tribal health depart12 ments under paragraph (1)(B). 

13 ‘‘(c) USE OF FUNDS.—The Secretary may award a 

14 grant to an entity under subsection (b)(1) only if the enti15 ty agrees to use the grant to address core public health 

16 infrastructure needs, including those identified in the ac17 creditation process under subsection (g). 

18 ‘‘(d) FORMULA GRANTS TO STATE HEALTH DEPART19 MENTS.—In making grants under subsection (b)(1)(A), 

20 the Secretary shall award funds to each State health de21 partment in accordance with— 

22 ‘‘(1) a formula based on population size; burden 

23 of preventable disease and disability; and core public 

24 health infrastructure gaps, including those identified 
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1 in the accreditation process under subsection (g); 

2 and 

3 ‘‘(2) application requirements established by the 

4 Secretary, including a requirement that the State 

5 submit a plan that demonstrates to the satisfaction 

6 of the Secretary that the State’s health department 

7 will— 

8 ‘‘(A) address its highest priority core pub9 lic health infrastructure needs; and 

10 ‘‘(B) as appropriate, allocate funds to local 

11 health departments within the State. 

12 ‘‘(e) COMPETITIVE GRANTS TO STATE, LOCAL, AND

13 TRIBAL HEALTH DEPARTMENTS.—In making grants 

14 under subsection (b)(1)(B), the Secretary shall give pri15 ority to applicants demonstrating core public health infra16 structure needs identified in the accreditation process 

17 under subsection (g). 

18 ‘‘(f) MAINTENANCE OF EFFORT.—The Secretary 

19 may award a grant to an entity under subsection (b) only 

20 if the entity demonstrates to the satisfaction of the Sec21 retary that— 

22 ‘‘(1) funds received through the grant will be 

23 expended only to supplement, and not supplant, non24 Federal and Federal funds otherwise available to the 
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1 entity for the purpose of addressing core public 

2 health infrastructure needs; and 

3 ‘‘(2) with respect to activities for which the 

4 grant is awarded, the entity will maintain expendi5 tures of non-Federal amounts for such activities at 

6 a level not less than the level of such expenditures 

7 maintained by the entity for the fiscal year pre8 ceding the fiscal year for which the entity receives 

9 the grant. 

10 ‘‘(g) ESTABLISHMENT OF A PUBLIC HEALTH AC11 CREDITATION PROGRAM.— 

12 ‘‘(1) IN GENERAL.—The Secretary, acting 

13 through the Director of the Centers for Disease 

14 Control and Prevention, shall— 

15 ‘‘(A) develop, and periodically review and 

16 update, standards for voluntary accreditation of 

17 State, local, or tribal health departments and 

18 public health laboratories for the purpose of ad19 vancing the quality and performance of such de20 partments and laboratories; and 

21 ‘‘(B) implement a program to accredit 

22 such health departments and laboratories in ac23 cordance with such standards. 

24 ‘‘(2) COOPERATIVE AGREEMENT.—The Sec25 retary may enter into a cooperative agreement with 
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1 a private nonprofit entity to carry out paragraph 

2 (1). 

3 ‘‘(h) REPORT.—The Secretary shall submit to the 

4 Congress an annual report on progress being made to ac5 credit entities under subsection (g), including— 

6 ‘‘(1) a strategy, including goals and objectives, 

7 for accrediting entities under subsection (g) and 

8 achieving the purpose described in subsection (g)(1); 

9 and 

10 ‘‘(2) identification of gaps in research related to 

11 core public health infrastructure and recommenda12 tions of priority areas for such research. 

13 ‘‘SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND 

14 ACTIVITIES FOR CDC. 

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

16 the Director of the Centers for Disease Control and Pre17 vention, shall expand and improve the core public health 

18 infrastructure and activities of the Centers for Disease 

19 Control and Prevention to address unmet and emerging 

20 public health needs. 

21 ‘‘(b) REPORT.—The Secretary shall submit to the 

22 Congress an annual report on the activities funded 

23 through this section. 
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1 ‘‘Subtitle G—General Provisions 

2 ‘‘SEC. 3171. DEFINITIONS. 

3 ‘‘In this title: 

4 ‘‘(1) The term ‘core public health infrastruc5 ture’ includes workforce capacity and competency; 

6 laboratory systems; health information, health infor7 mation systems, and health information analysis; 

8 communications; financing; other relevant compo9 nents of organizational capacity; and other related 

10 activities. 

11 ‘‘(2) The terms ‘Department’ and ‘depart12 mental’ refer to the Department of Health and 

13 Human Services. 

14 ‘‘(3) The term ‘health disparities’ includes 

15 health and health care disparities and means popu16 lation-specific differences in the presence of disease, 

17 health outcomes, or access to health care. For pur18 poses of the preceding sentence, a population may be 

19 delineated by race, ethnicity, primary language, sex, 

20 sexual orientation, gender identity, disability, socio21 economic status, or rural, urban, or other geographic 

22 setting, and any other population or subpopulation 

23 determined by the Secretary to experience significant 

24 gaps in disease, health outcomes, or access to health 

25 care. 
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1 ‘‘(4) The term ‘tribal’ refers to an Indian tribe, 

2 a Tribal organization, or an Urban Indian organiza3 tion, as such terms are defined in section 4 of the 

4 Indian Health Care Improvement Act.’’. 

5 (b) TRANSITION PROVISIONS APPLICABLE TO TASK

6 FORCES.— 

7 (1) FUNCTIONS, PERSONNEL, ASSETS, LIABIL8 ITIES, AND ADMINISTRATIVE ACTIONS.—All func9 tions, personnel, assets, and liabilities of, and ad10 ministrative actions applicable to, the Preventive 

11 Services Task Force convened under section 915(a) 

12 of the Public Health Service Act and the Task Force 

13 on Community Preventive Services (as such section 

14 and Task Forces were in existence on the day before 

15 the date of the enactment of this Act) shall be trans16 ferred to the Task Force on Clinical Preventive 

17 Services and the Task Force on Community Preven18 tive Services, respectively, established under sections 

19 3131 and 3132 of the Public Health Service Act, as 

20 added by subsection (a). 

21 (2) RECOMMENDATIONS.—All recommendations 

22 of the Preventive Services Task Force and the Task 

23 Force on Community Preventive Services, as in ex24 istence on the day before the date of the enactment 

25 of this Act, shall be considered to be recommenda-
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1 tions of the Task Force on Clinical Preventive Serv2 ices and the Task Force on Community Preventive 

3 Services, respectively, established under sections 

4 3131 and 3132 of the Public Health Service Act, as 

5 added by subsection (a). 

6 (3) MEMBERS ALREADY SERVING.— 

7 (A) INITIAL MEMBERS.—The Secretary of 

8 Health and Human Services may select those 

9 individuals already serving on the Preventive 

10 Services Task Force and the Task Force on 

11 Community Preventive Services, as in existence 

12 on the day before the date of the enactment of 

13 this Act, to be among the first members ap14 pointed to the Task Force on Clinical Preven15 tive Services and the Task Force on Commu16 nity Preventive Services, respectively, under sec17 tions 3131 and 3132 of the Public Health Serv18 ice Act, as added by subsection (a). 

19 (B) CALCULATION OF TOTAL SERVICE.—In 

20 calculating the total years of service of a mem21 ber of a task force for purposes of section 

22 3131(d)(2)(A) or 3132(d)(2)(A) of the Public 

23 Health Service Act, as added by subsection (a), 

24 the Secretary of Health and Human Services 

25 shall not include any period of service by the 
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1 member on the Preventive Services Task Force 

2 or the Task Force on Community Preventive 

3 Services, respectively, as in existence on the day 

4 before the date of the enactment of this Act. 

5 (c) PERIOD BEFORE COMPLETION OF NATIONAL

6 STRATEGY.—Pending completion of the national strategy 

7 under section 3121 of the Public Health Service Act, as 

8 added by subsection (a), the Secretary of Health and 

9 Human Services, acting through the relevant agency head, 

10 may make a judgment about how the strategy will address 

11 an issue and rely on such judgment in carrying out any 

12 provision of subtitle C, D, E, or F of title XXXI of such 

13 Act, as added by subsection (a), that requires the Sec14 retary— 

15 (1) to take into consideration such strategy; 

16 (2) to conduct or support research or provide 

17 services in priority areas identified in such strategy; 

18 or 

19 (3) to take any other action in reliance on such 

20 strategy. 

21 (d) CONFORMING AMENDMENTS.— 

22 (1) Paragraph (61) of section 3(b) of the In23 dian Health Care Improvement Act (25 U.S.C. 

24 1602) is amended by striking ‘‘United States Pre-
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1 ventive Services Task Force’’ and inserting ‘‘Task 

2 Force on Clinical Preventive Services’’. 

3 (2) Section 126 of the Medicare, Medicaid, and 

4 SCHIP Benefits Improvement and Protection Act of 

5 2000 (Appendix F of Public Law 106–554) is 

6 amended by striking ‘‘United States Preventive 

7 Services Task Force’’ each place it appears and in8 serting ‘‘Task Force on Clinical Preventive Serv9 ices’’. 

10 (3) Paragraph (7) of section 317D(a) of the 

11 Public Health Service Act (42 U.S.C. 247b–5(a)) is 

12 amended by striking ‘‘United States Preventive 

13 Services Task Force’’ and inserting ‘‘Task Force on 

14 Clinical Preventive Services’’. 

15 (4) Section 915 of the Public Health Service 

16 Act (42 U.S.C. 299b–4) is amended by striking sub17 section (a). 

18 (5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and 

19 (ddd)(1)(B) of section 1861 of the Social Security 

20 Act (42 U.S.C. 1395x) are amended by striking 

21 ‘‘United States Preventive Services Task Force’’ 

22 each place it appears and inserting ‘‘Task Force on 

23 Clinical Preventive Services’’. 
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1 TITLE IV—QUALITY AND 

2 SURVEILLANCE 

3 SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE 

4 DELIVERY OF HEALTH CARE. 

5 (a) IN GENERAL.—Title IX of the Public Health 

6 Service Act (42 U.S.C. 299 et seq.) is amended— 

7 (1) by redesignating part D as part E; 

8 (2) by redesignating sections 931 through 938 

9 as sections 941 through 948, respectively; 

10 (3) in section 948(1), as redesignated, by strik11 ing ‘‘931’’ and inserting ‘‘941’’; and 

12 (4) by inserting after part C the following: 

13 ‘‘PART D—IMPLEMENTATION OF BEST 

14 PRACTICES IN THE DELIVERY OF HEALTH CARE 

15 ‘‘SEC. 931. CENTER FOR QUALITY IMPROVEMENT. 

16 ‘‘(a) IN GENERAL.—There is established the Center 

17 for Quality Improvement (referred to in this part as the 

18 ‘Center’), to be headed by the Director. 

19 ‘‘(b) PRIORITIZATION.— 

20 ‘‘(1) IN GENERAL.—The Director shall 

21 prioritize areas for the identification, development, 

22 evaluation, and implementation of best practices (in23 cluding innovative methodologies and strategies) for 

24 quality improvement activities in the delivery of 
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1 health care services (in this section referred to as 

2 ‘best practices’). 

3 ‘‘(2) CONSIDERATIONS.—In prioritizing areas 

4 under paragraph (1), the Director shall consider— 

5 ‘‘(A) the priorities established under sec6 tion 1191 of the Social Security Act; and 

7 ‘‘(B) the key health indicators identified by 

8 the Assistant Secretary for Health Information 

9 under section 1709. 

10 ‘‘(3) LIMITATIONS.—In conducting its duties 

11 under this subsection, the Center for Quality Im12 provement shall not develop quality-adjusted life 

13 year measures or any other methodologies that can 

14 be used to deny benefits to a beneficiary against the 

15 beneficiary’s wishes on the basis of the beneficiary’s 

16 age, life expectancy, present or predicted disability, 

17 or expected quality of life. 

18 ‘‘(c) OTHER RESPONSIBILITIES.—The Director, act19 ing directly or by awarding a grant or contract to an eligi20 ble entity, shall— 

21 ‘‘(1) identify existing best practices under sub22 section (e); 

23 ‘‘(2) develop new best practices under sub24 section (f); 
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1 ‘‘(3) evaluate best practices under subsection 

2 (g); 

3 ‘‘(4) implement best practices under subsection 

4 (h); 

5 ‘‘(5) ensure that best practices are identified, 

6 developed, evaluated, and implemented under this 

7 section consistent with standards adopted by the 

8 Secretary under section 3004 for health information 

9 technology used in the collection and reporting of 

10 quality information (including for purposes of the 

11 demonstration of meaningful use of certified elec12 tronic health record (EHR) technology by physicians 

13 and hospitals under the Medicare program (under 

14 sections 1848(o)(2) and 1886(n)(3), respectively, of 

15 the Social Security Act)); and 

16 ‘‘(6) provide for dissemination of information 

17 and reporting under subsections (i) and (j). 

18 ‘‘(d) ELIGIBILITY.—To be eligible for a grant or con19 tract under subsection (c), an entity shall— 

20 ‘‘(1) be a nonprofit entity; 

21 ‘‘(2) agree to work with a variety of institu22 tional health care providers, physicians, nurses, and 

23 other health care practitioners; and 

24 ‘‘(3) if the entity is not the organization holding 

25 a contract under section 1153 of the Social Security 
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1 Act for the area to be served, agree to cooperate 

2 with and avoid duplication of the activities of such 

3 organization. 

4 ‘‘(e) IDENTIFYING EXISTING BEST PRACTICES.—The 

5 Director shall identify best practices that are— 

6 ‘‘(1) currently utilized by health care providers 

7 (including hospitals, physician and other clinician 

8 practices, community cooperatives, and other health 

9 care entities) that deliver consistently high-quality, 

10 efficient health care services; and 

11 ‘‘(2) easily adapted for use by other health care 

12 providers and for use across a variety of health care 

13 settings. 

14 ‘‘(f) DEVELOPING NEW BEST PRACTICES.—The Di15 rector shall develop best practices that are— 

16 ‘‘(1) based on a review of existing scientific evi17 dence; 

18 ‘‘(2) sufficiently detailed for implementation 

19 and incorporation into the workflow of health care 

20 providers; and 

21 ‘‘(3) designed to be easily adapted for use by 

22 health care providers across a variety of health care 

23 settings. 
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1 ‘‘(g) EVALUATION OF BEST PRACTICES.—The Direc2 tor shall evaluate best practices identified or developed 

3 under this section. Such evaluation— 

4 ‘‘(1) shall include determinations of which best 

5 practices— 

6 ‘‘(A) most reliably and effectively achieve 

7 significant progress in improving the quality of 

8 patient care; and 

9 ‘‘(B) are easily adapted for use by health 

10 care providers across a variety of health care 

11 settings; 

12 ‘‘(2) shall include regular review, updating, and 

13 improvement of such best practices; and 

14 ‘‘(3) may include in-depth case studies or em15 pirical assessments of health care providers (includ16 ing hospitals, physician and other clinician practices, 

17 community cooperatives, and other health care enti18 ties) and simulations of such best practices for de19 terminations under paragraph (1). 

20 ‘‘(h) IMPLEMENTATION OF BEST PRACTICES.— 

21 ‘‘(1) IN GENERAL.—The Director shall enter 

22 into arrangements with entities in a State or region 

23 to implement best practices identified or developed 

24 under this section. Such implementation— 
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1 ‘‘(A) may include forming collaborative 

2 multi-institutional teams; and 

3 ‘‘(B) shall include an evaluation of the best 

4 practices being implemented, including the 

5 measurement of patient outcomes before, dur6 ing, and after implementation of such best 

7 practices. 

8 ‘‘(2) PREFERENCES.—In carrying out this sub9 section, the Director shall give priority to health 

10 care providers implementing best practices that— 

11 ‘‘(A) have the greatest impact on patient 

12 outcomes and satisfaction; 

13 ‘‘(B) are the most easily adapted for use 

14 by health care providers across a variety of 

15 health care settings; 

16 ‘‘(C) promote coordination of health care 

17 practitioners across the continuum of care; and 

18 ‘‘(D) engage patients and their families in 

19 improving patient care and outcomes. 

20 ‘‘(i) PUBLIC DISSEMINATION OF INFORMATION.— 

21 The Director shall provide for the public dissemination of 

22 information with respect to best practices and activities 

23 under this section. Such information shall be made avail24 able in appropriate formats and languages to reflect the 
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1 varying needs of consumers and diverse levels of health 

2 literacy. 

3 ‘‘(j) REPORT.— 

4 ‘‘(1) IN GENERAL.—The Director shall submit 

5 an annual report to the Congress and the Secretary 

6 on activities under this section. 

7 ‘‘(2) CONTENT.—Each report under paragraph 

8 (1) shall include— 

9 ‘‘(A) information on activities conducted 

10 pursuant to grants and contracts awarded; 

11 ‘‘(B) summary data on patient outcomes 

12 before, during, and after implementation of best 

13 practices; and 

14 ‘‘(C) recommendations on the adaptability 

15 of best practices for use by health providers.’’. 

16 (b) INITIAL QUALITY IMPROVEMENT ACTIVITIES AND

17 INITIATIVES TO BE IMPLEMENTED.—Until the Director 

18 of the Agency for Healthcare Research and Quality has 

19 established initial priorities under section 931(b) of the 

20 Public Health Service Act, as added by subsection (a), the 

21 Director shall, for purposes of such section, prioritize the 

22 following: 

23 (1) HEALTH CARE-ASSOCIATED INFECTIONS.— 

24 Reducing health care-associated infections, including 

25 infections in nursing homes and outpatient settings. 
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1 (2) SURGERY.—Increasing hospital and out2 patient perioperative patient safety, including reduc3 ing surgical-site infections and surgical errors (such 

4 as wrong-site surgery and retained foreign bodies). 

5 (3) EMERGENCY ROOM.—Improving care in 

6 hospital emergency rooms, including through the use 

7 of principles of efficiency of design and delivery to 

8 improve patient flow. 

9 (4) OBSTETRICS.—Improving the provision of 

10 obstetrical and neonatal care, including the identi11 fication of interventions that are effective in reduc12 ing the risk of preterm and premature labor and the 

13 implementation of best practices for labor and deliv14 ery care. 

15 (5) PEDIATRICS.—Improving the provision of 

16 preventive and developmental child health services, 

17 including interventions that can reduce child health 

18 disparities (as defined in section 3171 of the Public 

19 Health Service Act, as added by section 2301) and 

20 reduce the risk of developing chronic health-threat21 ening conditions that affect an individual’s life 

22 course development. 

23 (c) REPORT.—Not later than 18 months after the 

24 date of the enactment of this Act, the Director of the 

25 Agency for Healthcare Research and Quality shall submit 
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1 a report to the Congress on the impact of the nurse-to2 patient ratio on the quality of care and patient outcomes, 

3 including recommendations for further integration into 

4 quality measurement and quality improvement activities. 

5 SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMA6 TION. 

7 (a) ESTABLISHMENT.—Title XVII (42 U.S.C. 300u 

8 et seq.) is amended— 

9 (1) by redesignating sections 1709 and 1710 as 

10 sections 1710 and 1711, respectively; and 

11 (2) by inserting after section 1708 the fol12 lowing: 

13 ‘‘SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMA14 TION. 

15 ‘‘(a) IN GENERAL.—There is established within the 

16 Department an Assistant Secretary for Health Informa17 tion (in this section referred to as the ‘Assistant Sec18 retary’), to be appointed by the Secretary. 

19 ‘‘(b) RESPONSIBILITIES.—The Assistant Secretary 

20 shall— 

21 ‘‘(1) ensure the collection, collation, reporting, 

22 and publishing of information (including full and 

23 complete statistics) on key health indicators regard24 ing the Nation’s health and the performance of the 

25 Nation’s health care; 
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1 ‘‘(2) facilitate and coordinate the collection, col2 lation, reporting, and publishing of information re3 garding the Nation’s health and the performance of 

4 the Nation’s health care (other than information de5 scribed in paragraph (1)); 

6 ‘‘(3)(A) develop standards for the collection of 

7 data regarding the Nation’s health and the perform8 ance of the Nation’s health care; and 

9 ‘‘(B) in carrying out subparagraph (A)— 

10 ‘‘(i) ensure appropriate specificity and 

11 standardization for data collection at the na12 tional, regional, State, and local levels; 

13 ‘‘(ii) include standards, as appropriate, for 

14 the collection of accurate data on health dis15 parities; 

16 ‘‘(iii) ensure, with respect to data on race 

17 and ethnicity, consistency with the 1997 Office 

18 of Management and Budget Standards for 

19 Maintaining, Collecting and Presenting Federal 

20 Data on Race and Ethnicity (or any successor 

21 standards); and 

22 ‘‘(iv) in consultation with the Director of 

23 the Office of Minority Health, and the Director 

24 of the Office of Civil Rights of the Department, 

25 develop standards for the collection of data on 
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1 health and health care with respect to primary 

2 language; 

3 ‘‘(4) provide support to Federal departments 

4 and agencies whose programs have a significant im5 pact upon health (as determined by the Secretary) 

6 for the collection and collation of information de7 scribed in paragraphs (1) and (2); 

8 ‘‘(5) ensure the sharing of information de9 scribed in paragraphs (1) and (2) among the agen10 cies of the Department; 

11 ‘‘(6) facilitate the sharing of information de12 scribed in paragraphs (1) and (2) by Federal depart13 ments and agencies whose programs have a signifi14 cant impact upon health (as determined by the Sec15 retary); 

16 ‘‘(7) identify gaps in information described in 

17 paragraphs (1) and (2) and the appropriate agency 

18 or entity to address such gaps; 

19 ‘‘(8) facilitate and coordinate identification and 

20 monitoring of health disparities by the agencies of 

21 the Department to inform program and policy ef22 forts to reduce such disparities, including facilitating 

23 and funding analyses conducted in cooperation with 

24 the Social Security Administration, the Bureau of 
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1 the Census, and other appropriate agencies and enti2 ties; 

3 ‘‘(9) consistent with privacy, proprietary, and 

4 other appropriate safeguards, facilitate public acces5 sibility of datasets (such as de-identified Medicare 

6 datasets or publicly available data on key health in7 dicators) by means of the Internet; and 

8 ‘‘(10) award grants or contracts for the collec9 tion and collation of information described in para10 graphs (1) and (2) (including through statewide sur11 veys that provide standardized information). 

12 ‘‘(c) KEY HEALTH INDICATORS.— 

13 ‘‘(1) IN GENERAL.—In carrying out subsection 

14 (b)(1), the Assistant Secretary shall— 

15 ‘‘(A) identify, and reassess at least once 

16 every 3 years, key health indicators described in 

17 such subsection; 

18 ‘‘(B) publish statistics on such key health 

19 indicators for the public— 

20 ‘‘(i) not less than annually; and 

21 ‘‘(ii) on a supplemental basis when22 ever warranted by— 

23 ‘‘(I) the rate of change for a key 

24 health indicator; or 
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1 ‘‘(II) the need to inform policy 

2 regarding the Nation’s health and the 

3 performance of the Nation’s health 

4 care; and 

5 ‘‘(C) ensure consistency with the national 

6 strategy developed by the Secretary under sec7 tion 3121 and consideration of the indicators 

8 specified in the reports under sections 308, 

9 903(a)(6), and 913(b)(2). 

10 ‘‘(2) RELEASE OF KEY HEALTH INDICATORS.— 

11 The regulations, rules, processes, and procedures of 

12 the Office of Management and Budget governing the 

13 review, release, and dissemination of key health indi14 cators shall be the same as the regulations, rules, 

15 processes, and procedures of the Office of Manage16 ment and Budget governing the review, release, and 

17 dissemination of Principal Federal Economic Indica18 tors (or equivalent statistical data) by the Bureau of 

19 Labor Statistics. 

20 ‘‘(d) COORDINATION.—In carrying out this section, 

21 the Assistant Secretary shall coordinate with— 

22 ‘‘(1) public and private entities that collect and 

23 disseminate information on health and health care, 

24 including foundations; and 
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1 ‘‘(2) the head of the Office of the National Co2 ordinator for Health Information Technology to en3 sure optimal use of health information technology. 

4 ‘‘(e) REQUEST FOR INFORMATION FROM DEPART5 MENTS AND AGENCIES.—Consistent with applicable law, 

6 the Assistant Secretary may secure directly from any Fed7 eral department or agency information necessary to enable 

8 the Assistant Secretary to carry out this section. 

9 ‘‘(f) REPORT.— 

10 ‘‘(1) SUBMISSION.—The Assistant Secretary 

11 shall submit to the Secretary and the Congress an 

12 annual report containing— 

13 ‘‘(A) a description of national, regional, or 

14 State changes in health or health care, as re15 flected by the key health indicators identified 

16 under subsection (c)(1); 

17 ‘‘(B) a description of gaps in the collection, 

18 collation, reporting, and publishing of informa19 tion regarding the Nation’s health and the per20 formance of the Nation’s health care; 

21 ‘‘(C) recommendations for addressing such 

22 gaps and identification of the appropriate agen23 cy within the Department or other entity to ad24 dress such gaps; 
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1 ‘‘(D) a description of analyses of health 

2 disparities, including the results of completed 

3 analyses, the status of ongoing longitudinal 

4 studies, and proposed or planned research; and 

5 ‘‘(E) a plan for actions to be taken by the 

6 Assistant Secretary to address gaps described 

7 in subparagraph (B). 

8 ‘‘(2) CONSIDERATION.—In preparing a report 

9 under paragraph (1), the Assistant Secretary shall 

10 take into consideration the findings and conclusions 

11 in the reports under sections 308, 903(a)(6), and 

12 913(b)(2). 

13 ‘‘(g) PROPRIETARY AND PRIVACY PROTECTIONS.— 

14 Nothing in this section shall be construed to affect appli15 cable proprietary or privacy protections. 

16 ‘‘(h) CONSULTATION.—In carrying out this section, 

17 the Assistant Secretary shall consult with— 

18 ‘‘(1) the heads of appropriate health agencies 

19 and offices in the Department, including the Office 

20 of the Surgeon General of the Public Health Service, 

21 the Office of Minority Health, and the Office on 

22 Women’s Health; and 

23 ‘‘(2) as appropriate, the heads of other Federal 

24 departments and agencies whose programs have a 
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1 significant impact upon health (as determined by the 

2 Secretary). 

3 ‘‘(i) DEFINITION.—In this section: 

4 ‘‘(1) The terms ‘agency’ and ‘agencies’ include 

5 an epidemiology center established under section 214 

6 of the Indian Health Care Improvement Act. 

7 ‘‘(2) The term ‘Department’ means the Depart8 ment of Health and Human Services. 

9 ‘‘(3) The term ‘health disparities’ has the 

10 meaning given to such term in section 3171.’’. 

11 (b) OTHER COORDINATION RESPONSIBILITIES.— 

12 Title III (42 U.S.C. 241 et seq.) is amended— 

13 (1) in paragraphs (1) and (2) of section 304(c) 

14 (42 U.S.C. 242b(c)), by inserting ‘‘, acting through 

15 the Assistant Secretary for Health Information,’’ 

16 after ‘‘The Secretary’’ each place it appears; and 

17 (2) in section 306(j) (42 U.S.C. 242k(j)), by in18 serting ‘‘, acting through the Assistant Secretary for 

19 Health Information,’’ after ‘‘of this section, the Sec20 retary’’. 

21 SEC. 2403. AUTHORIZATION OF APPROPRIATIONS. 

22 Section 799C, as added and amended, is further 

23 amended by adding at the end the following: 

24 ‘‘(e) QUALITY AND SURVEILLANCE.—For the pur25 pose of carrying out part D of title IX and section 1709, 
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1 in addition to any other amounts authorized to be appro2 priated for such purpose, there are authorized to be appro3 priated, out of any monies in the Public Health Invest4 ment Fund, $300,000,000 for each of fiscal years 2011 

5 through 2015.’’. 

6 TITLE V—OTHER PROVISIONS 

7 Subtitle A—Drug Discount for 

8 Rural and Other Hospitals; 340B 

9 Program Integrity 

10 SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM. 

11 (a) EXPANSION OF COVERED ENTITIES RECEIVING

12 DISCOUNTED PRICES.—Section 340B(a)(4) (42 U.S.C. 

13 256b(a)(4)) is amended by adding at the end the fol14 lowing: 

15 ‘‘(M) A children’s hospital excluded from 

16 the Medicare prospective payment system pur17 suant to section 1886(d)(1)(B)(iii) of the Social 

18 Security Act, or a free-standing cancer hospital 

19 excluded from the Medicare prospective pay20 ment system pursuant to section 

21 1886(d)(1)(B)(v) of the Social Security Act 

22 that would meet the requirements of subpara23 graph (L), including the disproportionate share 

24 adjustment percentage requirement under 

25 clause (ii) of such subparagraph, if the hospital 
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1 were a subsection (d) hospital as defined by sec2 tion 1886(d)(1)(B) of the Social Security Act. 

3 ‘‘(N) An entity that is a critical access hos4 pital (as determined under section 1820(c)(2) 

5 of the Social Security Act). 

6 ‘‘(O) An entity receiving funds under title 

7 V of the Social Security Act (relating to mater8 nal and child health) for the provision of health 

9 services. 

10 ‘‘(P) An entity receiving funds under sub11 part I of part B of title XIX of the Public 

12 Health Service Act (relating to comprehensive 

13 mental health services) for the provision of com14 munity mental health services. 

15 ‘‘(Q) An entity receiving funds under sub16 part II of such part B (relating to the preven17 tion and treatment of substance abuse) for the 

18 provision of treatment services for substance 

19 abuse. 

20 ‘‘(R) An entity that is a Medicare-depend21 ent, small rural hospital (as defined in section 

22 1886(d)(5)(G)(iv) of the Social Security Act). 

23 ‘‘(S) An entity that is a sole community 

24 hospital (as defined in section 

25 1886(d)(5)(D)(iii) of the Social Security Act). 
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1 ‘‘(T) An entity that is classified as a rural 

2 referral center under section 1886(d)(5)(C) of 

3 the Social Security Act.’’. 

4 (b) PROHIBITION ON GROUP PURCHASING ARRANGE5 MENTS.—Section 340B(a) (42 U.S.C. 256b(a)) is amend6 ed— 

7 (1) in paragraph (4)(L)— 

8 (A) by adding ‘‘and’’ at the end of clause 

9 (i); 

10 (B) by striking ‘‘; and’’ at the end of 

11 clause (ii) and inserting a period; and 

12 (C) by striking clause (iii); and 

13 (2) in paragraph (5), by redesignating subpara14 graphs (C) and (D) as subparagraphs (D) and (E), 

15 respectively, and by inserting after subparagraph 

16 (B) the following: 

17 ‘‘(C) PROHIBITING USE OF GROUP PUR18 CHASING ARRANGEMENTS.—A hospital de19 scribed in subparagraph (L), (M), (N), (R), 

20 (S), or (T) of paragraph (4) shall not obtain 

21 covered outpatient drugs through a group pur22 chasing organization or other group purchasing 

23 arrangement.’’. 
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1 SEC. 2502. IMPROVEMENTS TO 340B PROGRAM INTEGRITY. 

2 (a) INTEGRITY IMPROVEMENTS.—Section 340B (42 

3 U.S.C. 256b) is amended— 

4 (1) by striking subsections (c) and (d); and 

5 (2) by inserting after subsection (b) the fol6 lowing: 

7 ‘‘(c) IMPROVEMENTS IN PROGRAM INTEGRITY.— 

8 ‘‘(1) MANUFACTURER COMPLIANCE.— 

9 ‘‘(A) IN GENERAL.—From amounts appro10 priated under paragraph (4), the Secretary 

11 shall provide for improvements in compliance by 

12 manufacturers with the requirements of this 

13 section in order to prevent overcharges and 

14 other violations of the discounted pricing re15 quirements specified in this section. 

16 ‘‘(B) IMPROVEMENTS.—The improvements 

17 described in subparagraph (A) shall include the 

18 following: 

19 ‘‘(i) The establishment of a process to 

20 enable the Secretary to verify the accuracy 

21 of ceiling prices calculated by manufactur22 ers under subsection (a)(1) and charged to 

23 covered entities, which shall include the 

24 following: 

25 ‘‘(I) Developing and publishing, 

26 through an appropriate policy or regu-
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1 latory issuance, standards and meth2 odology for the calculation of ceiling 

3 prices under such subsection. 

4 ‘‘(II) Comparing regularly the 

5 ceiling prices calculated by the Sec6 retary with the quarterly pricing data 

7 that is reported by manufacturers to 

8 the Secretary. 

9 ‘‘(III) Conducting periodic moni10 toring of sales transactions to covered 

11 entities. 

12 ‘‘(IV) Inquiring into any discrep13 ancies between ceiling prices and 

14 manufacturer pricing data that may 

15 be identified and taking, or requiring 

16 manufacturers to take, corrective ac17 tion in response to such discrepancies, 

18 including the issuance of refunds pur19 suant to the procedures set forth in 

20 clause (ii). 

21 ‘‘(ii) The establishment of procedures 

22 for the issuance of refunds to covered enti23 ties by manufacturers in the event that the 

24 Secretary finds there has been an over25 charge, including the following: 
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1 ‘‘(I) Submission to the Secretary 

2 by manufacturers of an explanation of 

3 why and how the overcharge occurred, 

4 how the refunds will be calculated, 

5 and to whom the refunds will be 

6 issued. 

7 ‘‘(II) Oversight by the Secretary 

8 to ensure that the refunds are issued 

9 accurately and within a reasonable pe10 riod of time. 

11 ‘‘(iii) Notwithstanding any other pro12 vision of law prohibiting the disclosure of 

13 ceiling prices or data used to calculate the 

14 ceiling price, the provision of access to cov15 ered entities and State Medicaid agencies 

16 through an Internet website of the Depart17 ment of Health and Human Services or 

18 contractor to the applicable ceiling prices 

19 for covered drugs as calculated and verified 

20 by the Secretary in a manner that ensures 

21 protection of privileged pricing data from 

22 unauthorized disclosure. 

23 ‘‘(iv) The development of a mecha24 nism by which— 
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1 ‘‘(I) rebates, discounts, or other 

2 price concessions provided by manu3 facturers to other purchasers subse4 quent to the sale of covered drugs to 

5 covered entities are reported to the 

6 Secretary; and 

7 ‘‘(II) appropriate credits and re8 funds are issued to covered entities if 

9 such rebates, discounts, or other price 

10 concessions have the effect of lowering 

11 the applicable ceiling price for the rel12 evant quarter for the drugs involved. 

13 ‘‘(v) In addition to authorities under 

14 section 1927(b)(3) of the Social Security 

15 Act, the Secretary may conduct audits of 

16 manufacturers and wholesalers to ensure 

17 the integrity of the program under this 

18 section, including audits on the market 

19 price of covered drugs. 

20 ‘‘(vi) The establishment of a require21 ment that manufacturers and wholesalers 

22 use the identification system developed by 

23 the Secretary for purposes of facilitating 

24 the ordering, purchasing, and delivery of 

25 covered drugs under this section, including 
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1 the processing of chargebacks for such 

2 drugs. 

3 ‘‘(vii) The imposition of sanctions in 

4 the form of civil monetary penalties, 

5 which— 

6 ‘‘(I) shall be assessed according 

7 to standards and procedures estab8 lished in regulations to be promul9 gated by the Secretary within one 

10 year of the date of the enactment of 

11 the Affordable Health Care for Amer12 ica Act; and 

13 ‘‘(II) shall apply to any manufac14 turer with an agreement under this 

15 section and shall not exceed $100,000 

16 for each instance where a manufac17 turer knowingly charges a covered en18 tity a price for purchase of a drug 

19 that exceeds the maximum applicable 

20 price under subsection (a)(1) or that 

21 knowingly violates any other provision 

22 of this section, or withholds or pro23 vides false information to the Sec24 retary or to covered entities under 

25 this section. 
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1 ‘‘(2) COVERED ENTITY COMPLIANCE.— 

2 ‘‘(A) IN GENERAL.—From amounts appro3 priated under paragraph (4), the Secretary 

4 shall provide for improvements in compliance by 

5 covered entities with the requirements of this 

6 section in order to prevent diversion and viola7 tions of the duplicate discount provision and 

8 other requirements under subsection (a)(5). 

9 ‘‘(B) IMPROVEMENTS.—The improvements 

10 described in subparagraph (A) shall include the 

11 following: 

12 ‘‘(i) The development of procedures to 

13 enable and require covered entities to up14 date at least annually the information on 

15 the Internet Web site of the Department of 

16 Health and Human Services relating to 

17 this section. 

18 ‘‘(ii) The development of procedures 

19 for the Secretary to verify the accuracy of 

20 information regarding covered entities that 

21 is listed on the Web site described in 

22 clause (i). 

23 ‘‘(iii) The development of more de24 tailed guidance describing methodologies 

25 and options available to covered entities for 
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1 billing covered drugs to State Medicaid 

2 agencies in a manner that avoids duplicate 

3 discounts pursuant to subsection (a)(5)(A). 

4 ‘‘(iv) The establishment of a single, 

5 universal, and standardized identification 

6 system by which each covered entity site 

7 can be identified by manufacturers, dis8 tributors, covered entities, and the Sec9 retary for purposes of facilitating the or10 dering, purchasing, and delivery of covered 

11 drugs under this section, including the 

12 processing of chargebacks for such drugs. 

13 ‘‘(v) The imposition of sanctions in 

14 the form of civil monetary penalties, 

15 which— 

16 ‘‘(I) shall be assessed according 

17 to standards and procedures estab18 lished in regulations promulgated by 

19 the Secretary; 

20 ‘‘(II) shall not exceed $5,000 for 

21 each violation; and 

22 ‘‘(III) shall apply to any covered 

23 entity that knowingly violates sub24 paragraph (a)(5)(B) or knowingly vio-
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1 lates any other provision of this sec2 tion. 

3 ‘‘(vi) The exclusion of a covered entity 

4 from participation in the program under 

5 this section, for a period of time to be de6 termined by the Secretary, in cases in 

7 which the Secretary determines, in accord8 ance with standards and procedures estab9 lished in regulations, that— 

10 ‘‘(I) a violation of a requirement 

11 of this section was repeated and 

12 knowing; and 

13 ‘‘(II) imposition of a monetary 

14 penalty would be insufficient to rea15 sonably ensure compliance. 

16 ‘‘(vii) The referral of matters as ap17 propriate to the Food and Drug Adminis18 tration, the Office of Inspector General of 

19 Department of Health and Human Serv20 ices, or other Federal agencies. 

21 ‘‘(3) ADMINISTRATIVE DISPUTE RESOLUTION

22 PROCESS.—From amounts appropriated under para23 graph (4), the Secretary may establish and imple24 ment an administrative process for the resolution of 

25 the following: 
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1 ‘‘(A) Claims by covered entities that manu2 facturers have violated the terms of their agree3 ment with the Secretary under subsection 

4 (a)(1). 

5 ‘‘(B) Claims by manufacturers that cov6 ered entities have violated subsection (a)(5)(A) 

7 or (a)(5)(B). 

8 ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— 

9 There are authorized to be appropriated to carry out 

10 this subsection, such sums as may be necessary for 

11 fiscal year 2011 and each succeeding fiscal year.’’. 

12 (b) CONFORMING AMENDMENTS.— 

13 (1) Section 340B(a) (42 U.S.C. 256b(a)) is 

14 amended— 

15 (A) by adding at the end of paragraph (1) 

16 the following: ‘‘Such agreement shall require 

17 that the manufacturer offer each covered entity 

18 covered drugs for purchase at or below the ap19 plicable ceiling price if such drug is made avail20 able to any other purchaser at any price. Such 

21 agreement shall require that, if the supply of a 

22 covered drug is insufficient to meet demand, 

23 then the manufacturer may utilize an allocation 

24 method that is reported in writing to the Sec25 retary and does not discriminate on the basis of 
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1 the price paid by covered entities or on any 

2 other basis related to an entity’s participation 

3 in the program under this section. Notwith4 standing any other provision of law, if the Sec5 retary requests a manufacturer to enter into a 

6 new or amended agreement under this section 

7 that complies with current law and if the manu8 facturer opts not to sign the new or amended 

9 agreement, then any existing agreement be10 tween the manufacturer and the Secretary 

11 under this section is deemed to no longer meet 

12 the requirements of this section for purposes of 

13 this section and section 1927 of the Social Se14 curity Act.’’; and 

15 (B) by adding at the end the following 

16 paragraph: 

17 ‘‘(11) QUARTERLY REPORTS.—An agreement 

18 described in paragraph (1) shall require that the 

19 manufacturer furnish the Secretary with reports on 

20 a quarterly basis that include the following informa21 tion: 

22 ‘‘(A) The price for each covered drug sub23 ject to the agreement that, according to the 

24 manufacturer, represents the maximum price 

25 that covered entities may permissibly be re-
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1 quired to pay for the drug (referred to in this 

2 section as the ‘ceiling price’). 

3 ‘‘(B) The component information used to 

4 calculate the ceiling price as determined nec5 essary to administer the requirements of the 

6 program under this section. 

7 ‘‘(C) Rebates, discounts, and other price 

8 concessions provided by manufacturers to other 

9 purchasers subsequent to the sale of covered 

10 drugs to covered entities.’’. 

11 (2) Section 1927(a)(5) of the Social Security 

12 Act (42 U.S.C. 1396r–8(a)(5)) is amended by strik13 ing subparagraph (D). 

14 SEC. 2503. EFFECTIVE DATE. 

15 (a) IN GENERAL.—The amendments made by this 

16 subtitle shall take effect on the date of the enactment of 

17 this Act, and sections 2501, 2502(a)(1), and 2502(b)(2) 

18 shall apply to drugs dispensed on or after such date. 

19 (b) EFFECTIVENESS.—The amendments made by 

20 this subtitle shall be effective, and shall be taken into ac21 count in determining whether a manufacturer is deemed 

22 to meet the requirements of section 340B(a) of the Public 

23 Health Service Act (42 U.S.C. 256b(a)), and of section 

24 1927(a)(5) of the Social Security Act (42 U.S.C. 1396r– 

25 8(a)(5)), notwithstanding any other provision of law. 
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1 Subtitle B—Programs 

2 PART 1—GRANTS FOR CLINICS AND CENTERS 

3 SEC. 2511. SCHOOL-BASED HEALTH CLINICS. 

4 (a) IN GENERAL.—Part Q of title III (42 U.S.C. 

5 280h et seq.) is amended by adding at the end the fol6 lowing: 

7 ‘‘SEC. 399Z–1. SCHOOL-BASED HEALTH CLINICS. 

8 ‘‘(a) PROGRAM.—The Secretary shall establish a 

9 school-based health clinic program consisting of awarding 

10 grants to eligible entities to support the operation of 

11 school-based health clinics (referred to in this section as 

12 ‘SBHCs’). 

13 ‘‘(b) ELIGIBILITY.—To be eligible for a grant under 

14 this section, an entity shall— 

15 ‘‘(1) be an SBHC (as defined in subsection 

16 (l)(3)); and 

17 ‘‘(2) submit an application at such time, in 

18 such manner, and containing such information as 

19 the Secretary may require, including at a min20 imum— 

21 ‘‘(A) evidence that the applicant meets all 

22 criteria necessary to be designated as an 

23 SBHC; 

24 ‘‘(B) evidence of local need for the services 

25 to be provided by the SBHC; 
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1 ‘‘(C) an assurance that— 

2 ‘‘(i) SBHC services will be provided in 

3 accordance with Federal, State, and local 

4 laws; 

5 ‘‘(ii) the SBHC has established and 

6 maintains collaborative relationships with 

7 other health care providers in the 

8 catchment area of the SBHC; 

9 ‘‘(iii) the SBHC will provide onsite ac10 cess during the academic day when school 

11 is in session and has an established net12 work of support and access to services with 

13 backup health providers when the school or 

14 SBHC is closed; 

15 ‘‘(iv) the SBHC will be integrated into 

16 the school environment and will coordinate 

17 health services with appropriate school per18 sonnel and other community providers co19 located at the school; and 

20 ‘‘(v) the SBHC sponsoring facility as21 sumes all responsibility for the SBHC ad22 ministration, operations, and oversight; 

23 and 

24 ‘‘(D) such other information as the Sec25 retary may require. 
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1 ‘‘(c) USE OF FUNDS.—Funds awarded under a grant 

2 under this section— 

3 ‘‘(1) may be used for— 

4 ‘‘(A) providing training related to the pro5 vision of comprehensive primary health services 

6 and additional health services; 

7 ‘‘(B) the management and operation of 

8 SBHC programs, including through sub9 contracts; and 

10 ‘‘(C) the payment of salaries for health 

11 professionals and other appropriate SBHC per12 sonnel; and 

13 ‘‘(2) may not be used to provide abortions. 

14 ‘‘(d) CONSIDERATION OF NEED.—In determining the 

15 amount of a grant under this section, the Secretary shall 

16 take into consideration— 

17 ‘‘(1) the financial need of the SBHC; 

18 ‘‘(2) State, local, or other sources of funding 

19 provided to the SBHC; and 

20 ‘‘(3) other factors as determined appropriate by 

21 the Secretary. 

22 ‘‘(e) PREFERENCES.—In awarding grants under this 

23 section, the Secretary shall give preference to SBHCs that 

24 have a demonstrated record of service to at least one of 

25 the following: 
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1 ‘‘(1) A high percentage of medically under2 served children and adolescents. 

3 ‘‘(2) Communities or populations in which chil4 dren and adolescents have difficulty accessing health 

5 and mental health services. 

6 ‘‘(3) Communities with high percentages of chil7 dren and adolescents who are uninsured, under8 insured, or eligible for medical assistance under Fed9 eral or State health benefits programs (including ti10 tles XIX and XXI of the Social Security Act). 

11 ‘‘(f) MATCHING REQUIREMENT.—The Secretary may 

12 award a grant to an SBHC under this section only if the 

13 SBHC agrees to provide, from non-Federal sources, an 

14 amount equal to 20 percent of the amount of the grant 

15 (which may be provided in cash or in kind) to carry out 

16 the activities supported by the grant. 

17 ‘‘(g) SUPPLEMENT, NOT SUPPLANT.—The Secretary 

18 may award a grant to an SBHC under this section only 

19 if the SBHC demonstrates to the satisfaction of the Sec20 retary that funds received through the grant will be ex21 pended only to supplement, and not supplant, non-Federal 

22 and Federal funds otherwise available to the SBHC for 

23 operation of the SBHC (including each activity described 

24 in paragraph (1) or (2) of subsection (c)). 
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1 ‘‘(h) PAYOR OF LAST RESORT.—The Secretary may 

2 award a grant to an SBHC under this section only if the 

3 SBHC demonstrates to the satisfaction of the Secretary 

4 that funds received through the grant will not be expended 

5 for any activity to the extent that payment has been made, 

6 or can reasonably be expected to be made— 

7 ‘‘(1) under any insurance policy; 

8 ‘‘(2) under any Federal or State health benefits 

9 program (including titles XIX and XXI of the Social 

10 Security Act); or 

11 ‘‘(3) by an entity which provides health services 

12 on a prepaid basis. 

13 ‘‘(i) REGULATIONS REGARDING REIMBURSEMENT

14 FOR HEALTH SERVICES.—The Secretary shall issue regu15 lations regarding the reimbursement for health services 

16 provided by SBHCs to individuals eligible to receive such 

17 services through the program under this section, including 

18 reimbursement under any insurance policy or any Federal 

19 or State health benefits program (including titles XIX and 

20 XXI of the Social Security Act). 

21 ‘‘(j) TECHNICAL ASSISTANCE.—The Secretary shall 

22 provide (either directly or by grant or contract) technical 

23 and other assistance to SBHCs to assist such SBHCs to 

24 meet the requirements of this section. Such assistance 

25 may include fiscal and program management assistance, 
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1 training in fiscal and program management, operational 

2 and administrative support, and the provision of informa3 tion to the SBHCs of the variety of resources available 

4 under this title and how those resources can be best used 

5 to meet the health needs of the communities served by 

6 the SBHCs. 

7 ‘‘(k) EVALUATION; REPORT.—The Secretary shall— 

8 ‘‘(1) develop and implement a plan for evalu9 ating SBHCs and monitoring quality performances 

10 under the awards made under this section; and 

11 ‘‘(2) submit to the Congress on an annual basis 

12 a report on the program under this section. 

13 ‘‘(l) DEFINITIONS.—In this section: 

14 ‘‘(1) COMPREHENSIVE PRIMARY HEALTH SERV15 ICES.—The term ‘comprehensive primary health 

16 services’ means the core services offered by SBHCs, 

17 which— 

18 ‘‘(A) shall include— 

19 ‘‘(i) comprehensive health assess20 ments, diagnosis, and treatment of minor, 

21 acute, and chronic medical conditions and 

22 referrals to, and followup for, specialty 

23 care; and 

24 ‘‘(ii) mental health assessments, crisis 

25 intervention, counseling, treatment, and re-
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1 ferral to a continuum of services including 

2 emergency psychiatric care, community 

3 support programs, inpatient care, and out4 patient programs; and 

5 ‘‘(B) may include additional services, such 

6 as oral health, social, and age-appropriate 

7 health education services, including nutritional 

8 counseling. 

9 ‘‘(2) MEDICALLY UNDERSERVED CHILDREN

10 AND ADOLESCENTS.—The term ‘medically under11 served children and adolescents’ means a population 

12 of children and adolescents who are residents of an 

13 area designated by the Secretary as an area with a 

14 shortage of personal health services and health in15 frastructure for such children and adolescents. 

16 ‘‘(3) SCHOOL-BASED HEALTH CLINIC.—The 

17 term ‘school-based health clinic’ means a health clin18 ic that— 

19 ‘‘(A) is located in, or is adjacent to, a 

20 school facility of a local educational agency; 

21 ‘‘(B) is organized through school, commu22 nity, and health provider relationships; 

23 ‘‘(C) is administered by a sponsoring facil24 ity; 
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1 ‘‘(D) provides comprehensive primary 

2 health services during school hours to children 

3 and adolescents by health professionals in ac4 cordance with State and local laws and regula5 tions, established standards, and community 

6 practice; and 

7 ‘‘(E) does not perform abortion services. 

8 ‘‘(4) SPONSORING FACILITY.—The term ‘spon9 soring facility’ is— 

10 ‘‘(A) a hospital; 

11 ‘‘(B) a public health department; 

12 ‘‘(C) a community health center; 

13 ‘‘(D) a nonprofit health care entity whose 

14 mission is to provide access to comprehensive 

15 primary health care services; 

16 ‘‘(E) a local educational agency; or 

17 ‘‘(F) a program administered by the In18 dian Health Service or the Bureau of Indian 

19 Affairs or operated by an Indian tribe or a trib20 al organization under the Indian Self-Deter21 mination and Education Assistance Act, a Na22 tive Hawaiian entity, or an urban Indian pro23 gram under title V of the Indian Health Care 

24 Improvement Act. 
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1 ‘‘(m) AUTHORIZATION OF APPROPRIATIONS.—For 

2 purposes of carrying out this section, there are authorized 

3 to be appropriated $50,000,000 for fiscal year 2011 and 

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

5 2012 through 2015.’’. 

6 (b) EFFECTIVE DATE.—The Secretary of Health and 

7 Human Services shall begin awarding grants under section 

8 399Z–1 of the Public Health Service Act, as added by sub9 section (a), not later than July 1, 2010, without regard 

10 to whether or not final regulations have been issued under 

11 section 399Z–1(i) of such Act. 

12 (c) TERMINATION OF STUDY.—Section 2(b) of the 

13 Health Care Safety Net Act of 2008 (42 U.S.C. 254b 

14 note) is amended by striking paragraph (2) (relating to 

15 a school-based health center study). 

16 SEC. 2512. NURSE-MANAGED HEALTH CENTERS. 

17 Title III (42 U.S.C. 241 et seq.) is amended by add18 ing at the end the following: 

19 ‘‘PART S—NURSE-MANAGED HEALTH CENTERS 

20 ‘‘SEC. 399FF. NURSE-MANAGED HEALTH CENTERS. 

21 ‘‘(a) PROGRAM.—The Secretary, acting through the 

22 Administrator of the Health Resources and Services Ad23 ministration, shall establish a nurse-managed health cen24 ter program consisting of awarding grants to entities 

25 under subsection (b). 
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1 ‘‘(b) GRANT.—The Secretary shall award grants to 

2 entities— 

3 ‘‘(1) to plan and develop a nurse-managed 

4 health center; or 

5 ‘‘(2) to operate a nurse-managed health center. 

6 ‘‘(c) USE OF FUNDS.—Amounts received as a grant 

7 under subsection (b) may be used for activities including 

8 the following: 

9 ‘‘(1) Purchasing or leasing equipment. 

10 ‘‘(2) Training and technical assistance related 

11 to the provision of comprehensive primary care serv12 ices and wellness services. 

13 ‘‘(3) Other activities for planning, developing, 

14 or operating, as applicable, a nurse-managed health 

15 center. 

16 ‘‘(d) ASSURANCES APPLICABLE TO BOTH PLANNING

17 AND OPERATION GRANTS.— 

18 ‘‘(1) IN GENERAL.—The Secretary may award 

19 a grant under this section to an entity only if the 

20 entity demonstrates to the Secretary’s satisfaction 

21 that— 

22 ‘‘(A) nurses, in addition to managing the 

23 center, will be adequately represented as pro24 viders at the center; and 
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1 ‘‘(B) not later than 90 days after receiving 

2 the grant, the entity will establish a community 

3 advisory committee composed of individuals, a 

4 majority of whom are being served by the cen5 ter, to provide input into the nurse-managed 

6 health center’s operations. 

7 ‘‘(2) MATCHING REQUIREMENT.—The Sec8 retary may award a grant under this section to an 

9 entity only if the entity agrees to provide, from non10 Federal sources, an amount equal to 20 percent of 

11 the amount of the grant (which may be provided in 

12 cash or in kind) to carry out the activities supported 

13 by the grant. 

14 ‘‘(3) PAYOR OF LAST RESORT.—The Secretary 

15 may award a grant under this section to an entity 

16 only if the entity demonstrates to the satisfaction of 

17 the Secretary that funds received through the grant 

18 will not be expended for any activity to the extent 

19 that payment has been made, or can reasonably be 

20 expected to be made— 

21 ‘‘(A) under any insurance policy; 

22 ‘‘(B) under any Federal or State health 

23 benefits program (including titles XIX and XXI 

24 of the Social Security Act); or 
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1 ‘‘(C) by an entity which provides health 

2 services on a prepaid basis. 

3 ‘‘(4) MAINTENANCE OF EFFORT.—The Sec4 retary may award a grant under this section to an 

5 entity only if the entity demonstrates to the satisfac6 tion of the Secretary that— 

7 ‘‘(A) funds received through the grant will 

8 be expended only to supplement, and not sup9 plant, non-Federal and Federal funds otherwise 

10 available to the entity for the activities to be 

11 funded through the grant; and 

12 ‘‘(B) with respect to such activities, the en13 tity will maintain expenditures of non-Federal 

14 amounts for such activities at a level not less 

15 than the lesser of such expenditures maintained 

16 by the entity for the fiscal year preceding the 

17 fiscal year for which the entity receives the 

18 grant. 

19 ‘‘(e) ADDITIONAL ASSURANCE FOR PLANNING

20 GRANTS.—The Secretary may award a grant under sub21 section (b)(1) to an entity only if the entity agrees— 

22 ‘‘(1) to assess the needs of the medically under23 served populations proposed to be served by the 

24 nurse-managed health center; and 
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1 ‘‘(2) to design services and operations of the 

2 nurse-managed health center for such populations 

3 based on such assessment. 

4 ‘‘(f) ADDITIONAL ASSURANCE FOR OPERATION

5 GRANTS.—The Secretary may award a grant under sub6 section (b)(2) to an entity only if the entity assures that 

7 the nurse-managed health center will provide— 

8 ‘‘(1) comprehensive primary care services, 

9 wellness services, and other health care services 

10 deemed appropriate by the Secretary; 

11 ‘‘(2) care without respect to insurance status or 

12 income of the patient; and 

13 ‘‘(3) direct access to client-centered services of14 fered by advanced practice nurses, other nurses, 

15 physicians, physician assistants, or other qualified 

16 health professionals. 

17 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 

18 provide (either directly or by grant or contract) technical 

19 and other assistance to nurse-managed health centers to 

20 assist such centers in meeting the requirements of this 

21 section. Such assistance may include fiscal and program 

22 management assistance, training in fiscal and program 

23 management, operational and administrative support, and 

24 the provision of information to nurse-managed health cen25 ters regarding the various resources available under this 
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1 section and how those resources can best be used to meet 

2 the health needs of the communities served by nurse-man3 aged health centers. 

4 ‘‘(h) REPORT.—The Secretary shall submit to the 

5 Congress an annual report on the program under this sec6 tion. 

7 ‘‘(i) DEFINITIONS.—In this section: 

8 ‘‘(1) COMPREHENSIVE PRIMARY CARE SERV9 ICES.—The term ‘comprehensive primary care serv10 ices’ has the meaning given to the term ‘required 

11 primary health services’ in section 330(b)(1). 

12 ‘‘(2) MEDICALLY UNDERSERVED POPU13 LATION.—The term ‘medically underserved popu14 lation’ has the meaning given to such term in section 

15 330(b)(3). 

16 ‘‘(3) NURSE-MANAGED HEALTH CENTER.—The 

17 term ‘nurse-managed health center’ has the meaning 

18 given to such term in section 801. 

19 ‘‘(4) WELLNESS SERVICES.—The term ‘wellness 

20 services’ means any health-related service or inter21 vention, not including primary care, which is de22 signed to reduce identifiable health risks and in23 crease healthy behaviors intended to prevent the 

24 onset of disease or lessen the impact of existing 

25 chronic conditions by teaching more effective man-
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1 agement techniques that focus on individual self-care 

2 and patient-driven decisionmaking. 

3 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—To 

4 carry out this section, there are authorized to be appro5 priated such sums as may be necessary for each of fiscal 

6 years 2011 through 2015.’’. 

7 SEC. 2513. FEDERALLY QUALIFIED BEHAVIORAL HEALTH 

8 CENTERS. 

9 Section 1913 (42 U.S.C. 300x–3) is amended— 

10 (1) in subsection (a)(2)(A), by striking ‘‘com11 munity mental health services’’ and inserting ‘‘be12 havioral health services (of the type offered by feder13 ally qualified behavioral health centers consistent 

14 with subsection (c)(3))’’; 

15 (2) in subsection (b)— 

16 (A) by striking paragraph (1) and insert17 ing the following: 

18 ‘‘(1) services under the plan will be provided 

19 only through appropriate, qualified community pro20 grams (which may include federally qualified behav21 ioral health centers, child mental health programs, 

22 psychosocial rehabilitation programs, mental health 

23 peer-support programs, and mental health primary 

24 consumer-directed programs); and’’; and 
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1 (B) in paragraph (2), by striking ‘‘commu2 nity mental health centers’’ and inserting ‘‘fed3 erally qualified behavioral health centers’’; and 

4 (3) by striking subsection (c) and inserting the 

5 following: 

6 ‘‘(c) CRITERIA FOR FEDERALLY QUALIFIED BEHAV7 IORAL HEALTH CENTERS.— 

8 ‘‘(1) IN GENERAL.—The Administrator shall 

9 certify, and recertify at least every 5 years, federally 

10 qualified behavioral health centers as meeting the 

11 criteria specified in this subsection. 

12 ‘‘(2) REGULATIONS.—Not later than 18 months 

13 after the date of the enactment of the Affordable 

14 Health Care for America Act, the Administrator 

15 shall issue final regulations for certifying centers 

16 under paragraph (1). 

17 ‘‘(3) CRITERIA.—The criteria referred to in 

18 subsection (b)(2) are that the center performs each 

19 of the following: 

20 ‘‘(A) Provide services in locations that en21 sure services will be available and accessible 

22 promptly and in a manner which preserves 

23 human dignity and assures continuity of care. 

24 ‘‘(B) Provide services in a mode of service 

25 delivery appropriate for the target population. 
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1 ‘‘(C) Provide individuals with a choice of 

2 service options where there is more than one ef3 ficacious treatment. 

4 ‘‘(D) Employ a core staff of clinical staff 

5 that is multidisciplinary and culturally and lin6 guistically competent. 

7 ‘‘(E) Provide services, within the limits of 

8 the capacities of the center, to any individual 

9 residing or employed in the service area of the 

10 center. 

11 ‘‘(F) Provide, directly or through contract, 

12 to the extent covered for adults in the State 

13 Medicaid plan and for children in accordance 

14 with section 1905(r) of the Social Security Act 

15 regarding early and periodic screening, diag16 nosis, and treatment, each of the following serv17 ices: 

18 ‘‘(i) Screening, assessment, and diag19 nosis, including risk assessment. 

20 ‘‘(ii) Person-centered treatment plan21 ning or similar processes, including risk as22 sessment and crisis planning. 

23 ‘‘(iii) Outpatient clinic mental health 

24 services, including screening, assessment, 

25 diagnosis, psychotherapy, substance abuse 
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1 counseling, medication management, and 

2 integrated treatment for mental illness and 

3 substance abuse which shall be evidence4 based (including cognitive behavioral ther5 apy, dialectical behavioral therapy, motiva6 tional interviewing, and other such thera7 pies which are evidence-based). 

8 ‘‘(iv) Outpatient clinic primary care 

9 services, including screening and moni10 toring of key health indicators and health 

11 risk (including screening for diabetes, hy12 pertension, and cardiovascular disease and 

13 monitoring of weight, height, body mass 

14 index (BMI), blood pressure, blood glucose 

15 or HbA1C, and lipid profile). 

16 ‘‘(v) Crisis mental health services, in17 cluding 24-hour mobile crisis teams, emer18 gency crisis intervention services, and cri19 sis stabilization. 

20 ‘‘(vi) Targeted case management 

21 (services to assist individuals gaining ac22 cess to needed medical, social, educational, 

23 and other services and applying for income 

24 security and other benefits to which they 

25 may be entitled). 
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1 ‘‘(vii) Psychiatric rehabilitation serv2 ices including skills training, assertive com3 munity treatment, family psychoeducation, 

4 disability self-management, supported em5 ployment, supported housing services, 

6 therapeutic foster care services, multisys7 temic therapy, and such other evidence8 based practices as the Secretary may re9 quire. 

10 ‘‘(viii) Peer support and counselor 

11 services and family supports. 

12 ‘‘(G) Maintain linkages, and where possible 

13 enter into formal contracts with, inpatient psy14 chiatric facilities and substance abuse detoxi15 fication and residential programs. 

16 ‘‘(H) Make available to individuals served 

17 by the center, directly, through contract, or 

18 through linkages with other programs, each of 

19 the following: 

20 ‘‘(i) Adult and youth peer support and 

21 counselor services. 

22 ‘‘(ii) Family support services for fami23 lies of children with serious mental dis24 orders. 
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1 ‘‘(iii) Other community or regional 

2 services, supports, and providers, including 

3 schools, child welfare agencies, juvenile and 

4 criminal justice agencies and facilities, 

5 housing agencies and programs, employers, 

6 and other social services. 

7 ‘‘(iv) Onsite or offsite access to pri8 mary care services. 

9 ‘‘(v) Enabling services, including out10 reach, transportation, and translation. 

11 ‘‘(vi) Health and wellness services, in12 cluding services for tobacco cessation.’’. 

13 PART 2—OTHER GRANT PROGRAMS 

14 SEC. 2521. COMPREHENSIVE PROGRAMS TO PROVIDE EDU15 CATION TO NURSES AND CREATE A PIPELINE 

16 TO NURSING. 

17 (a) PURPOSES.—It is the purpose of this section to 

18 authorize grants to— 

19 (1) address the projected shortage of nurses by 

20 funding comprehensive programs to create a career 

21 ladder to nursing (including certified nurse assist22 ants, licensed practical nurses, licensed vocational 

23 nurses, and registered nurses) for incumbent ancil24 lary health care workers; 
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1 (2) increase the capacity for educating nurses 

2 by increasing both nurse faculty and clinical oppor3 tunities through collaborative programs between 

4 staff nurse organizations, health care providers, and 

5 accredited schools of nursing; and 

6 (3) provide training programs through edu7 cation and training organizations jointly adminis8 tered by health care providers and health care labor 

9 organizations or other organizations representing 

10 staff nurses and frontline health care workers, work11 ing in collaboration with accredited schools of nurs12 ing and academic institutions. 

13 (b) GRANTS.—Not later than 6 months after the date 

14 of the enactment of this Act, the Secretary of Labor (re15 ferred to in this section as the ‘‘Secretary’’) shall establish 

16 a partnership grant program to award grants to eligible 

17 entities to carry out comprehensive programs to provide 

18 education to nurses and create a pipeline to nursing for 

19 incumbent ancillary health care workers who wish to ad20 vance their careers, and to otherwise carry out the pur21 poses of this section. 

22 (c) ELIGIBILITY.—To be eligible for a grant under 

23 this section, an entity shall be— 

24 (1) a health care entity that is jointly adminis25 tered by a health care employer and a labor union 
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1 representing the health care employees of the em2 ployer and that carries out activities using labor3 management training funds as provided for under 

4 section 302(c)(6) of the Labor Management Rela5 tions Act, 1947 (29 U.S.C. 186(c)(6)); 

6 (2) an entity that operates a training program 

7 that is jointly administered by— 

8 (A) one or more health care providers or 

9 facilities, or a trade association of health care 

10 providers; and 

11 (B) one or more organizations which rep12 resent the interests of direct care health care 

13 workers or staff nurses and in which the direct 

14 care health care workers or staff nurses have 

15 direct input as to the leadership of the organi16 zation; 

17 (3) a State training partnership program that 

18 consists of nonprofit organizations that include equal 

19 participation from industry, including public or pri20 vate employers, and labor organizations including 

21 joint labor-management training programs, and 

22 which may include representatives from local govern23 ments, worker investment agency one-stop career 

24 centers, community-based organizations, community 

25 colleges, and accredited schools of nursing; or 
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1 (4) a school of nursing (as defined in section 

2 801 of the Public Health Service Act (42 U.S.C. 

3 296)). 

4 (d) ADDITIONAL REQUIREMENTS FOR HEALTH CARE

5 EMPLOYER DESCRIBED IN SUBSECTION (c).—To be eligi6 ble for a grant under this section, a health care employer 

7 described in subsection (c) shall demonstrate that it— 

8 (1) has an established program within its facil9 ity to encourage the retention of existing nurses; 

10 (2) provides wages and benefits to its nurses 

11 that are competitive for its market or that have been 

12 collectively bargained with a labor organization; and 

13 (3) supports programs funded under this sec14 tion through 1 or more of the following: 

15 (A) The provision of paid leave time and 

16 continued health coverage to incumbent health 

17 care workers to allow their participation in 

18 nursing career ladder programs, including cer19 tified nurse assistants, licensed practical nurses, 

20 licensed vocational nurses, and registered 

21 nurses. 

22 (B) Contributions to a joint labor-manage23 ment training fund which administers the pro24 gram involved. 
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1 (C) The provision of paid release time, in2 centive compensation, or continued health cov3 erage to staff nurses who desire to work full- or 

4 part-time in a faculty position. 

5 (D) The provision of paid release time for 

6 staff nurses to enable them to obtain a bachelor 

7 of science in nursing degree, other advanced 

8 nursing degrees, specialty training, or certifi9 cation program. 

10 (E) The payment of tuition assistance 

11 which is managed by a joint labor-management 

12 training fund or other jointly administered pro13 gram. 

14 (e) OTHER REQUIREMENTS.— 

15 (1) MATCHING REQUIREMENT.— 

16 (A) IN GENERAL.—The Secretary may not 

17 make a grant under this section unless the ap18 plicant involved agrees, with respect to the costs 

19 to be incurred by the applicant in carrying out 

20 the program under the grant, to make available 

21 non-Federal contributions (in cash or in kind 

22 under subparagraph (B)) toward such costs in 

23 an amount equal to not less than $1 for each 

24 $1 of Federal funds provided in the grant. Such 

25 contributions may be made directly or through 
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1 donations from public or private entities, or 

2 may be provided through the cash equivalent of 

3 paid release time provided to incumbent worker 

4 students. 

5 (B) DETERMINATION OF AMOUNT OF NON6 FEDERAL CONTRIBUTION.—Non-Federal con7 tributions required in subparagraph (A) may be 

8 in cash or in kind (including paid release time), 

9 fairly evaluated, including equipment or services 

10 (and excluding indirect or overhead costs). 

11 Amounts provided by the Federal Government, 

12 or services assisted or subsidized to any signifi13 cant extent by the Federal Government, may 

14 not be included in determining the amount of 

15 such non-Federal contributions. 

16 (2) REQUIRED COLLABORATION.—Entities car17 rying out or overseeing programs carried out with 

18 assistance provided under this section shall dem19 onstrate collaboration with accredited schools of 

20 nursing which may include community colleges and 

21 other academic institutions providing associate’s, 

22 bachelor’s, or advanced nursing degree programs or 

23 specialty training or certification programs. 
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1 (f) USE OF FUNDS.—Amounts awarded to an entity 

2 under a grant under this section shall be used for the fol3 lowing: 

4 (1) To carry out programs that provide edu5 cation and training to establish nursing career lad6 ders to educate incumbent health care workers to be7 come nurses (including certified nurse assistants, li8 censed practical nurses, licensed vocational nurses, 

9 and registered nurses). Such programs shall include 

10 one or more of the following: 

11 (A) Preparing incumbent workers to return 

12 to the classroom through English-as-a-second13 language education, GED education, precollege 

14 counseling, college preparation classes, and sup15 port with entry level college classes that are a 

16 prerequisite to nursing. 

17 (B) Providing tuition assistance with pref18 erence for dedicated cohort classes in commu19 nity colleges, universities, and accredited 

20 schools of nursing with supportive services in21 cluding tutoring and counseling. 

22 (C) Providing assistance in preparing for 

23 and meeting all nursing licensure tests and re24 quirements. 
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1 (D) Carrying out orientation and 

2 mentorship programs that assist newly grad3 uated nurses in adjusting to working at the 

4 bedside to ensure their retention 

5 postgraduation, and ongoing programs to sup6 port nurse retention. 

7 (E) Providing stipends for release time and 

8 continued health care coverage to enable incum9 bent health care workers to participate in these 

10 programs. 

11 (2) To carry out programs that assist nurses in 

12 obtaining advanced degrees and completing specialty 

13 training or certification programs and to establish 

14 incentives for nurses to assume nurse faculty posi15 tions on a part-time or full-time basis. Such pro16 grams shall include one or more of the following: 

17 (A) Increasing the pool of nurses with ad18 vanced degrees who are interested in teaching 

19 by funding programs that enable incumbent 

20 nurses to return to school. 

21 (B) Establishing incentives for advanced 

22 degree bedside nurses who wish to teach in 

23 nursing programs so they can obtain a leave 

24 from their bedside position to assume a full- or 
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1 part-time position as adjunct or full-time fac2 ulty without the loss of salary or benefits. 

3 (C) Collaboration with accredited schools 

4 of nursing which may include community col5 leges and other academic institutions providing 

6 associate’s, bachelor’s, or advanced nursing de7 gree programs, or specialty training or certifi8 cation programs, for nurses to carry out innova9 tive nursing programs which meet the needs of 

10 bedside nursing and health care providers. 

11 (g) PREFERENCE.—In awarding grants under this 

12 section the Secretary shall give preference to programs 

13 that— 

14 (1) provide for improving nurse retention; 

15 (2) provide for improving the diversity of the 

16 new nurse graduates to reflect changes in the demo17 graphics of the patient population; 

18 (3) provide for improving the quality of nursing 

19 education to improve patient care and safety; 

20 (4) have demonstrated success in upgrading in21 cumbent health care workers to become nurses or 

22 which have established effective programs or pilots 

23 to increase nurse faculty; or 

24 (5) are modeled after or affiliated with such 

25 programs described in paragraph (4). 
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1 (h) EVALUATION.— 

2 (1) PROGRAM EVALUATIONS.—An entity that 

3 receives a grant under this section shall annually 

4 evaluate, and submit to the Secretary a report on, 

5 the activities carried out under the grant and the 

6 outcomes of such activities. Such outcomes may in7 clude— 

8 (A) an increased number of incumbent 

9 workers entering an accredited school of nurs10 ing and in the pipeline for nursing programs; 

11 (B) an increasing number of graduating 

12 nurses and improved nurse graduation and li13 censure rates; 

14 (C) improved nurse retention; 

15 (D) an increase in the number of staff 

16 nurses at the health care facility involved; 

17 (E) an increase in the number of nurses 

18 with advanced degrees in nursing; 

19 (F) an increase in the number of nurse 

20 faculty; 

21 (G) improved measures of patient quality 

22 (which may include staffing ratios of nurses, 

23 patient satisfaction rates, and patient safety 

24 measures); and 
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1 (H) an increase in the diversity of new 

2 nurse graduates relative to the patient popu3 lation. 

4 (2) GENERAL REPORT.—Not later than 2 years 

5 after the date of the enactment of this Act, and an6 nually thereafter, the Secretary of Labor shall, using 

7 data and information from the reports received 

8 under paragraph (1), submit to the Congress a re9 port concerning the overall effectiveness of the grant 

10 program carried out under this section. 

11 (i) AUTHORIZATION OF APPROPRIATIONS.—There 

12 are authorized to be appropriated to carry out this section 

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

14 2011 through 2015. 

15 SEC. 2522. MENTAL AND BEHAVIORAL HEALTH TRAINING. 

16 Part E of title VII (42 U.S.C. 294n et seq.) is amend17 ed by adding at the end the following: 

18 ‘‘Subpart 3—Mental and Behavioral Health Training 

19 ‘‘SEC. 775. MENTAL AND BEHAVIORAL HEALTH TRAINING 

20 PROGRAM. 

21 ‘‘(a) PROGRAM.—The Secretary, acting through the 

22 Administrator of the Health Resources and Services Ad23 ministration and in consultation with the Administrator 

24 of the Substance Abuse and Mental Health Services Ad25 ministration, shall establish an interdisciplinary mental 
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1 and behavioral health training program consisting of 

2 awarding grants and contracts under subsection (b). 

3 ‘‘(b) SUPPORT AND DEVELOPMENT OF MENTAL AND

4 BEHAVIORAL HEALTH TRAINING PROGRAMS.—The Sec5 retary shall make grants to, or enter into contracts with, 

6 eligible entities— 

7 ‘‘(1) to plan, develop, operate, or participate in 

8 an accredited professional training program for men9 tal and behavioral health professionals to promote— 

10 ‘‘(A) interdisciplinary training; and 

11 ‘‘(B) coordination of the delivery of health 

12 care within and across settings, including health 

13 care institutions, community-based settings, 

14 and the patient’s home; 

15 ‘‘(2) to provide financial assistance to mental 

16 and behavioral health professionals, who are partici17 pants in any such program, and who plan to work 

18 in the field of mental and behavioral health; 

19 ‘‘(3) to plan, develop, operate, or participate in 

20 an accredited program for the training of mental 

21 and behavioral health professionals who plan to 

22 teach in the field of mental and behavioral health; 

23 and 

24 ‘‘(4) to provide financial assistance in the form 

25 of traineeships and fellowships to mental and behav-
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1 ioral health professionals who are participants in any 

2 such program and who plan to teach in the field of 

3 mental and behavioral health. 

4 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con5 tract under subsection (b), an entity shall be— 

6 ‘‘(1) an accredited health professions school, in7 cluding an accredited school or program of psy8 chology, psychiatry, social work, marriage and family 

9 therapy, professional mental health or substance 

10 abuse counseling, or addiction medicine; 

11 ‘‘(2) an accredited public or nonprofit private 

12 hospital; 

13 ‘‘(3) a public or private nonprofit entity; or 

14 ‘‘(4) a consortium of 2 or more entities de15 scribed in paragraphs (1) through (3). 

16 ‘‘(d) PREFERENCE.—In awarding grants or contracts 

17 under this section, the Secretary shall give preference to 

18 entities that have a demonstrated record of at least one 

19 of the following: 

20 ‘‘(1) Training a high or significantly improved 

21 percentage of health professionals who serve in un22 derserved communities. 

23 ‘‘(2) Supporting teaching programs that ad24 dress the health care needs of vulnerable popu25 lations. 
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1 ‘‘(3) Training individuals who are from dis2 advantaged backgrounds (including racial and ethnic 

3 minorities underrepresented among mental and be4 havioral health professionals). 

5 ‘‘(4) Training individuals who serve geriatric 

6 populations with an emphasis on underserved elder7 ly. 

8 ‘‘(5) Training individuals who serve pediatric 

9 populations with an emphasis on underserved chil10 dren. 

11 ‘‘(e) REPORT.—The Secretary shall submit to the 

12 Congress an annual report on the program under this sec13 tion. 

14 ‘‘(f) DEFINITION.—In this section: 

15 ‘‘(1) The term ‘interdisciplinary’ means collabo16 ration across health professions, specialties, and sub17 specialties, which may include public health, nursing, 

18 allied health, dietetics or nutrition, and appropriate 

19 health specialties. 

20 ‘‘(2) The term ‘mental and behavioral health 

21 professional’ means an individual training or prac22 ticing— 

23 ‘‘(A) in psychology; general, geriatric, child 

24 or adolescent psychiatry; social work; marriage 

25 and family therapy; professional mental health 
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1 or substance abuse counseling; or addiction 

2 medicine; or 

3 ‘‘(B) another mental and behavioral health 

4 specialty, as deemed appropriate by the Sec5 retary. 

6 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.—To 

7 carry out this section, there is authorized to be appro8 priated $60,000,000 for each of fiscal years 2011 through 

9 2015. Of the amounts appropriated to carry out this sec10 tion for a fiscal year, not less than 15 percent shall be 

11 used for training programs in psychology.’’. 

12 SEC. 2523. REAUTHORIZATION OF TELEHEALTH AND TELE13 MEDICINE GRANT PROGRAMS. 

14 (a) TELEHEALTH NETWORK AND TELEHEALTH RE15 SOURCE CENTERS GRANT PROGRAMS.—Section 330I (42 

16 U.S.C. 254c–14) is amended— 

17 (1) in subsection (a)— 

18 (A) by striking paragraph (3) (relating to 

19 frontier communities); and 

20 (B) by inserting after paragraph (2) the 

21 following: 

22 ‘‘(3) HEALTH DISPARITIES.—The term ‘health 

23 disparities’ has the meaning given such term in sec24 tion 3171.’’; 

25 (2) in subsection (d)(1)— 
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1 (A) in subparagraph (B), by striking 

2 ‘‘and’’ at the end; 

3 (B) in subparagraph (C), by striking the 

4 period at the end and inserting ‘‘; and’’; and 

5 (C) by adding at the end the following: 

6 ‘‘(D) reduce health disparities.’’; 

7 (3) in subsection (f)(1)(B)(iii)— 

8 (A) in subclause (VII), by inserting ‘‘, in9 cluding skilled nursing facilities’’ before the pe10 riod at the end; 

11 (B) in subclause (IX), by inserting ‘‘, in12 cluding county mental health and public mental 

13 health facilities’’ before the period at the end; 

14 and 

15 (C) by adding at the end the following: 

16 ‘‘(XIII) Renal dialysis facilities.’’; 

17 (4) by amending subsection (i) to read as fol18 lows: 

19 ‘‘(i) PREFERENCES.— 

20 ‘‘(1) TELEHEALTH NETWORKS.—In awarding 

21 grants under subsection (d)(1) for projects involving 

22 telehealth networks, the Secretary shall give pref23 erence to eligible entities meeting at least one of the 

24 following: 
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1 ‘‘(A) NETWORK.—The eligible entity is a 

2 health care provider in, or proposing to form, a 

3 health care network that furnishes services in a 

4 medically underserved area or a health profes5 sional shortage area. 

6 ‘‘(B) BROAD GEOGRAPHIC COVERAGE.— 

7 The eligible entity demonstrates broad geo8 graphic coverage in the rural or medically un9 derserved areas of the State or States in which 

10 the entity is located. 

11 ‘‘(C) HEALTH DISPARITIES.—The eligible 

12 entity demonstrates how the project to be fund13 ed through the grant will address health dis14 parities. 

15 ‘‘(D) LINKAGES.—The eligible entity 

16 agrees to use the grant to establish or develop 

17 plans for telehealth systems that will link rural 

18 hospitals and rural health care providers to 

19 other hospitals, health care providers, and pa20 tients. 

21 ‘‘(E) EFFICIENCY.—The eligible entity 

22 agrees to use the grant to promote greater effi23 ciency in the use of health care resources. 
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1 ‘‘(F) VIABILITY.—The eligible entity dem2 onstrates the long-term viability of projects 

3 through— 

4 ‘‘(i) availability of non-Federal fund5 ing sources; or 

6 ‘‘(ii) institutional and community sup7 port for the telehealth network. 

8 ‘‘(G) SERVICES.—The eligible entity pro9 vides a plan for coordinating system use by eli10 gible entities and prioritizes use of grant funds 

11 for health care services over nonclinical uses. 

12 ‘‘(2) TELEHEALTH RESOURCE CENTERS.—In 

13 awarding grants under subsection (d)(2) for projects 

14 involving telehealth resource centers, the Secretary 

15 shall give preference to eligible entities meeting at 

16 least one of the following: 

17 ‘‘(A) PROVISION OF A BROAD RANGE OF

18 SERVICES.—The eligible entity has a record of 

19 success in the provision of a broad range of 

20 telehealth services to medically underserved 

21 areas or populations. 

22 ‘‘(B) PROVISION OF TELEHEALTH TECH23 NICAL ASSISTANCE.—The eligible entity has a 

24 record of success in the provision of technical 

25 assistance to providers serving medically under-
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1 served communities or populations in the estab2 lishment and implementation of telehealth serv3 ices. 

4 ‘‘(C) COLLABORATION AND SHARING OF

5 EXPERTISE.—The eligible entity has a dem6 onstrated record of collaborating and sharing 

7 expertise with providers of telehealth services at 

8 the national, regional, State, and local levels.’’; 

9 (5) in subsection (j)(2)(B), by striking ‘‘such 

10 projects for fiscal year 2001’’ and all that follows 

11 through the period and inserting ‘‘such projects for 

12 fiscal year 2010.’’; 

13 (6) in subsection (k)(1)— 

14 (A) in subparagraph (E)(i), by striking 

15 ‘‘transmission of medical data’’ and inserting 

16 ‘‘transmission and electronic archival of medical 

17 data’’; and 

18 (B) by amending subparagraph (F) to read 

19 as follows: 

20 ‘‘(F) developing projects to use telehealth 

21 technology to— 

22 ‘‘(i) facilitate collaboration between 

23 health care providers; 

24 ‘‘(ii) promote telenursing services; or 
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1 ‘‘(iii) promote patient understanding 

2 and adherence to national guidelines for 

3 chronic disease and self-management of 

4 such conditions;’’; 

5 (7) in subsection (q), by striking ‘‘Not later 

6 than September 30, 2005’’ and inserting ‘‘Not later 

7 than 1 year after the date of the enactment of the 

8 Affordable Health Care for America Act, and annu9 ally thereafter’’; 

10 (8) by striking subsection (r); 

11 (9) by redesignating subsection (s) as sub12 section (r); and 

13 (10) in subsection (r) (as so redesignated)— 

14 (A) in paragraph (1)— 

15 (i) by striking ‘‘and’’ before ‘‘such 

16 sums’’; and 

17 (ii) by inserting ‘‘, $10,000,000 for 

18 fiscal year 2011, and such sums as may be 

19 necessary for each of fiscal years 2012 

20 through 2015’’ before the semicolon; and 

21 (B) in paragraph (2)— 

22 (i) by striking ‘‘and’’ before ‘‘such 

23 sums’’; and 

24 (ii) by inserting ‘‘, $10,000,000 for 

25 fiscal year 2011, and such sums as may be 
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1 necessary for each of fiscal years 2012 

2 through 2015’’ before the period. 

3 (b) TELEMEDICINE; INCENTIVE GRANTS REGARDING

4 COORDINATION AMONG STATES.—Subsection (b) of sec5 tion 330L (42 U.S.C. 254c–18) is amended by inserting 

6 ‘‘, $10,000,000 for fiscal year 2011, and such sums as 

7 may be necessary for each of fiscal years 2012 through 

8 2015’’ before the period at the end. 

9 SEC. 2524. NO CHILD LEFT UNIMMUNIZED AGAINST INFLU10 ENZA: DEMONSTRATION PROGRAM USING EL11 EMENTARY AND SECONDARY SCHOOLS AS IN12 FLUENZA VACCINATION CENTERS. 

13 (a) PURPOSE.—The Secretary of Health and Human 

14 Services in consultation with the Secretary of Education, 

15 shall award grants to eligible partnerships to carry out 

16 demonstration programs designed to test the feasibility of 

17 using the Nation’s elementary schools and secondary 

18 schools as influenza vaccination centers. 

19 (b) IN GENERAL.—The Secretary shall coordinate 

20 with the Secretary of Labor, the Secretary of Education, 

21 State Medicaid agencies, State insurance agencies, and 

22 private insurers to carry out a program consisting of 

23 awarding grants under subsection (c) to ensure that chil24 dren have coverage for all reasonable and customary ex25 penses related to influenza vaccinations, including the 
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1 costs of purchasing and administering the vaccine in2 curred when influenza vaccine is administered outside of 

3 the physician’s office in a school or other related setting. 

4 (c) PROGRAM DESCRIPTION.— 

5 (1) GRANTS.—From amounts appropriated pur6 suant to subsection (l), the Secretary shall award 

7 grants to eligible partnerships to be used to provide 

8 influenza vaccinations to children in elementary and 

9 secondary schools, in coordination with school 

10 nurses, school health care programs, community 

11 health care providers, State insurance agencies, or 

12 private insurers. 

13 (2) ACIP RECOMMENDATIONS.—The program 

14 under this section shall be designed to administer 

15 vaccines consistent with the recommendations of the 

16 Centers for Disease Control and Prevention’s Advi17 sory Committee on Immunization Practices (ACIP) 

18 for the annual vaccination of all children 5 through 

19 19 years of age. 

20 (3) PARTICIPATION VOLUNTARY.—Participation 

21 by a school or an individual shall be voluntary. 

22 (d) USE OF FUNDS.—Eligible partnerships receiving 

23 a grant under this section shall ensure the maximum num24 ber of children access influenza vaccinations as follows: 
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1 (1) COVERED CHILDREN.—To the extent to 

2 which payment of the costs of purchasing or admin3 istering the influenza vaccine for children is not cov4 ered through other federally funded programs or 

5 through private insurance, eligible partnerships re6 ceiving a grant shall use funds to purchase and ad7 minister influenza vaccinations. 

8 (2) CHILDREN COVERED BY OTHER FEDERAL

9 PROGRAMS.—For children who are eligible under 

10 other federally funded programs for payment of the 

11 costs of purchasing or administering the influenza 

12 vaccine, eligible partnerships receiving a grant shall 

13 not use funds provided under this section for such 

14 costs. 

15 (3) CHILDREN COVERED BY PRIVATE HEALTH

16 INSURANCE.—For children who have private insur17 ance, eligible partnerships receiving a grant shall 

18 offer assistance in accessing coverage for vaccina19 tions administered through the program under this 

20 section. 

21 (e) PRIVACY.—The Secretary shall ensure that the 

22 program under this section adheres to confidentiality and 

23 privacy requirements of section 264 of the Health Insur24 ance Portability and Accountability Act of 1996 (42 

25 U.S.C. 1320d–2 note) and section 444 of the General 
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1 Education Provisions Act (20 U.S.C. 1232g; commonly re2 ferred to as the ‘‘Family Educational Rights and Privacy 

3 Act of 1974’’). 

4 (f) APPLICATION.—An eligible partnership desiring a 

5 grant under this section shall submit an application to the 

6 Secretary at such time, in such manner, and containing 

7 such information as the Secretary may require. 

8 (g) DURATION.—Eligible partnerships receiving a 

9 grant shall administer a demonstration program funded 

10 through this section over a period of 2 consecutive school 

11 years. 

12 (h) CHOICE OF VACCINE.—The program under this 

13 section shall not restrict the discretion of a health care 

14 provider to administer any influenza vaccine approved by 

15 the Food and Drug Administration for use in pediatric 

16 populations. 

17 (i) AWARDS.—The Secretary shall award— 

18 (1) a minimum of 10 grants in 10 different 

19 States to eligible partnerships that each include one 

20 or more public schools serving primarily low-income 

21 students; and 

22 (2) a minimum of 5 grants in 5 different States 

23 to eligible partnerships that each include one or 

24 more public schools located in a rural local edu25 cational agency. 
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1 (j) REPORT.—Not later than 90 days following the 

2 completion of the program under this section, the Sec3 retary shall submit to the Committees on Education and 

4 Labor, Energy and Commerce, and Appropriations of the 

5 House of Representatives and to the Committees on 

6 Health, Education, Labor, and Pensions and Appropria7 tions of the Senate a report on the results of the program. 

8 The report shall include— 

9 (1) an assessment of the influenza vaccination 

10 rates of school-age children in localities where the 

11 program is implemented, compared to the national 

12 average influenza vaccination rates for school-aged 

13 children, including whether school-based vaccination 

14 assists in achieving the recommendations of the Ad15 visory Committee on Immunization Practices; 

16 (2) an assessment of the utility of employing el17 ementary schools and secondary schools as a part of 

18 a multistate, community-based pandemic response 

19 program that is consistent with existing Federal and 

20 State pandemic response plans; 

21 (3) an assessment of the feasibility of using ex22 isting Federal and private insurance funding in es23 tablishing a multistate, school-based vaccination pro24 gram for seasonal influenza vaccination; 
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1 (4) an assessment of the number of education 

2 days gained by students as a result of seasonal vac3 cinations based on absenteeism rates; 

4 (5) a determination of whether the program 

5 under this section— 

6 (A) increased vaccination rates in the par7 ticipating localities; and 

8 (B) was implemented for sufficient time 

9 for gathering enough valid data; and 

10 (6) a recommendation on whether the program 

11 should be continued, expanded, or terminated. 

12 (k) DEFINITIONS.—In this section: 

13 (1) ELIGIBLE PARTNERSHIP.—The term ‘‘eligi14 ble partnership’’ means a local public health depart15 ment, or another health organization defined by the 

16 Secretary as eligible to submit an application, and 

17 one or more elementary and secondary schools. 

18 (2) ELEMENTARY SCHOOL.—The terms ‘‘ele19 mentary school’’ and ‘‘secondary school’’ have the 

20 meanings given such terms in section 9101 of the 

21 Elementary and Secondary Education Act of 1965 

22 (20 U.S.C. 7801). 

23 (3) LOW-INCOME.—The term ‘‘low-income’’ 

24 means a student, age 5 through 19, eligible for free 
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1 or reduced-price lunch under the National School 

2 Lunch Act (42 U.S.C. 1751 et seq.). 

3 (4) RURAL LOCAL EDUCATIONAL AGENCY.— 

4 The term ‘‘rural local educational agency’’ means an 

5 eligible local educational agency described in section 

6 6211(b)(1) of the Elementary and Secondary Edu7 cation Act of 1965 (20 U.S.C. 7345(b)(1)). 

8 (5) SECRETARY.—Except as otherwise speci9 fied, the term ‘‘Secretary’’ means the Secretary of 

10 Health and Human Services. 

11 (l) AUTHORIZATION OF APPROPRIATIONS.—To carry 

12 out this section, there are authorized to be appropriated 

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

14 2011 through 2015. 

15 SEC. 2525. EXTENSION OF WISEWOMAN PROGRAM. 

16 Section 1509 of the Public Health Service Act (42 

17 U.S.C. 300n–4a) is amended— 

18 (1) in subsection (a)— 

19 (A) by striking the heading and inserting 

20 ‘‘IN GENERAL.—’’; and 

21 (B) in the matter preceding paragraph (1), 

22 by striking ‘‘may make grants’’ and all that fol23 lows through ‘‘purpose’’ and inserting the fol24 lowing: ‘‘may make grants to such States for 

25 the purpose’’; and 
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1 (2) in subsection (d)(1), by striking ‘‘there are 

2 authorized’’ and all that follows through the period 

3 and inserting ‘‘there are authorized to be appro4 priated $70,000,000 for fiscal year 2011, 

5 $73,500,000 for fiscal year 2012, $77,000,000 for 

6 fiscal year 2013, $81,000,000 for fiscal year 2014, 

7 and $85,000,000 for fiscal year 2015.’’. 

8 SEC. 2526. HEALTHY TEEN INITIATIVE TO PREVENT TEEN 

9 PREGNANCY. 

10 Part B of title III (42 U.S.C. 243 et seq.) is amended 

11 by inserting after section 317T the following: 

12 ‘‘SEC. 317U. HEALTHY TEEN INITIATIVE TO PREVENT TEEN 

13 PREGNANCY. 

14 ‘‘(a) PROGRAM.—To the extent and in the amount 

15 of appropriations made in advance in appropriations Acts, 

16 the Secretary, acting through the Director of the Centers 

17 for Disease Control and Prevention, shall establish a pro18 gram consisting of making grants, in amounts determined 

19 under subsection (c), to each State that submits an appli20 cation in accordance with subsection (d) for an evidence21 based education program described in subsection (b). 

22 ‘‘(b) USE OF FUNDS.—Amounts received by a State 

23 under this section shall be used to conduct or support evi24 dence-based education programs (directly or through 

25 grants or contracts to public or private nonprofit entities, 
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1 including schools and community-based and faith-based 

2 organizations) to reduce teen pregnancy or sexually trans3 mitted diseases. 

4 ‘‘(c) DISTRIBUTION OF FUNDS.—The Director shall, 

5 for fiscal year 2011 and each subsequent fiscal year, make 

6 a grant to each State described in subsection (a) in an 

7 amount equal to the product of— 

8 ‘‘(1) the amount appropriated to carry out this 

9 section for the fiscal year; and 

10 ‘‘(2) the percentage determined for the State 

11 under section 502(c)(1)(B)(ii) of the Social Security 

12 Act. 

13 ‘‘(d) APPLICATION.—To seek a grant under this sec14 tion, a State shall submit an application at such time, in 

15 such manner, and containing such information and assur16 ance of compliance with this section as the Secretary may 

17 require. At a minimum, an application shall to the satis18 faction of the Secretary— 

19 ‘‘(1) describe how the State’s proposal will ad20 dress the needs of at-risk teens in the State; 

21 ‘‘(2) identify the evidence-based education pro22 gram or programs selected from the registry devel23 oped under subsection (g) that will be used to ad24 dress risks in priority populations; 
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1 ‘‘(3) describe how the program or programs will 

2 be implemented and any adaptations to the evidence3 based model that will be made; 

4 ‘‘(4) list any private and public entities with 

5 whom the State proposes to work, including schools 

6 and community-based and faith-based organizations, 

7 and demonstrate their capacity to implement the 

8 proposed program or programs; and 

9 ‘‘(5) identify an independent entity that will 

10 evaluate the impact of the program or programs. 

11 ‘‘(e) EVALUATION.— 

12 ‘‘(1) REQUIREMENT.—As a condition on receipt 

13 of a grant under this section, a State shall agree— 

14 ‘‘(A) to arrange for an independent evalua15 tion of the impact of the programs to be con16 ducted or supported through the grant; and 

17 ‘‘(B) submit reports to the Secretary on 

18 such programs and the results of evaluation of 

19 such programs. 

20 ‘‘(2) FUNDING LIMITATION.—Of the amounts 

21 made available to a State through a grant under this 

22 section for any fiscal year, not more than 10 percent 

23 may be used for such evaluation. 

24 ‘‘(f) RULE OF CONSTRUCTION.—This section shall 

25 not be construed to preempt or limit any State law regard-
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1 ing parental involvement and decisionmaking in children’s 

2 education. 

3 ‘‘(g) REGISTRY OF ELIGIBLE PROGRAMS.—The Sec4 retary shall develop not later than 180 days after the date 

5 of the enactment of the Affordable Health Care for Amer6 ica Act, and periodically update thereafter, a publicly 

7 available registry of programs described in subsection (b) 

8 that, as determined by the Secretary— 

9 ‘‘(1) meet the definition of the term ‘evidence10 based’ in subsection (i); 

11 ‘‘(2) are medically and scientifically accurate; 

12 and 

13 ‘‘(3) provide age-appropriate information. 

14 ‘‘(h) MATCHING FUNDS.—The Secretary may award 

15 a grant to a State under this section for a fiscal year only 

16 if the State agrees to provide, from non-Federal sources, 

17 an amount equal to $1 (in cash or in kind) for each $4 

18 provided through the grant to carry out the activities sup19 ported by the grant. 

20 ‘‘(i) DEFINITION.—In this section, the term ‘evi21 dence-based’ means based on a model that has been found, 

22 in methodologically sound research— 

23 ‘‘(1) to delay initiation of sex; 

24 ‘‘(2) to decrease number of partners; 

25 ‘‘(3) to reduce teen pregnancy; 
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1 ‘‘(4) to reduce sexually transmitted infection 

2 rates; or 

3 ‘‘(5) to improve rates of contraceptive use. 

4 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.—To 

5 carry out this section, there is authorized to be appro6 priated $50,000,000 for each of fiscal years 2011 through 

7 2015.’’. 

8 SEC. 2527. NATIONAL TRAINING INITIATIVES ON AUTISM 

9 SPECTRUM DISORDERS. 

10 Title I of the Developmental Disabilities Assistance 

11 and Bill of Rights Act of 2000 (42 U.S.C. 15001 et seq.) 

12 is amended by adding at the end the following: 

13 ‘‘Subtitle F—National Training Ini14 tiative on Autism Spectrum Dis15 orders 

16 ‘‘SEC. 171. NATIONAL TRAINING INITIATIVE. 

17 ‘‘(a) GRANTS AND TECHNICAL ASSISTANCE.— 

18 ‘‘(1) GRANTS.— 

19 ‘‘(A) IN GENERAL.—The Secretary, in con20 sultation with the Interagency Autism Coordi21 nating Committee, shall award multiyear grants 

22 to eligible entities to provide individuals (includ23 ing parents and health, allied health, vocational, 

24 and educational professionals) with interdiscipli25 nary training, continuing education, technical 
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1 assistance, and information for the purpose of 

2 improving services rendered to children and 

3 adults with autism, and their families, to ad4 dress unmet needs related to autism. 

5 ‘‘(B) ELIGIBLE ENTITY.—To be eligible to 

6 receive a grant under this subsection, an entity 

7 shall be— 

8 ‘‘(i) a University Center for Excel9 lence in Developmental Disabilities Edu10 cation, Research, and Service; or 

11 ‘‘(ii) a comparable interdisciplinary 

12 education, research, and service entity. 

13 ‘‘(C) APPLICATION REQUIREMENTS.—An 

14 entity that desires to receive a grant for a pro15 gram under this paragraph shall submit to the 

16 Secretary an application— 

17 ‘‘(i) demonstrating that the entity has 

18 capacity to— 

19 ‘‘(I) provide training and tech20 nical assistance in evidence-based 

21 practices to evaluate, and provide ef22 fective interventions, services, treat23 ments, and supports to, children and 

24 adults with autism and their families; 
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1 ‘‘(II) include individuals with au2 tism and their families as part of the 

3 program to ensure that an individual4 and family-centered approach is used; 

5 ‘‘(III) share and disseminate ma6 terials and practices that are devel7 oped for, and evaluated to be effective 

8 in, the provision of training and tech9 nical assistance; and 

10 ‘‘(IV) provide training, technical 

11 assistance, interventions, services, 

12 treatments, and supports under this 

13 subsection statewide. 

14 ‘‘(ii) providing assurances that the en15 tity will— 

16 ‘‘(I) provide trainees under this 

17 subsection with an appropriate bal18 ance of interdisciplinary academic and 

19 community-based experiences; and 

20 ‘‘(II) provide to the Secretary, in 

21 the manner prescribed by the Sec22 retary, data regarding the number of 

23 individuals who have benefitted from, 

24 and outcomes of, the provision of 
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1 training and technical assistance 

2 under this subsection; 

3 ‘‘(iii) providing assurances that train4 ing, technical assistance, dissemination of 

5 information, and services under this sub6 section will be— 

7 ‘‘(I) consistent with the goals of 

8 this Act, the Americans with Disabil9 ities Act of 1990, the Individuals with 

10 Disabilities Education Act, and the 

11 Elementary and Secondary Education 

12 Act of 1965; and 

13 ‘‘(II) conducted in coordination 

14 with relevant State agencies, institu15 tions of higher education, and service 

16 providers; and 

17 ‘‘(iv) containing such other informa18 tion and assurances as the Secretary may 

19 require. 

20 ‘‘(D) USE OF FUNDS.—A grant received 

21 under this subsection shall be used to provide 

22 individuals (including parents and health, allied 

23 health, vocational, and educational profes24 sionals) with interdisciplinary training, con25 tinuing education, technical assistance, and in-
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1 formation for the purpose of improving services 

2 rendered to children and adults with autism, 

3 and their families, to address unmet needs re4 lated to autism. Such training, education, as5 sistance, and information shall include each of 

6 the following: 

7 ‘‘(i) Training health, allied health, vo8 cational, and educational professionals to 

9 identify, evaluate the needs of, and develop 

10 interventions, services, treatments, and 

11 supports for, children and adults with au12 tism. 

13 ‘‘(ii) Developing model services and 

14 supports that demonstrate evidence-based 

15 practices. 

16 ‘‘(iii) Developing systems and prod17 ucts that allow for the interventions, serv18 ices, treatments, and supports to be evalu19 ated for fidelity of implementation. 

20 ‘‘(iv) Working to expand the avail21 ability of evidence-based, lifelong interven22 tions; educational, employment, and transi23 tion services; and community supports. 

24 ‘‘(v) Providing statewide technical as25 sistance in collaboration with relevant 
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1 State agencies, institutions of higher edu2 cation, autism advocacy groups, and com3 munity-based service providers. 

4 ‘‘(vi) Working to develop comprehen5 sive systems of supports and services for 

6 individuals with autism and their families, 

7 including seamless transitions between 

8 education and health systems across the 

9 lifespan. 

10 ‘‘(vii) Promoting training, technical 

11 assistance, dissemination of information, 

12 supports, and services. 

13 ‘‘(viii) Developing mechanisms to pro14 vide training and technical assistance, in15 cluding for-credit courses, intensive sum16 mer institutes, continuing education pro17 grams, distance based programs, and Web18 based information dissemination strategies. 

19 ‘‘(ix) Promoting activities that sup20 port community-based family and indi21 vidual services and enable individuals with 

22 autism and related developmental disabil23 ities to fully participate in society and 

24 achieve good quality-of-life outcomes. 
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1 ‘‘(x) Collecting data on the outcomes 

2 of training and technical assistance pro3 grams to meet statewide needs for the ex4 pansion of services to children and adults 

5 with autism. 

6 ‘‘(E) AMOUNT OF GRANTS.—The amount 

7 of a grant to any entity for a fiscal year under 

8 this section shall be not less than $250,000. 

9 ‘‘(2) TECHNICAL ASSISTANCE.—The Secretary 

10 shall reserve 2 percent of the amount appropriated 

11 to carry out this subsection for a fiscal year to make 

12 a grant to a national organization with dem13 onstrated capacity for providing training and tech14 nical assistance to— 

15 ‘‘(A) assist in national dissemination of 

16 specific information, including evidence-based 

17 best practices, from interdisciplinary training 

18 programs, and when appropriate, other entities 

19 whose findings would inform the work per20 formed by entities awarded grants; 

21 ‘‘(B) compile and disseminate strategies 

22 and materials that prove to be effective in the 

23 provision of training and technical assistance so 

24 that the entire network can benefit from the 
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1 models, materials, and practices developed in 

2 individual centers; 

3 ‘‘(C) assist in the coordination of activities 

4 of grantees under this subsection; 

5 ‘‘(D) develop a Web portal that will pro6 vide linkages to each of the individual training 

7 initiatives and provide access to training mod8 ules, promising training, and technical assist9 ance practices and other materials developed by 

10 grantees; 

11 ‘‘(E) serve as a research-based resource for 

12 Federal and State policymakers on information 

13 concerning the provision of training and tech14 nical assistance for the assessment, and provi15 sion of supports and services for, children and 

16 adults with autism; 

17 ‘‘(F) convene experts from multiple inter18 disciplinary training programs, individuals with 

19 autism, and the families of such individuals to 

20 discuss and make recommendations with regard 

21 to training issues related to assessment, inter22 ventions, services, treatment, and supports for 

23 children and adults with autism; and 

24 ‘‘(H) undertake any other functions that 

25 the Secretary determines to be appropriate. 
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1 ‘‘(3) AUTHORIZATION OF APPROPRIATIONS.— 

2 To carry out this subsection, there are authorized to 

3 be appropriated $17,000,000 for fiscal year 2011 

4 and such sums as may be necessary for each of fis5 cal years 2012 through 2015. 

6 ‘‘(b) EXPANSION OF THE NUMBER OF UNIVERSITY

7 CENTERS FOR EXCELLENCE IN DEVELOPMENTAL DIS8 ABILITIES EDUCATION, RESEARCH, AND SERVICE.— 

9 ‘‘(1) GRANTS.—To provide for the establish10 ment of up to 4 new University Centers for Excel11 lence in Developmental Disabilities Education, Re12 search, and Service, the Secretary shall award up to 

13 4 grants to institutions of higher education. 

14 ‘‘(2) APPLICABLE PROVISIONS.—Except for 

15 subsection (a)(3), the provisions of subsection (a) 

16 shall apply with respect to grants under this sub17 section to the same extent and in the same manner 

18 as such provisions apply with respect to grants 

19 under subsection (a). 

20 ‘‘(3) PRIORITY.—In awarding grants under this 

21 subsection, the Secretary shall give priority to appli22 cants that— 

23 ‘‘(A) are minority institutions that have 

24 demonstrated capacity to meet the requirements 
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1 of this section and provide services to individ2 uals with autism and their families; or 

3 ‘‘(B) are located in a State with one or 

4 more underserved populations. 

5 ‘‘(4) AUTHORIZATION OF APPROPRIATIONS.— 

6 To carry out this subsection, there is authorized to 

7 be appropriated $2,000,000 for each of fiscal years 

8 2011 through 2015. 

9 ‘‘(c) DEFINITIONS.—In this section: 

10 ‘‘(1) The term ‘autism’ means an autism spec11 trum disorder or a related developmental disability. 

12 ‘‘(2) The term ‘interventions’ means edu13 cational methods and positive behavioral support 

14 strategies designed to improve or ameliorate symp15 toms associated with autism. 

16 ‘‘(3) The term ‘minority institution’ has the 

17 meaning given to such term in section 365 of the 

18 Higher Education Act of 1965. 

19 ‘‘(4) The term ‘services’ means services to as20 sist individuals with autism to live more independ21 ently in their communities. 

22 ‘‘(5) The term ‘treatments’ means health serv23 ices, including mental health services, designed to 

24 improve or ameliorate symptoms associated with au25 tism. 
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1 ‘‘(6) The term ‘University Center for Excellence 

2 in Developmental Disabilities Education, Research, 

3 and Service’ means a University Center for Excel4 lence in Development Disabilities Education, Re5 search, and Service that has been or is funded 

6 through subtitle D or subsection (b).’’. 

7 SEC. 2528. IMPLEMENTATION OF MEDICATION MANAGE8 MENT SERVICES IN TREATMENT OF CHRONIC 

9 DISEASES. 

10 (a) IN GENERAL.—The Secretary of Health and 

11 Human Services (referred to in this section as the ‘‘Sec12 retary’’), acting through the Director of the Agency for 

13 Health Care Research and Quality, shall establish a pro14 gram to provide grants to eligible entities to implement 

15 medication management services (referred to in this sec16 tion as ‘‘MTM services’’) provided by licensed phar17 macists, as a part of a collaborative, multidisciplinary, 

18 interprofessional approach to the treatment of chronic dis19 eases for targeted individuals, to improve the quality of 

20 care and reduce overall cost in the treatment of such dis21 eases. The Secretary shall commence the grant program 

22 not later than May 1, 2011. 

23 (b) ELIGIBLE ENTITIES.—To be eligible to receive a 

24 grant under subsection (a), an entity shall— 
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1 (1) provide a setting appropriate for MTM serv2 ices, as recommended by the experts described in 

3 subsection (e); 

4 (2) submit to the Secretary a plan for achieving 

5 long-term financial sustainability; 

6 (3) where applicable, submit a plan for coordi7 nating MTM services with other local providers and 

8 where applicable, through or in collaboration with 

9 the Medicare Medical Home Pilot program as estab10 lished by section 1866F of the Social Security Act, 

11 as added by section 1302(a) of this Act; 

12 (4) submit a plan for meeting the requirements 

13 under subsection (c); and 

14 (5) submit to the Secretary such other informa15 tion as the Secretary may require. 

16 (c) MTM SERVICES TO TARGETED INDIVIDUALS.— 

17 The MTM services provided with the assistance of a grant 

18 awarded under subsection (a) shall, as allowed by State 

19 law (including applicable collaborative pharmacy practice 

20 agreements), include— 

21 (1) performing or obtaining necessary assess22 ments of the health and functional status of each 

23 patient receiving such MTM services; 

24 (2) formulating a medication treatment plan ac25 cording to therapeutic goals agreed upon by the pre-
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1 scriber and the patient or caregiver or authorized 

2 representative of the patient; 

3 (3) selecting, initiating, modifying, recom4 mending changes to, or administering medication 

5 therapy; 

6 (4) monitoring, which may include access to, or7 dering, or performing laboratory assessments, and 

8 evaluating the response of the patient to therapy, in9 cluding safety and effectiveness; 

10 (5) performing an initial comprehensive medica11 tion review to identify, resolve, and prevent medica12 tion-related problems, including adverse drug events, 

13 quarterly targeted medication reviews for ongoing 

14 monitoring, and additional followup interventions on 

15 a schedule developed collaboratively with the pre16 scriber; 

17 (6) documenting the care delivered and commu18 nicating essential information about such care (in19 cluding a summary of the medication review) and 

20 the recommendations of the pharmacist to other ap21 propriate health care providers of the patient in a 

22 timely fashion; 

23 (7) providing education and training designed 

24 to enhance the understanding and appropriate use of 
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1 the medications by the patient, caregiver, and other 

2 authorized representative; 

3 (8) providing information, support services, and 

4 resources and strategies designed to enhance patient 

5 adherence with therapeutic regimens; 

6 (9) coordinating and integrating MTM services 

7 within the broader health care management services 

8 provided to the patient; and 

9 (10) such other patient care services as are al10 lowed under the scopes of practice for pharmacists 

11 for purposes of other Federal programs. 

12 (d) TARGETED INDIVIDUALS.—MTM services pro13 vided by licensed pharmacists under a grant awarded 

14 under subsection (a) shall be offered to targeted individ15 uals who— 

16 (1) take 4 or more prescribed medications (in17 cluding over-the-counter and dietary supplements); 

18 (2) take any high-risk medications; 

19 (3) have 2 or more chronic diseases, as identi20 fied by the Secretary; or 

21 (4) have undergone a transition of care, or 

22 other factors, as determined by the Secretary, that 

23 are likely to create a high risk of medication-related 

24 problems. 
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1 (e) CONSULTATION WITH EXPERTS.—In designing 

2 and implementing MTM services provided under grants 

3 awarded under subsection (a), the Secretary shall consult 

4 with Federal, State, private, public-private, and academic 

5 entities, pharmacy and pharmacist organizations, health 

6 care organizations, consumer advocates, chronic disease 

7 groups, and other stakeholders involved with the research, 

8 dissemination, and implementation of pharmacist-deliv9 ered MTM services, as the Secretary determines appro10 priate. The Secretary, in collaboration with this group, 

11 shall determine whether it is possible to incorporate rapid 

12 cycle process improvement concepts in use in other Fed13 eral programs that have implemented MTM services. 

14 (f) REPORTING TO THE SECRETARY.—An entity that 

15 receives a grant under subsection (a) shall submit to the 

16 Secretary a report that describes and evaluates, as re17 quested by the Secretary, the activities carried out under 

18 subsection (c), including quality measures, as determined 

19 by the Secretary. 

20 (g) EVALUATION AND REPORT.—The Secretary shall 

21 submit to the relevant committees of Congress a report 

22 which shall— 

23 (1) assess the clinical effectiveness of phar24 macist-provided services under the MTM services 

25 program, as compared to usual care, including an 
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1 evaluation of whether enrollees maintained better 

2 health with fewer hospitalizations and emergency 

3 room visits than similar patients not enrolled in the 

4 program; 

5 (2) assess changes in overall health care re6 source of targeted individuals; 

7 (3) assess patient and prescriber satisfaction 

8 with MTM services; 

9 (4) assess the impact of patient-cost-sharing re10 quirements on medication adherence and rec11 ommendations for modifications; 

12 (5) identify and evaluate other factors that may 

13 impact clinical and economic outcomes, including de14 mographic characteristics, clinical characteristics, 

15 and health services use of the patient, as well as 

16 characteristics of the regimen, pharmacy benefit, 

17 and MTM services provided; and 

18 (6) evaluate the extent to which participating 

19 pharmacists who maintain a dispensing role have a 

20 conflict of interest in the provision of MTM services, 

21 and if such conflict is found, provide recommenda22 tions on how such a conflict might be appropriately 

23 addressed. 

24 (h) GRANT TO FUND DEVELOPMENT OF PERFORM25 ANCE MEASURES.—The Secretary may award grants or 
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1 contracts to eligible entities for the purpose of funding the 

2 development of performance measures that assess the use 

3 and effectiveness of medication therapy management serv4 ices. 

5 SEC. 2529. POSTPARTUM DEPRESSION. 

6 (a) EXPANSION AND INTENSIFICATION OF ACTIVI7 TIES.— 

8 (1) CONTINUATION OF ACTIVITIES.—The Sec9 retary is encouraged to expand and intensify activi10 ties on postpartum conditions. 

11 (2) PROGRAMS FOR POSTPARTUM CONDI12 TIONS.—In carrying out paragraph (1), the Sec13 retary is encouraged to continue research to expand 

14 the understanding of the causes of, and treatments 

15 for, postpartum conditions, including conducting and 

16 supporting the following: 

17 (A) Basic research concerning the etiology 

18 and causes of the conditions. 

19 (B) Epidemiological studies to address the 

20 frequency and natural history of the conditions 

21 and the differences among racial and ethnic 

22 groups with respect to the conditions. 

23 (C) The development of improved screen24 ing and diagnostic techniques. 
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1 (D) Clinical research for the development 

2 and evaluation of new treatments. 

3 (E) Information and education programs 

4 for health professionals and the public, which 

5 may include a coordinated national campaign 

6 that— 

7 (i) is designed to increase the aware8 ness and knowledge of postpartum condi9 tions; 

10 (ii) may include public service an11 nouncements through television, radio, and 

12 other means; and 

13 (iii) may focus on— 

14 (I) raising awareness about 

15 screening; 

16 (II) educating new mothers and 

17 their families about postpartum condi18 tions to promote earlier diagnosis and 

19 treatment; and 

20 (III) ensuring that such edu21 cation includes complete information 

22 concerning postpartum conditions, in23 cluding its symptoms, methods of cop24 ing with the illness, and treatment re25 sources. 
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1 (b) REPORT BY THE SECRETARY.— 

2 (1) STUDY.—The Secretary shall conduct a 

3 study on the benefits of screening for postpartum 

4 conditions. 

5 (2) REPORT.—Not later than 2 years after the 

6 date of the enactment of this Act, the Secretary 

7 shall complete the study required by paragraph (1) 

8 and submit a report to the Congress on the results 

9 of such study. 

10 (c) SENSE OF CONGRESS REGARDING LONGITU11 DINAL STUDY OF RELATIVE MENTAL HEALTH CON12 SEQUENCES FOR WOMEN OF RESOLVING A PREG13 NANCY.— 

14 (1) SENSE OF CONGRESS.—It is the sense of 

15 the Congress that the Director of the National Insti16 tute of Mental Health may conduct a nationally rep17 resentative longitudinal study (during the period of 

18 fiscal years 2011 through 2020) on the relative men19 tal health consequences for women of resolving a 

20 pregnancy (intended and unintended) in various 

21 ways, including carrying the pregnancy to term and 

22 parenting the child, carrying the pregnancy to term 

23 and placing the child for adoption, miscarriage, and 

24 having an abortion. This study may assess the inci25 dence, timing, magnitude, and duration of the imme-
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1 diate and long-term mental health consequences 

2 (positive or negative) of these pregnancy outcomes. 

3 (2) REPORT.—Beginning not later than 3 years 

4 after the date of the enactment of this Act, and peri5 odically thereafter for the duration of the study, 

6 such Director may prepare and submit to the Con7 gress reports on the findings of the study. 

8 (d) DEFINITIONS.—In this section: 

9 (1) The term ‘‘postpartum condition’’ means 

10 postpartum depression or postpartum psychosis. 

11 (2) The term ‘‘Secretary’’ means the Secretary 

12 of Health and Human Services. 

13 (e) AUTHORIZATION OF APPROPRIATIONS.—For the 

14 purpose of carrying out this section, in addition to any 

15 other amounts authorized to be appropriated for such pur16 pose, there are authorized to be appropriated such sums 

17 as may be necessary for each of fiscal years 2011 through 

18 2013. 

19 SEC. 2530. GRANTS TO PROMOTE POSITIVE HEALTH BEHAV20 IORS AND OUTCOMES. 

21 Part P of title III (42 U.S.C. 280g et seq.) is amend22 ed by adding at the end the following: 
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1 ‘‘SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BE2 HAVIORS AND OUTCOMES. 

3 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, in col4 laboration with the Director of the Centers for Disease 

5 Control and Prevention and other Federal officials deter6 mined appropriate by the Secretary, is authorized to 

7 award grants to eligible entities to promote positive health 

8 behaviors for populations in medically underserved com9 munities through the use of community health workers. 

10 ‘‘(b) USE OF FUNDS.—Grants awarded under sub11 section (a) shall be used to support community health 

12 workers— 

13 ‘‘(1) to educate, guide, and provide outreach in 

14 a community setting regarding health problems prev15 alent in medically underserved communities, espe16 cially racial and ethnic minority populations; 

17 ‘‘(2) to educate, guide, and provide experiential 

18 learning opportunities that target behavioral risk 

19 factors including— 

20 ‘‘(A) poor nutrition; 

21 ‘‘(B) physical inactivity; 

22 ‘‘(C) being overweight or obese; 

23 ‘‘(D) tobacco use; 

24 ‘‘(E) alcohol and substance use; 

25 ‘‘(F) injury and violence; 

26 ‘‘(G) risky sexual behavior; 
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1 ‘‘(H) untreated mental health problems; 

2 ‘‘(I) untreated dental and oral health prob3 lems; and 

4 ‘‘(J) understanding informed consent; 

5 ‘‘(3) to educate and provide guidance regarding 

6 effective strategies to promote positive health behav7 iors within the family; 

8 ‘‘(4) to educate and provide outreach regarding 

9 enrollment in health insurance including the State 

10 Children’s Health Insurance Program under title 

11 XXI of the Social Security Act, Medicare under title 

12 XVIII of such Act, and Medicaid under title XIX of 

13 such Act; 

14 ‘‘(5) to educate and refer underserved popu15 lations to appropriate health care agencies and com16 munity-based programs and organizations in order 

17 to increase access to quality health care services, in18 cluding preventive health services, and to eliminate 

19 duplicative care; or 

20 ‘‘(6) to educate, guide, and provide home visita21 tion services regarding maternal health and prenatal 

22 care. 

23 ‘‘(c) APPLICATION.— 

24 ‘‘(1) IN GENERAL.—Each eligible entity that 

25 desires to receive a grant under subsection (a) shall 
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•HR 3962 EH

1 submit an application to the Secretary, at such time, 

2 in such manner, and accompanied by such informa3 tion as the Secretary may require. 

4 ‘‘(2) CONTENTS.—Each application submitted 

5 pursuant to paragraph (1) shall— 

6 ‘‘(A) describe the activities for which as7 sistance is sought under this section; 

8 ‘‘(B) contain an assurance that, with re9 spect to each community health worker pro10 gram receiving funds under the grant, such pro11 gram will provide training and supervision to 

12 community health workers to enable such work13 ers to provide authorized program services; 

14 ‘‘(C) contain an assurance that the appli15 cant will evaluate the effectiveness of commu16 nity health worker programs receiving funds 

17 under the grant; 

18 ‘‘(D) contain an assurance that each com19 munity health worker program receiving funds 

20 under the grant will provide services in the cul21 tural context most appropriate for the individ22 uals served by the program; 

23 ‘‘(E) contain a plan to document and dis24 seminate project descriptions and results to 
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1 other States and organizations as identified by 

2 the Secretary; and 

3 ‘‘(F) describe plans to enhance the capac4 ity of individuals to utilize health services and 

5 health-related social services under Federal, 

6 State, and local programs by— 

7 ‘‘(i) assisting individuals in estab8 lishing eligibility under the programs and 

9 in receiving the services or other benefits 

10 of the programs; and 

11 ‘‘(ii) providing other services as the 

12 Secretary determines to be appropriate, 

13 that may include transportation and trans14 lation services. 

15 ‘‘(d) PRIORITY.—In awarding grants under sub16 section (a), the Secretary shall give priority to applicants 

17 that— 

18 ‘‘(1) propose to target geographic areas— 

19 ‘‘(A) with a high percentage of residents 

20 who are eligible for health insurance but are 

21 uninsured or underinsured; 

22 ‘‘(B) with a high percentage of residents 

23 who suffer from chronic diseases including pul24 monary conditions, hypertension, heart disease, 

25 mental disorders, diabetes, and asthma; and 
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1 ‘‘(C) with a high infant mortality rate; 

2 ‘‘(2) have experience in providing health or 

3 health-related social services to individuals who are 

4 underserved with respect to such services; and 

5 ‘‘(3) have documented community activity and 

6 experience with community health workers. 

7 ‘‘(e) COLLABORATION WITH ACADEMIC INSTITU8 TIONS.—The Secretary shall encourage community health 

9 worker programs receiving funds under this section to col10 laborate with academic institutions, especially those that 

11 graduate a disproportionate number of health and health 

12 care students from underrepresented racial and ethnic mi13 nority backgrounds. Nothing in this section shall be con14 strued to require such collaboration. 

15 ‘‘(f) EVIDENCE-BASED INTERVENTIONS.—The Sec16 retary shall encourage community health worker programs 

17 receiving funding under this section to implement an out18 come-based payment system that rewards community 

19 health workers for connecting underserved populations 

20 with the most appropriate services at the most appropriate 

21 time. Nothing in this section shall be construed to require 

22 such payment. 

23 ‘‘(g) QUALITY ASSURANCE AND COST EFFECTIVE24 NESS.—The Secretary shall establish guidelines for assur25 ing the quality of the training and supervision of commu-
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1 nity health workers under the programs funded under this 

2 section and for assuring the cost-effectiveness of such pro3 grams. 

4 ‘‘(h) MONITORING.—The Secretary shall monitor 

5 community health worker programs identified in approved 

6 applications under this section and shall determine wheth7 er such programs are in compliance with the guidelines 

8 established under subsection (g). 

9 ‘‘(i) TECHNICAL ASSISTANCE.—The Secretary may 

10 provide technical assistance to community health worker 

11 programs identified in approved applications under this 

12 section with respect to planning, developing, and operating 

13 programs under the grant. 

14 ‘‘(j) REPORT TO CONGRESS.— 

15 ‘‘(1) IN GENERAL.—Not later than 4 years 

16 after the date on which the Secretary first awards 

17 grants under subsection (a), the Secretary shall sub18 mit to Congress a report regarding the grant 

19 project. 

20 ‘‘(2) CONTENTS.—The report required under 

21 paragraph (1) shall include the following: 

22 ‘‘(A) A description of the programs for 

23 which grant funds were used. 

24 ‘‘(B) The number of individuals served 

25 under such programs. 
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1 ‘‘(C) An evaluation of— 

2 ‘‘(i) the effectiveness of such pro3 grams; 

4 ‘‘(ii) the cost of such programs; and 

5 ‘‘(iii) the impact of the programs on 

6 the health outcomes of the community resi7 dents. 

8 ‘‘(D) Recommendations for sustaining the 

9 community health worker programs developed 

10 or assisted under this section. 

11 ‘‘(E) Recommendations regarding training 

12 to enhance career opportunities for community 

13 health workers. 

14 ‘‘(k) DEFINITIONS.—In this section: 

15 ‘‘(1) COMMUNITY HEALTH WORKER.—The term 

16 ‘community health worker’ means an individual who 

17 promotes health or nutrition within the community 

18 in which the individual resides— 

19 ‘‘(A) by serving as a liaison between com20 munities and health care agencies; 

21 ‘‘(B) by providing guidance and social as22 sistance to community residents; 

23 ‘‘(C) by enhancing community residents’ 

24 ability to effectively communicate with health 

25 care providers; 
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1 ‘‘(D) by providing culturally and linguis2 tically appropriate health or nutrition edu3 cation; 

4 ‘‘(E) by advocating for individual and com5 munity health, including oral and mental, or 

6 nutrition needs; and 

7 ‘‘(F) by providing referral and followup 

8 services or otherwise coordinating care. 

9 ‘‘(2) COMMUNITY SETTING.—The term ‘commu10 nity setting’ means a home or a community organi11 zation located in the neighborhood in which a partic12 ipant resides. 

13 ‘‘(3) MEDICALLY UNDERSERVED COMMUNITY.— 

14 The term ‘medically underserved community’ means 

15 a community identified by a State, United States 

16 territory or possession, or federally recognized In17 dian tribe— 

18 ‘‘(A) that has a substantial number of in19 dividuals who are members of a medically un20 derserved population, as defined by section 

21 330(b)(3); and 

22 ‘‘(B) a significant portion of which is a 

23 health professional shortage area as designated 

24 under section 332. 
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1 ‘‘(4) SUPPORT.—The term ‘support’ means the 

2 provision of training, supervision, and materials 

3 needed to effectively deliver the services described in 

4 subsection (b), reimbursement for services, and 

5 other benefits. 

6 ‘‘(5) ELIGIBLE ENTITY.—The term ‘eligible en7 tity’ means a public or private nonprofit entity (in8 cluding a State or public subdivision of a State, a 

9 public health department, or a federally qualified 

10 health center), or a consortium of any of such enti11 ties, located in the United States or territory there12 of. 

13 ‘‘(l) AUTHORIZATION OF APPROPRIATIONS.—There is 

14 authorized to be appropriated to carry out this section 

15 $30,000,000 for each of fiscal years 2011 through 2015.’’. 

16 SEC. 2531. MEDICAL LIABILITY ALTERNATIVES. 

17 (a) INCENTIVE PAYMENTS FOR MEDICAL LIABILITY

18 REFORM.— 

19 (1) IN GENERAL.—To the extent and in the 

20 amounts made available in advance in appropriations 

21 Acts, the Secretary shall make an incentive payment, 

22 in an amount determined by the Secretary, to each 

23 State that has an alternative medical liability law in 

24 compliance with this section. 
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1 (2) DETERMINATION BY SECRETARY.—The 

2 Secretary shall determine that a State has an alter3 native medical liability law in compliance with this 

4 section if the Secretary is satisfied that— 

5 (A) the State enacted the law after the 

6 date of the enactment of this Act and is imple7 menting the law; 

8 (B) the law is effective; and 

9 (C) the contents of the law are in accord10 ance with paragraph (4). 

11 (3) CONSIDERATIONS FOR DETERMINING EF12 FECTIVENESS.—In determining whether an alter13 native medical liability law is effective under para14 graph (2)(B), the Secretary shall consider whether 

15 the law— 

16 (A) makes the medical liability system 

17 more reliable through prevention of, or prompt 

18 and fair resolution of, disputes; 

19 (B) encourages the disclosure of health 

20 care errors; and 

21 (C) maintains access to affordable liability 

22 insurance. 

23 (4) CONTENTS OF ALTERNATIVE MEDICAL LI24 ABILITY LAW.—The contents of an alternative liabil25 ity law are in accordance with this paragraph if— 
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1 (A) the litigation alternatives contained in 

2 the law consist of certificate of merit, early 

3 offer, or both; and 

4 (B) the law does not limit attorneys’ fees 

5 or impose caps on damages. 

6 (5) NO LIMITATION ON OTHER STATE LAWS.— 

7 Nothing in this section shall be construed to— 

8 (A) preempt or modify the application of 

9 any existing State law that limits attorneys’ 

10 fees or imposes caps on damages; 

11 (B) impair the authority of a State to es12 tablish or implement a law limiting attorneys’ 

13 fees or imposing caps on damages; or 

14 (C) restrict the eligibility of a State for an 

15 incentive payment under this section on the 

16 basis of a law described in subparagraph (A) or 

17 (B) so long as any such law is not established 

18 or implemented as part of the law described in 

19 paragraph (4), as determined by the Secretary. 

20 (b) USE OF INCENTIVE PAYMENTS.—Amounts re21 ceived by a State as an incentive payment under this sec22 tion shall be used to improve health care in that State. 

23 (c) TECHNICAL ASSISTANCE.—The Secretary may 

24 provide technical assistance to the States applying for or 

25 receiving an incentive payment under this section. 
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1 (d) REPORTS.—Beginning not later than one year 

2 after the date of the enactment of this Act, the Secretary 

3 shall submit to the Congress an annual report on the 

4 progress States have made in enacting and implementing 

5 alternative medical liability laws in compliance with this 

6 section. Such reports shall contain sufficient documenta7 tion regarding the effectiveness of such laws to enable an 

8 objective comparative analysis of such laws. 

9 (e) DEFINITION.—In this section— 

10 (1) the term ‘‘Secretary’’ means the Secretary 

11 of Health and Human Services; and 

12 (2) the term ‘‘State’’ includes the several 

13 States, District of Columbia, the Commonwealth of 

14 Puerto Rico, and each other territory or possession 

15 of the United States. 

16 (f) AUTHORIZATION OF APPROPRIATIONS.—There 

17 are authorized to be appropriated to carry out this section 

18 such sums as may be necessary, to remain available until 

19 expended. 

20 SEC. 2532. INFANT MORTALITY PILOT PROGRAMS. 

21 (a) IN GENERAL.—The Secretary of Health and 

22 Human Services (in this section referred to as the ‘‘Sec23 retary’’), acting through the Director, shall award grants 

24 to eligible entities to create, implement, and oversee infant 

25 mortality pilot programs. 
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1 (b) PERIOD OF A GRANT.—The period of a grant 

2 under this section shall be 5 consecutive fiscal years. 

3 (c) PREFERENCE.—In awarding grants under this 

4 section, the Secretary shall give preference to eligible enti5 ties proposing to serve any of the 15 counties or groups 

6 of counties with the highest rates of infant mortality in 

7 the United States in the past 3 years. 

8 (d) USE OF FUNDS.—Any infant mortality pilot pro9 gram funded under this section may— 

10 (1) include the development of a plan that iden11 tifies the individual needs of each community to be 

12 served and strategies to address those needs; 

13 (2) provide outreach to at-risk mothers through 

14 programs deemed appropriate by the Director; 

15 (3) develop and implement standardized sys16 tems for improved access, utilization, and quality of 

17 social, educational, and clinical services to promote 

18 healthy pregnancies, full term births, and healthy in19 fancies delivered to women and their infants, such 

20 as— 

21 (A) counseling on infant care, feeding, and 

22 parenting; 

23 (B) postpartum care; 

24 (C) prevention of premature delivery; and 
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1 (D) additional counseling for at-risk moth2 ers, including smoking cessation programs, 

3 drug treatment programs, alcohol treatment 

4 programs, nutrition and physical activity pro5 grams, postpartum depression and domestic vio6 lence programs, social and psychological serv7 ices, dental care, and parenting programs; 

8 (4) establish a rural outreach program to pro9 vide care to at-risk mothers in rural areas; 

10 (5) establish a regional public education cam11 paign, including a campaign to— 

12 (A) prevent preterm births; and 

13 (B) educate the public about infant mor14 tality; and 

15 (6) provide for any other activities, programs, 

16 or strategies as identified by the community plan. 

17 (e) LIMITATION.—Of the funds received through a 

18 grant under this section for a fiscal year, an eligible entity 

19 shall not use more than 10 percent for program evalua20 tion. 

21 (f) REPORTS ON PILOT PROGRAMS.— 

22 (1) IN GENERAL.—Not later than 1 year after 

23 receiving a grant, and annually thereafter for the 

24 duration of the grant period, each entity that re25 ceives a grant under subsection (a) shall submit a 
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1 report to the Secretary detailing its infant mortality 

2 pilot program. 

3 (2) CONTENTS OF REPORT.—The reports re4 quired under paragraph (1) shall include informa5 tion such as the methodology of, and outcomes and 

6 statistics from, the grantee’s infant mortality pilot 

7 program. 

8 (3) EVALUATION.—The Secretary shall use the 

9 reports required under paragraph (1) to evaluate, 

10 and conduct statistical research on, infant mortality 

11 pilot programs funded through this section. 

12 (g) DEFINITIONS.—For the purposes of this section: 

13 (1) DIRECTOR.—The term ‘‘Director’’ means 

14 the Director of the Centers for Disease Control and 

15 Prevention. 

16 (2) ELIGIBLE ENTITY.—The term ‘‘eligible enti17 ty’’ means a State, county, city, territorial, or tribal 

18 health department that has submitted a proposal to 

19 the Secretary that the Secretary deems likely to re20 duce infant mortality rates within the standard met21 ropolitan statistical area involved. 

22 (3) TRIBAL.—The term ‘‘tribal’’ refers to an 

23 Indian tribe, a Tribal organization, or an Urban In24 dian organization, as such terms are defined in sec25 tion 4 of the Indian Health Care Improvement Act. 
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1 (h) AUTHORIZATION OF APPROPRIATIONS.—To carry 

2 out this section, there are authorized to be appropriated 

3 $10,000,000 for each of fiscal years 2011 through 2015. 

4 SEC. 2533. SECONDARY SCHOOL HEALTH SCIENCES TRAIN5 ING PROGRAM. 

6 (a) PROGRAM.—The Secretary of Health and Human 

7 Services, acting through the Administrator of the Health 

8 Resources and Services Administration, and in consulta9 tion with the Secretary of Education, may establish a 

10 health sciences training program consisting of awarding 

11 grants and contracts under subsection (b) to prepare sec12 ondary school students for careers in health professions. 

13 (b) DEVELOPMENT AND IMPLEMENTATION OF

14 HEALTH SCIENCES CURRICULA.—The Secretary may 

15 make grants to, or enter into contracts with, eligible enti16 ties— 

17 (1) to plan, develop, or implement secondary 

18 school health sciences curricula, including curricula 

19 in biology, chemistry, physiology, mathematics, nu20 trition, and other courses deemed appropriate by the 

21 Secretary to prepare students for associate’s or 

22 bachelor’s degree programs in health professions or 

23 bachelor’s degree programs in health professions-re24 lated majors; and 
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1 (2) to increase the interest of secondary school 

2 students in applying to, and enrolling in, accredited 

3 associate’s or bachelor’s degree programs in health 

4 professions or bachelor’s degree programs in health 

5 professions-related majors, including through— 

6 (A) work-study programs; 

7 (B) programs to increase awareness of ca8 reers in health professions; and 

9 (C) other activities to increase such inter10 est. 

11 (c) ELIGIBILITY.—To be eligible for a grant or con12 tract under subsection (b), an entity shall— 

13 (1) be a local educational agency; and 

14 (2) provide assurances that activities under the 

15 grant or contract will be carried out in partnership 

16 with an accredited health professions school or pro17 gram, public or private nonprofit hospital, or public 

18 or private nonprofit entity. 

19 (d) PREFERENCE.—In awarding grants and con20 tracts under subsection (b), the Secretary shall give pref21 erence to entities that have a demonstrated record of at 

22 least one of the following: 

23 (1) Graduating a high or significantly improved 

24 percentage of students who have exhibited mastery 

25 in secondary school State science standards. 
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1 (2) Graduating students from disadvantaged 

2 backgrounds, including racial and ethnic minorities 

3 who are underrepresented in— 

4 (A) associate’s or bachelor’s degree pro5 grams in health professions or bachelor’s degree 

6 programs in health professions-related majors; 

7 or 

8 (B) health professions. 

9 (e) REPORT.—The Secretary shall submit to the Con10 gress an annual report on the program carried out under 

11 this section. 

12 (f) DEFINITIONS.—In this section: 

13 (1) The term ‘‘health profession’’ means the 

14 profession of any member of the health workforce, 

15 as defined in section 764(i) of the Public Health 

16 Service Act, as added by section 2261. 

17 (2) The term ‘‘local educational agency’’ has 

18 the meaning given to the term in section 9101 of the 

19 Elementary and Secondary Education Act of 1965 

20 (20 U.S.C. 7801). 

21 (3) The term ‘‘secondary school’’— 

22 (A) means a secondary school, as defined 

23 in section 9101 of the Elementary and Sec24 ondary Education Act of 1965 (20 U.S.C. 

25 7801); and 
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1 (B) includes any such school that is a mid2 dle school. 

3 (4) The term ‘‘Secretary’’ means the Secretary 

4 of Health and Human Services except as otherwise 

5 specified. 

6 (g) AUTHORIZATION OF APPROPRIATIONS.—To carry 

7 out this section, there are authorized to be appropriated 

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

9 2011 through 2015. 

10 SEC. 2534. COMMUNITY-BASED COLLABORATIVE CARE NET11 WORKS. 

12 (a) PURPOSE.—The purpose of this subtitle is to es13 tablish and provide assistance to community-based col14 laborative care networks— 

15 (1) to develop or strengthen coordination of 

16 services to allow all individuals, including the unin17 sured and low-income, to receive efficient and higher 

18 quality care and to gain entry into and receive serv19 ices from a comprehensive system of care; 

20 (2) to develop efficient and sustainable infra21 structure for a health care delivery system charac22 terized by effective collaboration, information shar23 ing, and clinical and financial coordination among 

24 providers of care in the community; 
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1 (3) to develop or strengthen activities related to 

2 providing coordinated care for individuals with 

3 chronic conditions; and 

4 (4) to reduce the use of emergency depart5 ments, inpatient and other expensive resources of 

6 hospitals and other providers. 

7 (b) CREATION OF THE COMMUNITY-BASED COL8 LABORATIVE CARE NETWORK PROGRAM.—Part D of title 

9 III (42 U.S.C. 254b et seq.), as amended, is further 

10 amended by inserting after subpart XII the following new 

11 subpart: 

12 ‘‘Subpart XIII—Community-Based Collaborative Care 

13 Network Program 

14 ‘‘SEC. 340O. COMMUNITY-BASED COLLABORATIVE CARE 

15 NETWORK PROGRAM. 

16 ‘‘(a) IN GENERAL.—The Secretary may award grants 

17 to eligible entities for the purpose of establishing model 

18 projects to accomplish the following goals: 

19 ‘‘(1) To reduce unnecessary use of items and 

20 services furnished in emergency departments of hos21 pitals (especially to ensure that individuals without 

22 health insurance coverage or with inadequate health 

23 insurance coverage do not use the services of such 

24 department instead of the services of a primary care 

25 provider) through methods such as— 
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1 ‘‘(A) screening individuals who seek emer2 gency department services for possible eligibility 

3 under relevant governmental health programs 

4 or for subsidies under such programs; and 

5 ‘‘(B) providing such individuals referrals 

6 for followup care and chronic condition care. 

7 ‘‘(2) To manage chronic conditions to reduce 

8 their severity, negative health outcomes, and ex9 pense. 

10 ‘‘(3) To encourage health care providers to co11 ordinate their efforts so that the most vulnerable pa12 tient populations seek and obtain primary care. 

13 ‘‘(4) To provide more comprehensive and co14 ordinated care to vulnerable low-income individuals 

15 and individuals without health insurance coverage or 

16 with inadequate coverage. 

17 ‘‘(5) To provide mechanisms for improving both 

18 quality and efficiency of care for low-income individ19 uals and families, with an emphasis on those most 

20 likely to remain uninsured despite the existence of 

21 government programs to make health insurance 

22 more affordable. 

23 ‘‘(6) To increase preventive services, including 

24 screening and counseling, to those who would other25 wise not receive such screening, in order to improve 
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1 health status and reduce long-term complications 

2 and costs. 

3 ‘‘(7) To ensure the availability of community4 wide safety net services, including emergency and 

5 trauma care. 

6 ‘‘(b) ELIGIBILITY AND GRANTEE SELECTION.— 

7 ‘‘(1) APPLICATION.—A community-based col8 laborative care network described in subsection (d) 

9 shall submit to the Secretary an application in such 

10 form and manner and containing such information 

11 as specified by the Secretary. Such information shall 

12 at least— 

13 ‘‘(A) identify the health care providers par14 ticipating in the community-based collaborative 

15 care network proposed by the applicant and, if 

16 a provider designated in paragraph (d)(1)(B) is 

17 not included, the reason such provider is not so 

18 included; 

19 ‘‘(B) include a description of how the pro20 viders plan to collaborate to provide comprehen21 sive and integrated care for low-income individ22 uals, including uninsured and underinsured in23 dividuals; 

24 ‘‘(C) include a description of the organiza25 tional and joint governance structure of the 
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1 community-based collaborative care network in 

2 a manner so that it is clear how decisions will 

3 be made, and how the decisionmaking process 

4 of the network will include appropriate rep5 resentation of the participating entities; 

6 ‘‘(D) define the geographic areas and pop7 ulations that the network intends to serve; 

8 ‘‘(E) define the scope of services that the 

9 network intends to provide and identify any 

10 reasons why such services would not include a 

11 suggested core service identified by the Sec12 retary under paragraph (3); 

13 ‘‘(F) demonstrate the network’s ability to 

14 meet the requirements of this section; and 

15 ‘‘(G) provide assurances that grant funds 

16 received shall be used to support the entire 

17 community-based collaborative care network. 

18 ‘‘(2) SELECTION OF GRANTEES.— 

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

20 select community-based collaborative care net21 works to receive grants from applications sub22 mitted under paragraph (1) on the basis of 

23 quality of the proposal involved, geographic di24 versity (including different States and regions 

25 served and urban and rural diversity), and the 
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1 number of low-income and uninsured individ2 uals that the proposal intends to serve. 

3 ‘‘(B) PRIORITY.—The Secretary shall give 

4 priority to proposals from community-based col5 laborative care networks that— 

6 ‘‘(i) include the capability to provide 

7 the broadest range of services to low-in8 come individuals; and 

9 ‘‘(ii) include providers that currently 

10 serve a high volume of low-income individ11 uals. 

12 ‘‘(C) RENEWAL.—In subsequent years, 

13 based on the performance of grantees, the Sec14 retary may provide renewal grants to prior year 

15 grant recipients. 

16 ‘‘(3) SUGGESTED CORE SERVICES.—For pur17 poses of paragraph (1)(E), the Secretary shall de18 velop a list of suggested core patient and core net19 work services to be provided by a community-based 

20 collaborative care network. The Secretary may select 

21 a community-based collaborative care network under 

22 paragraph (2), the application of which does not in23 clude all such services, if such application provides 

24 a reasonable explanation why such services are not 
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1 proposed to be included, and the Secretary deter2 mines that the application is otherwise high quality. 

3 ‘‘(4) TERMINATION AUTHORITY.—The Sec4 retary may terminate selection of a community5 based collaborative care network under this section 

6 for good cause. Such good cause shall include a de7 termination that the network— 

8 ‘‘(A) has failed to provide a comprehensive 

9 range of coordinated and integrated health care 

10 services as required under subsection (d)(2); 

11 ‘‘(B) has failed to meet reasonable quality 

12 standards; 

13 ‘‘(C) has misappropriated funds provided 

14 under this section; or 

15 ‘‘(D) has failed to make progress toward 

16 accomplishing goals set out in subsection (a). 

17 ‘‘(c) USE OF FUNDS.— 

18 ‘‘(1) USE BY GRANTEES.—Grant funds are pro19 vided to community-based collaborative care net20 works to carry out the following activities: 

21 ‘‘(A) Assist low-income individuals without 

22 adequate health care coverage to— 

23 ‘‘(i) access and appropriately use 

24 health services; 
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1 ‘‘(ii) enroll in applicable public or pri2 vate health insurance programs; 

3 ‘‘(iii) obtain referrals to and see a pri4 mary care provider in case such an indi5 vidual does not have a primary care pro6 vider; and 

7 ‘‘(iv) obtain appropriate care for 

8 chronic conditions. 

9 ‘‘(B) Improve heath care by providing case 

10 management, application assistance, and appro11 priate referrals such as through methods to— 

12 ‘‘(i) create and meaningfully use a 

13 health information technology network to 

14 track patients across collaborative pro15 viders; 

16 ‘‘(ii) perform health outreach, such as 

17 by using neighborhood health workers who 

18 may inform individuals about the avail19 ability of safety net and primary care pro20 viders available through the community21 based collaborative care network; 

22 ‘‘(iii) provide for followup outreach to 

23 remind patients of appointments or follow24 up care instructions; 
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1 ‘‘(iv) provide transportation to individ2 uals to and from the site of care; 

3 ‘‘(v) expand the capacity to provide 

4 care at any provider participating in the 

5 community-based collaborative care net6 work, including telehealth, hiring new clin7 ical or administrative staff, providing ac8 cess to services after-hours, on weekends, 

9 or otherwise providing an urgent care al10 ternative to an emergency department; and 

11 ‘‘(vi) provide a primary care provider 

12 or medical home for each network patient. 

13 ‘‘(C) Provide direct patient care services as 

14 described in their application and approved by 

15 the Secretary. 

16 ‘‘(2) GRANT FUNDS TO HRSA GRANTEES.—The 

17 Secretary may limit the percent of grant funding 

18 that may be spent on direct care services provided 

19 by grantees of programs administered by the Health 

20 Resources and Services Administration (in this sec21 tion referred to as ‘HRSA’) or impose other require22 ments on HRSA grantees participating in a commu23 nity-based collaborative care network as may be nec24 essary for consistency with the requirements of such 

25 programs. 
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1 ‘‘(3) RESERVATION OF FUNDS FOR NATIONAL

2 PROGRAM PURPOSES.—The Secretary may use not 

3 more than 7 percent of funds appropriated to carry 

4 out this section for providing technical assistance to 

5 grantees, obtaining assistance of experts and con6 sultants, holding meetings, developing of tools, dis7 seminating of information, and evaluation. 

8 ‘‘(d) COMMUNITY-BASED COLLABORATIVE CARE

9 NETWORKS.— 

10 ‘‘(1) IN GENERAL.— 

11 ‘‘(A) DESCRIPTION.—A community-based 

12 collaborative care network described in this sub13 section is a consortium of health care providers 

14 with a joint governance structure that provides 

15 a comprehensive range of coordinated and inte16 grated health care services for low-income pa17 tient populations or medically underserved com18 munities (whether or not such individuals re19 ceive benefits under title XVIII, XIX, or XXI 

20 of the Social Security Act, private or other 

21 health insurance or are uninsured or under22 insured) and that complies with any applicable 

23 minimum eligibility requirements that the Sec24 retary may determine appropriate. 
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1 ‘‘(B) REQUIRED INCLUSION.—Each such 

2 network shall include the following providers 

3 that serve the community (unless such provider 

4 does not exist within the community, declines or 

5 refuses to participate, or places unreasonable 

6 conditions on their participation)— 

7 ‘‘(i) A safety net hospital that pro8 vides services to a high volume of low-in9 come patients, as demonstrated by meeting 

10 the criteria in section 1923(b)(1) of the 

11 Social Security Act, or other similar cri12 teria determined by the Secretary; and 

13 ‘‘(ii) All Federally qualified health 

14 centers (as defined in section 1861(aa) of 

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

16 1395x(aa))) located in the geographic area 

17 served by the Coordinated Care Network; 

18 ‘‘(C) ADDITIONAL INCLUSIONS.—Each 

19 such network may include any of the following 

20 additional providers: 

21 ‘‘(i) A hospital, including a critical ac22 cess hospital (as defined in section 

23 1820(c)(2) of the Social Security Act (42 

24 U.S.C. 1395i–4(c)(2))). 
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1 ‘‘(ii) A county or municipal depart2 ment of health. 

3 ‘‘(iii) A rural health clinic or a rural 

4 health network (as defined in sections 

5 1861(aa) and 1820(d) of the Social Secu6 rity Act, respectively (42 U.S.C. 

7 1395x(aa), 1395i–4(d))). 

8 ‘‘(iv) A community clinic, including a 

9 mental health clinic, substance abuse clin10 ic, or a reproductive health clinic. 

11 ‘‘(v) A health center controlled net12 work as defined by section 330(e)(1)(C) of 

13 the Public Health Service Act. 

14 ‘‘(vi) A private practice physician or 

15 group practice. 

16 ‘‘(vii) A nurse or physician assistant 

17 or group practice. 

18 ‘‘(viii) An adult day care center. 

19 ‘‘(ix) A home health provider. 

20 ‘‘(x) Any other type of provider speci21 fied by the Secretary, which has a desire to 

22 serve low-income and uninsured patients. 

23 ‘‘(D) CONSTRUCTION.— 

24 ‘‘(i) Nothing in this section shall pro25 hibit a single entity from qualifying as 
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1 community-based collaborative care net2 work so long as such single entity meets 

3 the criteria of a community-based collabo4 rative care network. If the network does 

5 not include the providers referenced in 

6 clauses (i) and (ii) of subparagraph (B) of 

7 this paragraph, the application must ex8 plain the reason pursuant to subsection 

9 (b)(1)(A). 

10 ‘‘(ii) Participation in a community11 based collaborative care network shall not 

12 affect Federally qualified health centers’ 

13 obligation to comply with the governance 

14 requirements under section 330 of the 

15 Public Health Service Act (42 U.S.C. 

16 254b). 

17 ‘‘(iii) Federally qualified health cen18 ters participating in a community-based 

19 collaborative care network may not be re20 quired to provide services beyond their 

21 Federal Health Center scope of project ap22 proved by HRSA. 

23 ‘‘(iv) Nothing in this section shall be 

24 construed to expand medical malpractice li25 ability protection under the Federal Tort 
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1 Claims Act for Section 330-funded Feder2 ally qualified health centers. 

3 ‘‘(2) COMPREHENSIVE RANGE OF COORDINATED

4 AND INTEGRATED HEALTH CARE SERVICES.—The 

5 Secretary shall define criteria for evaluating whether 

6 the services offered by a community-based collabo7 rative care network qualify as a comprehensive range 

8 of coordinated and integrated health care services. 

9 Such criteria may vary based on the needs of the ge10 ographic areas and populations to be served by the 

11 network and may include the following: 

12 ‘‘(A) Requiring community-based collabo13 rative care networks to include at least the sug14 gested core services identified under subsection 

15 (b)(3), or whichever subset of the suggested 

16 core services is applicable to a particular net17 work. 

18 ‘‘(B) Requiring such networks to assign 

19 each patient of the network to a primary care 

20 provider responsible for managing that patient’s 

21 care. 

22 ‘‘(C) Requiring the services provided by a 

23 community-based collaborative care network to 

24 include support services appropriate to meet the 

25 health needs of low-income populations in the 
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1 network’s community, which may include chron2 ic care management, nutritional counseling, 

3 transportation, language services, enrollment 

4 counselors, social services and other services as 

5 proposed by the network. 

6 ‘‘(D) Providing that the services provided 

7 by a community-based collaborative care net8 work may also include long-term care services 

9 and other services not specified in this sub10 section. 

11 ‘‘(E) Providing for the approval by the 

12 Secretary of a scope of community-based col13 laborative care network services for each net14 work that addresses an appropriate minimum 

15 scope of work consistent with the setting of the 

16 network and the health professionals available 

17 in the community the network serves. 

18 ‘‘(3) CLARIFICATION.—Participation in a com19 munity-based collaborative care network shall not 

20 disqualify a health care provider from reimburse21 ment under title XVIII, XIX, or XXI of the Social 

22 Security Act with respect to services otherwise reim23 bursable under such title. Nothing in this section 

24 shall prevent a community-based collaborative care 

25 network that is otherwise eligible to contract with 
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1 Medicare, a private health insurer, or any other ap2 propriate entity to provide care under Medicare, 

3 under health insurance coverage offered by the in4 surer, or otherwise. 

5 ‘‘(e) EVALUATIONS.— 

6 ‘‘(1) GRANTEE REPORTS.—Beginning in the 

7 third year following an initial grant, each commu8 nity-based collaborative care network shall submit to 

9 the Secretary, with respect to each year the grantee 

10 has received a grant, an evaluation on the activities 

11 carried out by the community-based collaborative 

12 care network under the community-based collabo13 rative care network program and shall include— 

14 ‘‘(A) the number of people served; 

15 ‘‘(B) the most common health problems 

16 treated; 

17 ‘‘(C) any reductions in emergency depart18 ment use; 

19 ‘‘(D) any improvements in access to pri20 mary care; 

21 ‘‘(E) an accounting of how amounts re22 ceived were used, including identification of 

23 amounts used for patient care services as may 

24 be required for HRSA grantees; and 
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1 ‘‘(F) to the extent requested by the Sec2 retary, any quality measures or any other meas3 ures specified by the Secretary. 

4 ‘‘(2) PROGRAM REPORTS.—The Secretary shall 

5 submit to Congress an annual evaluation (beginning 

6 not later than 6 months after the first reports under 

7 paragraph (1) are submitted) on the extent to which 

8 emergency department use was reduced as a result 

9 of the activities carried out by the community-based 

10 collaborative care network under the program. Each 

11 such evaluation shall also include information on— 

12 ‘‘(A) the prevalence of certain chronic con13 ditions in various populations, including a com14 parison of such prevalence in the general popu15 lation versus in the population of individuals 

16 with inadequate health insurance coverage; 

17 ‘‘(B) demographic characteristics of the 

18 population of uninsured and underinsured indi19 viduals served by the community-based collabo20 rative care network involved; and 

21 ‘‘(C) the conditions of such individuals for 

22 whom services were requested at such emer23 gency departments of participating hospitals. 

24 ‘‘(3) AUDIT AUTHORITY.—The Secretary may 

25 conduct periodic audits and request periodic spend-
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1 ing reports of community-based collaborative care 

2 networks under the community-based collaborative 

3 care network program. 

4 ‘‘(f) CLARIFICATION.—Nothing in this section re5 quires a provider to report individually identifiable infor6 mation of an individual to government agencies, unless the 

7 individual consents, consistent with HIPAA privacy and 

8 security law, as defined in section 3009(a)(2). 

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

10 are authorized to be appropriated to carry out this section 

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

12 2011 through 2015.’’. 

13 SEC. 2535. COMMUNITY-BASED OVERWEIGHT AND OBESITY 

14 PREVENTION PROGRAM. 

15 Part Q of title III (42 U.S.C. 280h et seq.) is amend16 ed by inserting after section 399W the following: 

17 ‘‘SEC. 399W–1. COMMUNITY-BASED OVERWEIGHT AND OBE18 SITY PREVENTION PROGRAM. 

19 ‘‘(a) PROGRAM.—The Secretary shall establish a 

20 community-based overweight and obesity prevention pro21 gram consisting of awarding grants and contracts under 

22 subsection (b). 

23 ‘‘(b) GRANTS.—The Secretary shall award grants to, 

24 or enter into contracts with, eligible entities— 
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1 ‘‘(1) to plan evidence-based programs for the 

2 prevention of overweight and obesity among children 

3 and their families through improved nutrition and 

4 increased physical activity; or 

5 ‘‘(2) to implement such programs. 

6 ‘‘(c) ELIGIBILITY.—To be eligible for a grant or con7 tract under subsection (b), an entity shall be a community 

8 partnership that demonstrates community support and in9 cludes— 

10 ‘‘(1) a broad cross section of stakeholders, such 

11 as— 

12 ‘‘(A) hospitals, health care systems, com13 munity health centers, or other health care pro14 viders; 

15 ‘‘(B) universities, local educational agen16 cies, or childcare providers; 

17 ‘‘(C) State, local, and tribal health depart18 ments; 

19 ‘‘(D) State, local, and tribal park and 

20 recreation departments; 

21 ‘‘(E) employers; and 

22 ‘‘(F) health insurance companies; 

23 ‘‘(2) residents of the community; and 
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1 ‘‘(3) representatives of public and private enti2 ties that have a history of working within and serv3 ing the community. 

4 ‘‘(d) PERIOD OF AWARDS.— 

5 ‘‘(1) IN GENERAL.—The period of a grant or 

6 contract under this section shall be 5 years, subject 

7 to renewal under paragraph (2). 

8 ‘‘(2) RENEWAL.—At the end of each fiscal year, 

9 the Secretary may renew a grant or contract award 

10 under this section only if the grant or contract re11 cipient demonstrates to the Secretary’s satisfaction 

12 that the recipient has made appropriate, measurable 

13 progress in preventing overweight and obesity. 

14 ‘‘(e) REQUIREMENTS.— 

15 ‘‘(1) IN GENERAL.—The Secretary may award 

16 a grant or contract under this section to an entity 

17 only if the entity demonstrates to the Secretary’s 

18 satisfaction that— 

19 ‘‘(A) not later than 90 days after receiving 

20 the grant or contract, the entity will establish 

21 a steering committee to provide input on the as22 sessment of, and recommendations on improve23 ments to, the entity’s program funded through 

24 the grant or contract; and 
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1 ‘‘(B) the entity has conducted or will con2 duct an assessment of the overweight and obe3 sity problem in its community, including the ex4 tent of the problem and factors contributing to 

5 the problem. 

6 ‘‘(2) MATCHING REQUIREMENT.—The Sec7 retary may award a grant or contract to an eligible 

8 entity under this section only if the entity agrees to 

9 provide, from non-Federal sources, an amount equal 

10 to $1 (in cash or in kind) for each $9 provided 

11 through the grant or contract to carry out the activi12 ties supported by the grant or contract. 

13 ‘‘(3) PAYOR OF LAST RESORT.—The Secretary 

14 may award a grant or contract under this section to 

15 an entity only if the entity demonstrates to the satis16 faction of the Secretary that funds received through 

17 the grant or contract will not be expended for any 

18 activity to the extent that payment has been made, 

19 or can reasonably be expected to be made— 

20 ‘‘(A) under any insurance policy; 

21 ‘‘(B) under any Federal or State health 

22 benefits program (including titles XIX and XXI 

23 of the Social Security Act); or 

24 ‘‘(C) by an entity which provides health 

25 services on a prepaid basis. 
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1 ‘‘(4) MAINTENANCE OF EFFORT.—The Sec2 retary may award a grant or contract under this sec3 tion to an entity only if the entity demonstrates to 

4 the satisfaction of the Secretary that— 

5 ‘‘(A) funds received through the grant or 

6 contract will be expended only to supplement, 

7 and not supplant, non-Federal and Federal 

8 funds otherwise available to the entity for the 

9 activities to be funded through the grant or 

10 contract; and 

11 ‘‘(B) with respect to such activities, the en12 tity will maintain expenditures of non-Federal 

13 amounts for such activities at a level not less 

14 than the lesser of such expenditures maintained 

15 by the entity for the fiscal year preceding the 

16 fiscal year for which the entity receives the 

17 grant or contract. 

18 ‘‘(f) PREFERENCES.—In awarding grants and con19 tracts under this section, the Secretary shall give pref20 erence to eligible entities that— 

21 ‘‘(1) will serve communities with high levels of 

22 overweight and obesity and related chronic diseases; 

23 or 
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1 ‘‘(2) will plan or implement activities for the 

2 prevention of overweight and obesity in school or 

3 workplace settings. 

4 ‘‘(g) REPORT.—The Secretary shall submit to the 

5 Congress an annual report on the program of grants and 

6 contracts awarded under this section. 

7 ‘‘(h) DEFINITIONS.—In this section: 

8 ‘‘(1) The term ‘evidence-based’ means that 

9 methodologically sound research has demonstrated a 

10 beneficial health effect in the judgment of the Sec11 retary and includes the Ways to Enhance Children’s 

12 Activity and Nutrition (We Can) program and cur13 riculum of the National Institutes of Health. 

14 ‘‘(2) The term ‘local educational agency’ has 

15 the meaning given to the term in section 9101 of the 

16 Elementary and Secondary Education Act of 1965. 

17 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—To 

18 carry out this section, there are authorized to be appro19 priated $10,000,000 for fiscal year 2011 and such sums 

20 as may be necessary for each of fiscal years 2012 through 

21 2015.’’. 

22 SEC. 2536. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS. 

23 (a) DEMONSTRATION GRANTS.— 

24 (1) IN GENERAL.—The Secretary of Education, 

25 in consultation with the Secretary of Health and 
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1 Human Services and the Director of the Centers for 

2 Disease Control and Prevention, may make dem3 onstration grants to eligible local educational agen4 cies for the purpose of reducing the student-to5 school nurse ratio in public elementary and sec6 ondary schools. 

7 (2) SPECIAL CONSIDERATION.—In awarding 

8 grants under this section, the Secretary of Edu9 cation shall give special consideration to applications 

10 submitted by high-need local educational agencies 

11 that demonstrate the greatest need for new or addi12 tional nursing services among children in the public 

13 elementary and secondary schools served by the 

14 agency, in part by providing information on current 

15 ratios of students to school nurses. 

16 (3) MATCHING FUNDS.—The Secretary of Edu17 cation may require recipients of grants under this 

18 subsection to provide matching funds from non-Fed19 eral sources, and shall permit the recipients to 

20 match funds in whole or in part with in-kind con21 tributions. 

22 (b) REPORT.—Not later than 24 months after the 

23 date on which assistance is first made available to local 

24 educational agencies under this section, the Secretary of 

25 Education shall submit to the Congress a report on the 
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1 results of the demonstration grant program carried out 

2 under this section, including an evaluation of the effective3 ness of the program in improving the student-to-school 

4 nurse ratios described in subsection (a) and an evaluation 

5 of the impact of any resulting enhanced health of students 

6 on learning. 

7 (c) DEFINITIONS.—For purposes of this section: 

8 (1) The terms ‘‘elementary school’’, ‘‘local edu9 cational agency’’, and ‘‘secondary school’’ have the 

10 meanings given to those terms in section 9101 of the 

11 Elementary and Secondary Education Act of 1965 

12 (20 U.S.C. 7801). 

13 (2) The term ‘‘eligible local educational agency’’ 

14 means a local educational agency in which the stu15 dent-to-school nurse ratio in the public elementary 

16 and secondary schools served by the agency is 750 

17 or more students to every school nurse. 

18 (3) The term ‘‘high-need local educational agen19 cy’’ means a local educational agency— 

20 (A) that serves not fewer than 10,000 chil21 dren from families with incomes below the pov22 erty line; or 

23 (B) for which not less than 20 percent of 

24 the children served by the agency are from fam25 ilies with incomes below the poverty line. 
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1 (4) The term ‘‘nurse’’ means a licensed nurse, 

2 as defined under State law. 

3 (d) AUTHORIZATION OF APPROPRIATIONS.—To carry 

4 out this section, there are authorized to be appropriated 

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

6 2011 through 2015. 

7 SEC. 2537. MEDICAL-LEGAL PARTNERSHIPS. 

8 (a) IN GENERAL.—The Secretary shall establish a 

9 nationwide demonstration project consisting of— 

10 (1) awarding grants to, and entering into con11 tracts with, medical-legal partnerships to assist pa12 tients and their families to navigate health-related 

13 programs and activities; and 

14 (2) evaluating the effectiveness of such partner15 ships. 

16 (b) USE OF FUNDS.—Amounts received as a grant 

17 or contract under this section shall be used to assist pa18 tients and their families to navigate health care-related 

19 programs and activities and thereby achieve one or more 

20 of the following goals: 

21 (1) Enhancing access to health care services. 

22 (2) Improving health outcomes for low-income 

23 individuals. 

24 (3) Reducing health disparities. 
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1 (4) Enhancing wellness and prevention of 

2 chronic conditions. 

3 (c) PROHIBITION.—No funds under this section may 

4 be used— 

5 (1) for any medical malpractice or other civil 

6 action or proceeding; or 

7 (2) to assist individuals who are not lawfully 

8 present in the United States. 

9 (d) REPORT.—Not later than 5 years after the date 

10 of the enactment of this Act, the Secretary shall submit 

11 a report to the Congress on the results of the demonstra12 tion project under this section. Such report shall include 

13 the following: 

14 (1) A description of the extent to which med15 ical-legal partnerships funded through this section 

16 achieved the goals described in subsection (b). 

17 (2) Recommendations on the possibility of ex18 tending or expanding the demonstration project. 

19 (e) DEFINITIONS.—In this section: 

20 (1) The term ‘‘health disparities’’ has the 

21 meaning given to the term in section 3171 of the 

22 Public Health Service Act, as added by section 

23 2301. 

24 (2) The term ‘‘medical-legal partnership’’ 

25 means an entity— 
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1 (A) that is a collaboration between— 

2 (i) a community health center, public 

3 hospital, children’s hospital, or other pro4 vider of health care services to a signifi5 cant number of low-income beneficiaries; 

6 and 

7 (ii) one or more attorneys; and 

8 (B) whose primary mission is to assist pa9 tients and their families navigate health care-re10 lated programs and activities. 

11 (3) The term ‘‘Secretary’’ means the Secretary 

12 of Health and Human Services. 

13 (f) AUTHORIZATION OF APPROPRIATIONS.—To carry 

14 out this section, there are authorized to be appropriated 

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

16 2011 through 2015. 

17 SEC. 2538. SCREENING, BRIEF INTERVENTION, REFERRAL, 

18 AND TREATMENT FOR MENTAL HEALTH AND 

19 SUBSTANCE ABUSE DISORDERS. 

20 Part D of title V (42 U.S.C. 290dd et seq.) is amend21 ed by adding at the end the following: 
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1 ‘‘SEC. 544. SCREENING, BRIEF INTERVENTION, REFERRAL, 

2 AND TREATMENT FOR MENTAL HEALTH AND 

3 SUBSTANCE ABUSE DISORDERS. 

4 ‘‘(a) PROGRAM.—The Secretary, acting through the 

5 Administrator, shall establish a program (consisting of 

6 awarding grants, contracts, and cooperative agreements 

7 under subsection (b)) on mental health and substance 

8 abuse screening, brief intervention, referral, and recovery 

9 services for individuals in primary health care settings. 

10 ‘‘(b) USE OF FUNDS.—The Secretary may award 

11 grants to, or enter into contracts or cooperative agree12 ments with, entities— 

13 ‘‘(1) to provide mental health and substance 

14 abuse screening, brief interventions, referral, and re15 covery services; 

16 ‘‘(2) to coordinate these services with primary 

17 health care services in the same program and set18 ting; 

19 ‘‘(3) to develop a network of facilities to which 

20 patients may be referred if needed; 

21 ‘‘(4) to purchase needed screening and other 

22 tools that are— 

23 ‘‘(A) necessary for providing these services; 

24 and 

25 ‘‘(B) supported by evidence-based research; 

26 and 
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1 ‘‘(5) to maintain communication with appro2 priate State mental health and substance abuse 

3 agencies. 

4 ‘‘(c) ELIGIBILITY.—To be eligible for a grant, con5 tract, or cooperative agreement under this section, an enti6 ty shall be a public or private nonprofit entity that— 

7 ‘‘(1) provides primary health services; 

8 ‘‘(2) seeks to integrate mental health and sub9 stance abuse services into its service system; 

10 ‘‘(3) has developed a working relationship with 

11 providers of mental health and substance abuse serv12 ices; 

13 ‘‘(4) demonstrates a need for the inclusion of 

14 mental health and substance abuse services in its 

15 service system; and 

16 ‘‘(5) agrees— 

17 ‘‘(A) to prepare and submit to the Sec18 retary at the end of the grant, contract, or co19 operative agreement period an evaluation of all 

20 activities funded through the grant, contract, or 

21 cooperative agreement; and 

22 ‘‘(B) to use such performance measures as 

23 may be stipulated by the Secretary for purposes 

24 of such evaluation. 
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1 ‘‘(d) PREFERENCE.—In awarding grants, contracts, 

2 and cooperative agreements under this section, the Sec3 retary shall give preference to entities that— 

4 ‘‘(1) provide services in rural or frontier areas 

5 of the Nation; 

6 ‘‘(2) provide services to special needs popu7 lations, including American Indian or Alaska Native 

8 populations; or 

9 ‘‘(3) provide services in school-based health 

10 clinics or on university and college campuses. 

11 ‘‘(e) DURATION.—The period of a grant, contract, or 

12 cooperative agreement under this section may not exceed 

13 5 years. 

14 ‘‘(f) REPORT.—Not later than 4 years after the first 

15 appropriation of funds to carry out this section, the Sec16 retary shall submit a report to the Congress on the pro17 gram under this section— 

18 ‘‘(1) including an evaluation of the benefits of 

19 integrating mental health and substance abuse care 

20 within primary health care; and 

21 ‘‘(2) focusing on the performance measures 

22 stipulated by the Secretary under subsection (c)(5). 

23 ‘‘(g) AUTHORIZATION OF APPROPRIATIONS.— 

24 ‘‘(1) IN GENERAL.—To carry out this section, 

25 there are authorized to be appropriated $30,000,000 
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1 for fiscal year 2011 and such sums as may be nec2 essary for each of fiscal years 2012 through 2015. 

3 ‘‘(2) PROGRAM MANAGEMENT.—Of the funds 

4 appropriated to carry out this section for a fiscal 

5 year, the Secretary may use not more than 5 percent 

6 to manage the program under this section.’’. 

7 SEC. 2539. GRANTS TO ASSIST IN DEVELOPING MEDICAL 

8 SCHOOLS IN FEDERALLY-DESIGNATED 

9 HEALTH PROFESSIONAL SHORTAGE AREAS. 

10 (a) GRANTS AUTHORIZED.—The Secretary of Health 

11 and Human Services may make grants to nonprofit orga12 nizations or institutions of higher education for the pur13 pose of assisting the organization or institution involved 

14 to develop a medical school if— 

15 (1) the medical school will be located in an area 

16 that is designated (under section 332 of the Public 

17 Health Service Act (42 U.S.C. 254e)) as a health 

18 professional shortage area; 

19 (2) the organization or institution provides as20 surances satisfactory to the Secretary of substantial 

21 private or public funding from non-Federal sources 

22 for the development of the medical school; and 

23 (3) the organization or institution provides as24 surances satisfactory to the Secretary that accredita25 tion will be achieved for the medical school. 
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1 (b) USE OF GRANT FUNDS.—Grants awarded under 

2 this section may be used for the acquisition and building 

3 of the medical school campus in a health professional 

4 shortage area and the purchase of equipment, curriculum 

5 and faculty development, and general operations related 

6 to the development and establishment of the medical 

7 school. 

8 (c) AUTHORIZATION OF APPROPRIATIONS.—For the 

9 purpose of carrying out this section, there is authorized 

10 to be appropriated $100,000,000 for each of fiscal years 

11 2011 through 2015. 

12 PART 3—EMERGENCY CARE-RELATED 

13 PROGRAMS 

14 SEC. 2551. TRAUMA CARE CENTERS. 

15 (a) GRANTS FOR TRAUMA CARE CENTERS.—Section 

16 1241 (42 U.S.C. 300d–41) is amended to read as follows: 

17 ‘‘SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS. 

18 ‘‘(a) IN GENERAL.—The Secretary shall establish a 

19 trauma center program consisting of awarding grants 

20 under section (b). 

21 ‘‘(b) GRANTS.—The Secretary shall award grants as 

22 follows: 

23 ‘‘(1) EXISTING CENTERS.—Grants to public, 

24 private nonprofit, Indian Health Service, Indian 

25 tribal, and urban Indian trauma centers— 
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1 ‘‘(A) to further the core missions of such 

2 centers; or 

3 ‘‘(B) to provide emergency relief to ensure 

4 the continued and future availability of trauma 

5 services by trauma centers— 

6 ‘‘(i) at risk of closing or operating in 

7 an area where a closing has occurred with8 in their primary service area; or 

9 ‘‘(ii) in need of financial assistance 

10 following a natural disaster or other cata11 strophic event, such as a terrorist attack. 

12 ‘‘(2) NEW CENTERS.—Grants to local govern13 ments and public or private nonprofit entities to es14 tablish new trauma centers in urban areas with a 

15 substantial degree of trauma resulting from violent 

16 crimes. 

17 ‘‘(c) MINIMUM QUALIFICATIONS OF TRAUMA CEN18 TERS.— 

19 ‘‘(1) PARTICIPATION IN TRAUMA CARE SYSTEM

20 OPERATING UNDER CERTAIN PROFESSIONAL GUIDE21 LINES.— 

22 ‘‘(A) LIMITATION.—Subject to subpara23 graph (B), the Secretary may not award a 

24 grant to an existing trauma center under this 

25 section unless the center is a participant in a 
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1 trauma care system that substantially complies 

2 with section 1213. 

3 ‘‘(B) EXEMPTION.—Subparagraph (A) 

4 shall not apply to trauma centers that are lo5 cated in States with no existing trauma care 

6 system. 

7 ‘‘(2) DESIGNATION.—The Secretary may not 

8 award a grant under this section to an existing trau9 ma center unless the center is— 

10 ‘‘(A) verified as a trauma center by the 

11 American College of Surgeons; or 

12 ‘‘(B) designated as a trauma center by the 

13 applicable State health or emergency medical 

14 services authority.’’. 

15 (b) CONSIDERATIONS IN MAKING GRANTS.—Section 

16 1242 (42 U.S.C. 300d–42) is amended to read as follows: 

17 ‘‘SEC. 1242. CONSIDERATIONS IN MAKING GRANTS. 

18 ‘‘(a) CORE MISSION AWARDS.— 

19 ‘‘(1) IN GENERAL.—In awarding grants under 

20 section 1241(b)(1)(A), the Secretary shall— 

21 ‘‘(A) reserve a minimum of 25 percent of 

22 the amount allocated for such grants for level 

23 III and level IV trauma centers in rural or un24 derserved areas; 
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1 ‘‘(B) reserve a minimum of 25 percent of 

2 the amount allocated for such grants for level 

3 I and level II trauma centers in urban areas; 

4 and 

5 ‘‘(C) give preference to any application 

6 made by a trauma center— 

7 ‘‘(i) in a geographic area where 

8 growth in demand for trauma services ex9 ceeds capacity; 

10 ‘‘(ii) that demonstrates the financial 

11 support of the State or political subdivision 

12 involved; 

13 ‘‘(iii) that has at least 1 graduate 

14 medical education fellowship in trauma or 

15 trauma-related specialties, including neuro16 logical surgery, surgical critical care, vas17 cular surgery, and spinal cord injury, for 

18 which demand is exceeding supply; or 

19 ‘‘(iv) that demonstrates a substantial 

20 commitment to serving vulnerable popu21 lations. 

22 ‘‘(2) FINANCIAL SUPPORT.—For purposes of 

23 paragraph (1)(C)(ii), financial support may be dem24 onstrated by State or political subdivision funding 

25 for the trauma center’s capital or operating expenses 
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1 (including through State trauma regional advisory 

2 coordination activities, Medicaid funding designated 

3 for trauma services, or other governmental funding). 

4 State funding derived from Federal support shall 

5 not constitute State or local financial support for 

6 purposes of preferential treatment under this sub7 section. 

8 ‘‘(3) USE OF FUNDS.—The recipient of a grant 

9 under section 1241(b)(1)(A) shall carry out, con10 sistent with furthering the core missions of the cen11 ter, one or more of the following activities: 

12 ‘‘(A) Providing 24-hour-a-day, 7-day-a13 week trauma care availability. 

14 ‘‘(B) Reducing overcrowding related to 

15 throughput of trauma patients. 

16 ‘‘(C) Enhancing trauma surge capacity. 

17 ‘‘(D) Ensuring physician and essential per18 sonnel availability. 

19 ‘‘(E) Trauma education and outreach. 

20 ‘‘(F) Coordination with local and regional 

21 trauma care systems. 

22 ‘‘(G) Such other activities as the Secretary 

23 may deem appropriate. 
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1 ‘‘(b) EMERGENCY AWARDS; NEW CENTERS.—In 

2 awarding grants under paragraphs (1)(B) and (2) of sec3 tion 1241(b), the Secretary shall— 

4 ‘‘(1) give preference to any application sub5 mitted by an applicant that demonstrates the finan6 cial support (in accordance with subsection (a)(2)) 

7 of the State or political subdivision involved for the 

8 activities to be funded through the grant for each 

9 fiscal year during which payments are made to the 

10 center under the grant; and 

11 ‘‘(2) give preference to any application sub12 mitted for a trauma center that— 

13 ‘‘(A) is providing or will provide trauma 

14 care in a geographic area in which the avail15 ability of trauma care has either significantly 

16 decreased as a result of a trauma center in the 

17 area permanently ceasing participation in a sys18 tem described in section 1241(c)(1) as of a date 

19 occurring during the 2-year period preceding 

20 the fiscal year for which the trauma center is 

21 applying to receive a grant, or in geographic 

22 areas where growth in demand for trauma serv23 ices exceeds capacity; 

24 ‘‘(B) will, in providing trauma care during 

25 the 1-year period beginning on the date on 
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1 which the application for the grant is sub2 mitted, incur substantial uncompensated care 

3 costs in an amount that renders the center un4 able to continue participation in such system 

5 and results in a significant decrease in the 

6 availability of trauma care in the geographic 

7 area; 

8 ‘‘(C) operates or will operate in rural areas 

9 where trauma care availability will significantly 

10 decrease if the center is forced to close or down11 grade service and substantial costs are contrib12 uting to a likelihood of such closure or 

13 downgradation; 

14 ‘‘(D) is in a geographic location substan15 tially affected by a natural disaster or other 

16 catastrophic event such as a terrorist attack; or 

17 ‘‘(E) will establish a new trauma service in 

18 an urban area with a substantial degree of 

19 trauma resulting from violent crimes. 

20 ‘‘(c) DESIGNATIONS OF LEVELS OF TRAUMA CEN21 TERS IN CERTAIN STATES.—In the case of a State which 

22 has not designated 4 levels of trauma centers, any ref23 erence in this section to— 

24 ‘‘(1) a level I or level II trauma center is 

25 deemed to be a reference to a trauma center within 
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1 the highest 2 levels of trauma centers designated 

2 under State guidelines; and 

3 ‘‘(2) a level III or IV trauma center is deemed 

4 to be a reference to a trauma center not within such 

5 highest 2 levels.’’. 

6 (c) CERTAIN AGREEMENTS.—Section 1243 (42 

7 U.S.C. 300d–43) is amended to read as follows: 

8 ‘‘SEC. 1243. CERTAIN AGREEMENTS. 

9 ‘‘(a) COMMITMENT REGARDING CONTINUED PAR10 TICIPATION IN TRAUMA CARE SYSTEM.—The Secretary 

11 may not award a grant to an applicant under section 

12 1241(b) unless the applicant agrees that— 

13 ‘‘(1) the trauma center involved will continue 

14 participation, or in the case of a new center will par15 ticipate, in the system described in section 

16 1241(c)(1), except as provided in section 

17 1241(c)(1)(B), throughout the grant period begin18 ning on the date that the center first receives pay19 ments under the grant; and 

20 ‘‘(2) if the agreement made pursuant to para21 graph (1) is violated by the center, the center will 

22 be liable to the United States for an amount equal 

23 to the sum of— 

24 ‘‘(A) the amount of assistance provided to 

25 the center under section 1241; and 
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1 ‘‘(B) an amount representing interest on 

2 the amount specified in subparagraph (A). 

3 ‘‘(b) MAINTENANCE OF FINANCIAL SUPPORT.—With 

4 respect to activities for which funds awarded through a 

5 grant under section 1241 are authorized to be expended, 

6 the Secretary may not award such a grant unless the ap7 plicant agrees that, during the period in which the trauma 

8 center involved is receiving payments under the grant, the 

9 center will maintain access to trauma services at levels not 

10 less than the levels for the prior year, taking into ac11 count— 

12 ‘‘(1) reasonable volume fluctuation that is not 

13 caused by intentional trauma boundary reduction; 

14 ‘‘(2) downgrading of the level of services; and 

15 ‘‘(3) whether such center diverts its incoming 

16 patients away from such center 5 percent or more 

17 of the time during which the center is in operation 

18 over the course of the year. 

19 ‘‘(c) TRAUMA CARE REGISTRY.—The Secretary may 

20 not award a grant to a trauma center under section 

21 1241(b)(1) unless the center agrees that— 

22 ‘‘(1) not later than 6 months after the date on 

23 which the center submits a grant application to the 

24 Secretary, the center will establish and operate a 

25 registry of trauma cases in accordance with guide-
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1 lines developed by the American College of Surgeons; 

2 and 

3 ‘‘(2) in carrying out paragraph (1), the center 

4 will maintain information on the number of trauma 

5 cases treated by the center and, for each such case, 

6 the extent to which the center incurs uncompensated 

7 costs in providing trauma care.’’. 

8 (d) GENERAL PROVISIONS.—Section 1244 (42 

9 U.S.C. 300d–44) is amended to read as follows: 

10 ‘‘SEC. 1244. GENERAL PROVISIONS. 

11 ‘‘(a) LIMITATION ON DURATION OF SUPPORT.—The 

12 period during which a trauma center receives payments 

13 under a grant under section 1241(b)(1) shall be for 3 fis14 cal years, except that the Secretary may waive such re15 quirement for the center and authorize the center to re16 ceive such payments for 1 additional fiscal year. 

17 ‘‘(b) ELIGIBILITY.—The acquisition of, or eligibility 

18 for, a grant under section 1241(b) shall not preclude a 

19 trauma center’s eligibility for another grant described in 

20 such section. 

21 ‘‘(c) FUNDING DISTRIBUTION.—Of the total amount 

22 appropriated for a fiscal year under section 1245— 

23 ‘‘(1) 90 percent shall be used for grants under 

24 paragraph (1)(A) of section 1241(b); and 
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1 ‘‘(2) 10 percent shall be used for grants under 

2 paragraphs (1)(B) and (2) of section 1241(b). 

3 ‘‘(d) REPORT.—Beginning 2 years after the date of 

4 the enactment of the Affordable Health Care for America 

5 Act, and every 2 years thereafter, the Secretary shall bien6 nially— 

7 ‘‘(1) report to Congress on the status of the 

8 grants made pursuant to section 1241; 

9 ‘‘(2) evaluate and report to Congress on the 

10 overall financial stability of trauma centers in the 

11 United States; 

12 ‘‘(3) report on the populations using trauma 

13 care centers and include aggregate patient data on 

14 income, race, ethnicity, and geography; and 

15 ‘‘(4) evaluate the effectiveness and efficiency of 

16 trauma care center activities using standard public 

17 health measures and evaluation methodologies.’’. 

18 (e) AUTHORIZATION OF APPROPRIATIONS.—Section 

19 1245 (42 U.S.C. 300d–45) is amended to read as follows: 

20 ‘‘SEC. 1245. AUTHORIZATION OF APPROPRIATIONS. 

21 ‘‘(a) IN GENERAL.—For the purpose of carrying out 

22 this part, there are authorized to be appropriated 

23 $100,000,000 for fiscal year 2011, and such sums as may 

24 be necessary for each of fiscal years 2012 through 2015. 

25 Such authorization of appropriations is in addition to any 
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1 other authorization of appropriations or amounts that are 

2 available for such purpose. 

3 ‘‘(b) REALLOCATION.—The Secretary shall reallocate 

4 for grants under section 1241(b)(1)(A) any funds appro5 priated for grants under paragraph (1)(B) or (2) of sec6 tion 1241(b), but not obligated due to insufficient applica7 tions eligible for funding.’’. 

8 SEC. 2552. EMERGENCY CARE COORDINATION. 

9 (a) IN GENERAL.—Subtitle B of title XXVIII (42 

10 U.S.C. 300hh–10 et seq.) is amended by adding at the 

11 end the following: 

12 ‘‘SEC. 2816. EMERGENCY CARE COORDINATION. 

13 ‘‘(a) EMERGENCY CARE COORDINATION CENTER.— 

14 ‘‘(1) ESTABLISHMENT.—The Secretary shall es15 tablish, within the Office of the Assistant Secretary 

16 for Preparedness and Response, an Emergency Care 

17 Coordination Center (in this section referred to as 

18 the ‘Center’), to be headed by a director. 

19 ‘‘(2) DUTIES.—The Secretary, acting through 

20 the Director of the Center, in coordination with the 

21 Federal Interagency Committee on Emergency Med22 ical Services, shall— 

23 ‘‘(A) promote and fund research in emer24 gency medicine and trauma health care; 
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1 ‘‘(B) promote regional partnerships and 

2 more effective emergency medical systems in 

3 order to enhance appropriate triage, distribu4 tion, and care of routine community patients; 

5 and 

6 ‘‘(C) promote local, regional, and State 

7 emergency medical systems’ preparedness for 

8 and response to public health events. 

9 ‘‘(b) COUNCIL OF EMERGENCY CARE.— 

10 ‘‘(1) ESTABLISHMENT.—The Secretary, acting 

11 through the Director of the Center, shall establish a 

12 Council of Emergency Care to provide advice and 

13 recommendations to the Director on carrying out 

14 this section. 

15 ‘‘(2) COMPOSITION.—The Council shall be com16 prised of employees of the departments and agencies 

17 of the Federal Government who are experts in emer18 gency care and management. 

19 ‘‘(c) REPORT.— 

20 ‘‘(1) SUBMISSION.—Not later than 12 months 

21 after the date of the enactment of the Affordable 

22 Health Care for America Act, the Secretary shall 

23 submit to the Congress an annual report on the ac24 tivities carried out under this section. 
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1 ‘‘(2) CONSIDERATIONS.—In preparing a report 

2 under paragraph (1), the Secretary shall consider 

3 factors including— 

4 ‘‘(A) emergency department crowding and 

5 boarding; and 

6 ‘‘(B) delays in care following presentation. 

7 ‘‘(d) AUTHORIZATION OF APPROPRIATIONS.—To 

8 carry out this section, there are authorized to be appro9 priated such sums as may be necessary for each of fiscal 

10 years 2011 through 2015.’’. 

11 (b) FUNCTIONS, PERSONNEL, ASSETS, LIABILITIES, 

12 AND ADMINISTRATIVE ACTIONS.—All functions, per13 sonnel, assets, and liabilities of, and administrative actions 

14 applicable to, the Emergency Care Coordination Center, 

15 as in existence on the day before the date of the enactment 

16 of this Act, shall be transferred to the Emergency Care 

17 Coordination Center established under section 2816(a) of 

18 the Public Health Service Act, as added by subsection (a). 

19 SEC. 2553. PILOT PROGRAMS TO IMPROVE EMERGENCY 

20 MEDICAL CARE. 

21 Part B of title III (42 U.S.C. 243 et seq.) is amended 

22 by inserting after section 314 the following: 
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1 ‘‘SEC. 315. REGIONALIZED COMMUNICATION SYSTEMS FOR 

2 EMERGENCY CARE RESPONSE. 

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

4 the Assistant Secretary for Preparedness and Response, 

5 shall award not fewer than 4 multiyear contracts or com6 petitive grants to eligible entities to support demonstration 

7 programs that design, implement, and evaluate innovative 

8 models of regionalized, comprehensive, and accountable 

9 emergency care systems. 

10 ‘‘(b) ELIGIBLE ENTITY; REGION.— 

11 ‘‘(1) ELIGIBLE ENTITY.—In this section, the 

12 term ‘eligible entity’ means a State or a partnership 

13 of 1 or more States and 1 or more local govern14 ments. 

15 ‘‘(2) REGION.—In this section, the term ‘re16 gion’ means an area within a State, an area that lies 

17 within multiple States, or a similar area (such as a 

18 multicounty area), as determined by the Secretary. 

19 ‘‘(c) DEMONSTRATION PROGRAM.—The Secretary 

20 shall award a contract or grant under subsection (a) to 

21 an eligible entity that proposes a demonstration program 

22 to design, implement, and evaluate an emergency medical 

23 system that— 

24 ‘‘(1) coordinates with public safety services, 

25 public health services, emergency medical services, 

26 medical facilities, and other entities within a region; 
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1 ‘‘(2) coordinates an approach to emergency 

2 medical system access throughout the region, includ3 ing 9–1–1 public safety answering points and emer4 gency medical dispatch; 

5 ‘‘(3) includes a mechanism, such as a regional 

6 medical direction or transport communications sys7 tem, that operates throughout the region to ensure 

8 that the correct patient is taken to the medically ap9 propriate facility (whether an initial facility or a 

10 higher level facility) in a timely fashion; 

11 ‘‘(4) allows for the tracking of prehospital and 

12 hospital resources, including inpatient bed capacity, 

13 emergency department capacity, on-call specialist 

14 coverage, ambulance diversion status, and the co15 ordination of such tracking with regional commu16 nications and hospital destination decisions; and 

17 ‘‘(5) includes a consistent regionwide 

18 prehospital, hospital, and interfacility data manage19 ment system that— 

20 ‘‘(A) complies with the National EMS In21 formation System, the National Trauma Data 

22 Bank, and others; 

23 ‘‘(B) reports data to appropriate Federal 

24 and State databanks and registries; and 
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1 ‘‘(C) contains information sufficient to 

2 evaluate key elements of prehospital care, hos3 pital destination decisions, including initial hos4 pital and interfacility decisions, and relevant 

5 outcomes of hospital care. 

6 ‘‘(d) APPLICATION.— 

7 ‘‘(1) IN GENERAL.—An eligible entity that 

8 seeks a contract or grant described in subsection (a) 

9 shall submit to the Secretary an application at such 

10 time and in such manner as the Secretary may re11 quire. 

12 ‘‘(2) APPLICATION INFORMATION.—Each appli13 cation shall include— 

14 ‘‘(A) an assurance from the eligible entity 

15 that the proposed system— 

16 ‘‘(i) has been coordinated with the ap17 plicable State office of emergency medical 

18 services (or equivalent State office); 

19 ‘‘(ii) is compatible with the applicable 

20 State emergency medical services system; 

21 ‘‘(iii) includes consistent indirect and 

22 direct medical oversight of prehospital, 

23 hospital, and interfacility transport 

24 throughout the region; 
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1 ‘‘(iv) coordinates prehospital treat2 ment and triage, hospital destination, and 

3 interfacility transport throughout the re4 gion; 

5 ‘‘(v) includes a categorization or des6 ignation system for special medical facili7 ties throughout the region that is— 

8 ‘‘(I) consistent with State laws 

9 and regulations; and 

10 ‘‘(II) integrated with the proto11 cols for transport and destination 

12 throughout the region; and 

13 ‘‘(vi) includes a regional medical di14 rection system, a patient tracking system, 

15 and a resource allocation system that— 

16 ‘‘(I) support day-to-day emer17 gency care system operation; 

18 ‘‘(II) can manage surge capacity 

19 during a major event or disaster; and 

20 ‘‘(III) are integrated with other 

21 components of the national and State 

22 emergency preparedness system; 

23 ‘‘(B) an agreement to make available non24 Federal contributions in accordance with sub25 section (e); and 
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1 ‘‘(C) such other information as the Sec2 retary may require. 

3 ‘‘(e) MATCHING FUNDS.— 

4 ‘‘(1) IN GENERAL.—With respect to the costs of 

5 the activities to be carried out each year with a con6 tract or grant under subsection (a), a condition for 

7 the receipt of the contract or grant is that the eligi8 ble entity involved agrees to make available (directly 

9 or through donations from public or private entities) 

10 non-Federal contributions toward such costs in an 

11 amount that is not less than 25 percent of such 

12 costs. 

13 ‘‘(2) DETERMINATION OF AMOUNT CONTRIB14 UTED.—Non-Federal contributions required in para15 graph (1) may be in cash or in kind, fairly evalu16 ated, including plant, equipment, or services. 

17 Amounts provided by the Federal Government, or 

18 services assisted or subsidized to any significant ex19 tent by the Federal Government, may not be in20 cluded in determining the amount of such non-Fed21 eral contributions. 

22 ‘‘(f) PRIORITY.—The Secretary shall give priority for 

23 the award of the contracts or grants described in sub24 section (a) to any eligible entity that serves a medically 

25 underserved population (as defined in section 330(b)(3)). 
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1 ‘‘(g) REPORT.—Not later than 90 days after the com2 pletion of a demonstration program under subsection (a), 

3 the recipient of such contract or grant described in such 

4 subsection shall submit to the Secretary a report con5 taining the results of an evaluation of the program, includ6 ing an identification of— 

7 ‘‘(1) the impact of the regional, accountable 

8 emergency care system on patient outcomes for var9 ious critical care categories, such as trauma, stroke, 

10 cardiac emergencies, and pediatric emergencies; 

11 ‘‘(2) the system characteristics that contribute 

12 to the effectiveness and efficiency of the program (or 

13 lack thereof); 

14 ‘‘(3) methods of assuring the long-term finan15 cial sustainability of the emergency care system; 

16 ‘‘(4) the State and local legislation necessary to 

17 implement and to maintain the system; and 

18 ‘‘(5) the barriers to developing regionalized, ac19 countable emergency care systems, as well as the 

20 methods to overcome such barriers. 

21 ‘‘(h) EVALUATION.—The Secretary, acting through 

22 the Assistant Secretary for Preparedness and Response, 

23 shall enter into a contract with an academic institution 

24 or other entity to conduct an independent evaluation of 
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1 the demonstration programs funded under subsection (a), 

2 including an evaluation of— 

3 ‘‘(1) the performance of the eligible entities re4 ceiving the funds; and 

5 ‘‘(2) the impact of the demonstration programs. 

6 ‘‘(i) DISSEMINATION OF FINDINGS.—The Secretary 

7 shall, as appropriate, disseminate to the public and to the 

8 appropriate committees of the Congress, the information 

9 contained in a report made under subsection (h). 

10 ‘‘(j) AUTHORIZATION OF APPROPRIATIONS.— 

11 ‘‘(1) IN GENERAL.—There is authorized to be 

12 appropriated to carry out this section $12,000,000 

13 for each of fiscal years 2011 through 2015. 

14 ‘‘(2) RESERVATION.—Of the amount appro15 priated to carry out this section for a fiscal year, the 

16 Secretary shall reserve 3 percent of such amount to 

17 carry out subsection (h) (relating to an independent 

18 evaluation).’’. 

19 SEC. 2554. ASSISTING VETERANS WITH MILITARY EMER20 GENCY MEDICAL TRAINING TO BECOME 

21 STATE-LICENSED OR CERTIFIED EMERGENCY 

22 MEDICAL TECHNICIANS (EMTS). 

23 (a) IN GENERAL.—Part B of title III (42 U.S.C. 243 

24 et seq.), as amended, is amended by inserting after section 

25 315 the following: 
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1 ‘‘SEC. 315A. ASSISTING VETERANS WITH MILITARY EMER2 GENCY MEDICAL TRAINING TO BECOME 

3 STATE-LICENSED OR CERTIFIED EMERGENCY 

4 MEDICAL TECHNICIANS (EMTS). 

5 ‘‘(a) PROGRAM.—The Secretary shall establish a pro6 gram consisting of awarding grants to States to assist vet7 erans who received and completed military emergency 

8 medical training while serving in the Armed Forces of the 

9 United States to become, upon their discharge or release 

10 from active duty service, State-licensed or certified emer11 gency medical technicians. 

12 ‘‘(b) USE OF FUNDS.—Amounts received as a grant 

13 under this section may be used to assist veterans described 

14 in subsection (a) to become State-licensed or certified 

15 emergency medical technicians as follows: 

16 ‘‘(1) Providing training. 

17 ‘‘(2) Providing reimbursement for costs associ18 ated with— 

19 ‘‘(A) training; or 

20 ‘‘(B) applying for licensure or certification. 

21 ‘‘(3) Expediting the licensing or certification 

22 process. 

23 ‘‘(c) ELIGIBILITY.—To be eligible for a grant under 

24 this section, a State shall demonstrate to the Secretary’s 

25 satisfaction that the State has a shortage of emergency 

26 medical technicians. 
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1 ‘‘(d) REPORT.—The Secretary shall submit to the 

2 Congress an annual report on the program under this sec3 tion. 

4 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.—To 

5 carry out this section, there are authorized to be appro6 priated such sums as may be necessary for each of fiscal 

7 years 2011 through 2015.’’. 

8 (b) GAO STUDY AND REPORT.—The Comptroller 

9 General of the United States shall— 

10 (1) conduct a study on the barriers experienced 

11 by veterans who received training as medical per12 sonnel while serving in the Armed Forces of the 

13 United States and, upon their discharge or release 

14 from active duty service, seek to become licensed or 

15 certified in a State as civilian health professionals; 

16 and 

17 (2) not later than 2 years after the date of the 

18 enactment of this Act, submit to the Congress a re19 port on the results of such study, including rec20 ommendations on whether the program established 

21 under section 315A of the Public Health Service 

22 Act, as added by subsection (a), should be expanded 

23 to assist veterans seeking to become licensed or cer24 tified in a State as health providers other than emer25 gency medical technicians. 
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1 SEC. 2555. DENTAL EMERGENCY RESPONDERS: PUBLIC 

2 HEALTH AND MEDICAL RESPONSE. 

3 (a) NATIONAL HEALTH SECURITY STRATEGY.—Sec4 tion 2802(b)(3) (42 U.S.C. 300hh–1(b)(3)) is amended— 

5 (1) in the matter preceding subparagraph (A), 

6 by inserting ‘‘dental and’’ before ‘‘mental health fa7 cilities’’; and 

8 (2) in subparagraph (D), by inserting ‘‘and 

9 dental’’ after ‘‘medical’’. 

10 (b) ALL-HAZARDS PUBLIC HEALTH AND MEDICAL

11 RESPONSE CURRICULA AND TRAINING.—Section 

12 319F(a)(5)(B) (42 U.S.C. 247d–6(a)(5)(B)) is amended 

13 by striking ‘‘public health or medical’’ and inserting ‘‘pub14 lic health, medical, or dental’’. 

15 SEC. 2556. DENTAL EMERGENCY RESPONDERS: HOMELAND 

16 SECURITY. 

17 (a) NATIONAL RESPONSE FRAMEWORK.—Paragraph 

18 (6) of section 2 of the Homeland Security Act of 2002 

19 (6 U.S.C. 101) is amended by inserting ‘‘and dental’’ after 

20 ‘‘emergency medical’’. 

21 (b) NATIONAL PREPAREDNESS SYSTEM.—Subpara22 graph (B) of section 653(b)(4) of the Post-Katrina Emer23 gency Management Reform Act of 2006 (6 U.S.C. 

24 753(b)(4)) is amended by striking ‘‘public health and med25 ical’’ and inserting ‘‘public health, medical, and dental’’. 
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1 (c) CHIEF MEDICAL OFFICER.—Paragraph (5) of 

2 section 516(c) of the Homeland Security Act of 2002 (6 

3 U.S.C. 321e(c)) is amended by striking ‘‘medical commu4 nity’’ and inserting ‘‘medical and dental communities’’. 

5 PART 4—PAIN CARE AND MANAGEMENT 

6 PROGRAMS 

7 SEC. 2561. INSTITUTE OF MEDICINE CONFERENCE ON PAIN. 

8 (a) CONVENING.—Not later than June 30, 2011, the 

9 Secretary of Health and Human Services shall seek to 

10 enter into an agreement with the Institute of Medicine of 

11 the National Academies to convene a Conference on Pain 

12 (in this section referred to as ‘‘the Conference’’). 

13 (b) PURPOSES.—The purposes of the Conference 

14 shall be to— 

15 (1) increase the recognition of pain as a signifi16 cant public health problem in the United States; 

17 (2) evaluate the adequacy of assessment, diag18 nosis, treatment, and management of acute and 

19 chronic pain in the general population, and in identi20 fied racial, ethnic, gender, age, and other demo21 graphic groups that may be disproportionately af22 fected by inadequacies in the assessment, diagnosis, 

23 treatment, and management of pain; 

24 (3) identify barriers to appropriate pain care, 

25 including— 
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1 (A) lack of understanding and education 

2 among employers, patients, health care pro3 viders, regulators, and third-party payors; 

4 (B) barriers to access to care at the pri5 mary, specialty, and tertiary care levels, includ6 ing barriers— 

7 (i) specific to those populations that 

8 are disproportionately undertreated for 

9 pain; 

10 (ii) related to physician concerns over 

11 regulatory and law enforcement policies 

12 applicable to some pain therapies; and 

13 (iii) attributable to benefit, coverage, 

14 and payment policies in both the public 

15 and private sectors; and 

16 (C) gaps in basic and clinical research on 

17 the symptoms and causes of pain, and potential 

18 assessment methods and new treatments to im19 prove pain care; and 

20 (4) establish an agenda for action in both the 

21 public and private sectors that will reduce such bar22 riers and significantly improve the state of pain care 

23 research, education, and clinical care in the United 

24 States. 
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1 (c) OTHER APPROPRIATE ENTITY.—If the Institute 

2 of Medicine declines to enter into an agreement under sub3 section (a), the Secretary of Health and Human Services 

4 may enter into such agreement with another appropriate 

5 entity. 

6 (d) REPORT.—A report summarizing the Con7 ference’s findings and recommendations shall be sub8 mitted to the Congress not later than June 30, 2012. 

9 (e) AUTHORIZATION OF APPROPRIATIONS.—For the 

10 purpose of carrying out this section, there is authorized 

11 to be appropriated $500,000 for each of fiscal years 2011 

12 and 2012. 

13 SEC. 2562. PAIN RESEARCH AT NATIONAL INSTITUTES OF 

14 HEALTH. 

15 Part B of title IV (42 U.S.C. 284 et seq.) is amended 

16 by adding at the end the following: 

17 ‘‘SEC. 409J. PAIN RESEARCH. 

18 ‘‘(a) RESEARCH INITIATIVES.— 

19 ‘‘(1) IN GENERAL.—The Director of NIH is en20 couraged to continue and expand, through the Pain 

21 Consortium, an aggressive program of basic and 

22 clinical research on the causes of and potential treat23 ments for pain. 

24 ‘‘(2) ANNUAL RECOMMENDATIONS.—Not less 

25 than annually, the Pain Consortium, in consultation 
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1 with the Division of Program Coordination, Plan2 ning, and Strategic Initiatives, shall develop and 

3 submit to the Director of NIH recommendations on 

4 appropriate pain research initiatives that could be 

5 undertaken with funds reserved under section 

6 402A(c)(1) for the Common Fund or otherwise 

7 available for such initiatives. 

8 ‘‘(3) DEFINITION.—In this subsection, the term 

9 ‘Pain Consortium’ means the Pain Consortium of 

10 the National Institutes of Health or a similar trans11 National Institutes of Health coordinating entity 

12 designated by the Secretary for purposes of this sub13 section. 

14 ‘‘(b) INTERAGENCY PAIN RESEARCH COORDINATING

15 COMMITTEE.— 

16 ‘‘(1) ESTABLISHMENT.—The Secretary shall es17 tablish not later than 1 year after the date of the 

18 enactment of this section and as necessary maintain 

19 a committee, to be known as the Interagency Pain 

20 Research Coordinating Committee (in this section 

21 referred to as the ‘Committee’), to coordinate all ef22 forts within the Department of Health and Human 

23 Services and other Federal agencies that relate to 

24 pain research. 

25 ‘‘(2) MEMBERSHIP.— 
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1 ‘‘(A) IN GENERAL.—The Committee shall 

2 be composed of the following voting members: 

3 ‘‘(i) Not more than 7 voting Federal 

4 representatives as follows: 

5 ‘‘(I) The Director of the Centers 

6 for Disease Control and Prevention. 

7 ‘‘(II) The Director of the Na8 tional Institutes of Health and the di9 rectors of such national research insti10 tutes and national centers as the Sec11 retary determines appropriate. 

12 ‘‘(III) The heads of such other 

13 agencies of the Department of Health 

14 and Human Services as the Secretary 

15 determines appropriate. 

16 ‘‘(IV) Representatives of other 

17 Federal agencies that conduct or sup18 port pain care research and treat19 ment, including the Department of 

20 Defense and the Department of Vet21 erans Affairs. 

22 ‘‘(ii) Twelve additional voting mem23 bers appointed under subparagraph (B). 
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1 ‘‘(B) ADDITIONAL MEMBERS.—The Com2 mittee shall include additional voting members 

3 appointed by the Secretary as follows: 

4 ‘‘(i) Six members shall be appointed 

5 from among scientists, physicians, and 

6 other health professionals, who— 

7 ‘‘(I) are not officers or employees 

8 of the United States; 

9 ‘‘(II) represent multiple dis10 ciplines, including clinical, basic, and 

11 public health sciences; 

12 ‘‘(III) represent different geo13 graphical regions of the United 

14 States; and 

15 ‘‘(IV) are from practice settings, 

16 academia, manufacturers, or other re17 search settings. 

18 ‘‘(ii) Six members shall be appointed 

19 from members of the general public, who 

20 are representatives of leading research, ad21 vocacy, and service organizations for indi22 viduals with pain-related conditions. 

23 ‘‘(C) NONVOTING MEMBERS.—The Com24 mittee shall include such nonvoting members as 

25 the Secretary determines to be appropriate. 
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1 ‘‘(3) CHAIRPERSON.—The voting members of 

2 the Committee shall select a chairperson from 

3 among such members. The selection of a chairperson 

4 shall be subject to the approval of the Director of 

5 NIH. 

6 ‘‘(4) MEETINGS.—The Committee shall meet at 

7 the call of the chairperson of the Committee or upon 

8 the request of the Director of NIH, but in no case 

9 less often than once each year. 

10 ‘‘(5) DUTIES.—The Committee shall— 

11 ‘‘(A) develop a summary of advances in 

12 pain care research supported or conducted by 

13 the Federal agencies relevant to the diagnosis, 

14 prevention, and treatment of pain and diseases 

15 and disorders associated with pain; 

16 ‘‘(B) identify critical gaps in basic and 

17 clinical research on the symptoms and causes of 

18 pain; 

19 ‘‘(C) make recommendations to ensure that 

20 the activities of the National Institutes of 

21 Health and other Federal agencies, including 

22 the Department of Defense and the Department 

23 of Veteran Affairs, are free of unnecessary du24 plication of effort; 
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1 ‘‘(D) make recommendations on how best 

2 to disseminate information on pain care; and 

3 ‘‘(E) make recommendations on how to ex4 pand partnerships between public entities, in5 cluding Federal agencies, and private entities to 

6 expand collaborative, crosscutting research. 

7 ‘‘(6) REVIEW.—The Secretary shall review the 

8 necessity of the Committee at least once every 2 

9 years.’’. 

10 SEC. 2563. PUBLIC AWARENESS CAMPAIGN ON PAIN MAN11 AGEMENT. 

12 Part B of title II (42 U.S.C. 238 et seq.) is amended 

13 by adding at the end the following: 

14 ‘‘SEC. 249. NATIONAL EDUCATION OUTREACH AND AWARE15 NESS CAMPAIGN ON PAIN MANAGEMENT. 

16 ‘‘(a) ESTABLISHMENT.—Not later than 12 months 

17 after the date of the enactment of this section, the Sec18 retary shall establish and implement a national pain care 

19 education outreach and awareness campaign described in 

20 subsection (b). 

21 ‘‘(b) REQUIREMENTS.—The Secretary shall design 

22 the public awareness campaign under this section to edu23 cate consumers, patients, their families, and other care24 givers with respect to— 
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1 ‘‘(1) the incidence and importance of pain as a 

2 national public health problem; 

3 ‘‘(2) the adverse physical, psychological, emo4 tional, societal, and financial consequences that can 

5 result if pain is not appropriately assessed, diag6 nosed, treated, or managed; 

7 ‘‘(3) the availability, benefits, and risks of all 

8 pain treatment and management options; 

9 ‘‘(4) having pain promptly assessed, appro10 priately diagnosed, treated, and managed, and regu11 larly reassessed with treatment adjusted as needed; 

12 ‘‘(5) the role of credentialed pain management 

13 specialists and subspecialists, and of comprehensive 

14 interdisciplinary centers of treatment expertise; 

15 ‘‘(6) the availability in the public, nonprofit, 

16 and private sectors of pain management-related in17 formation, services, and resources for consumers, 

18 employers, third-party payors, patients, their fami19 lies, and caregivers, including information on— 

20 ‘‘(A) appropriate assessment, diagnosis, 

21 treatment, and management options for all 

22 types of pain and pain-related symptoms; and 

23 ‘‘(B) conditions for which no treatment op24 tions are yet recognized; and 
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1 ‘‘(7) other issues the Secretary deems appro2 priate. 

3 ‘‘(c) CONSULTATION.—In designing and imple4 menting the public awareness campaign required by this 

5 section, the Secretary shall consult with organizations rep6 resenting patients in pain and other consumers, employ7 ers, physicians including physicians specializing in pain 

8 care, other pain management professionals, medical device 

9 manufacturers, and pharmaceutical companies. 

10 ‘‘(d) COORDINATION.— 

11 ‘‘(1) LEAD OFFICIAL.—The Secretary shall des12 ignate one official in the Department of Health and 

13 Human Services to oversee the campaign established 

14 under this section. 

15 ‘‘(2) AGENCY COORDINATION.—The Secretary 

16 shall ensure the involvement in the public awareness 

17 campaign under this section of the Surgeon General 

18 of the Public Health Service, the Director of the 

19 Centers for Disease Control and Prevention, and 

20 such other representatives of offices and agencies of 

21 the Department of Health and Human Services as 

22 the Secretary determines appropriate. 

23 ‘‘(e) UNDERSERVED AREAS AND POPULATIONS.—In 

24 designing the public awareness campaign under this sec25 tion, the Secretary shall— 
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1 ‘‘(1) take into account the special needs of geo2 graphic areas and racial, ethnic, gender, age, and 

3 other demographic groups that are currently under4 served; and 

5 ‘‘(2) provide resources that will reduce dispari6 ties in access to appropriate diagnosis, assessment, 

7 and treatment. 

8 ‘‘(f) GRANTS AND CONTRACTS.—The Secretary may 

9 make awards of grants, cooperative agreements, and con10 tracts to public agencies and private nonprofit organiza11 tions to assist with the development and implementation 

12 of the public awareness campaign under this section. 

13 ‘‘(g) EVALUATION AND REPORT.—Not later than the 

14 end of fiscal year 2012, the Secretary shall prepare and 

15 submit to the Congress a report evaluating the effective16 ness of the public awareness campaign under this section 

17 in educating the general public with respect to the matters 

18 described in subsection (b). 

19 ‘‘(h) AUTHORIZATION OF APPROPRIATIONS.—For 

20 purposes of carrying out this section, there are authorized 

21 to be appropriated $2,000,000 for fiscal year 2011 and 

22 $4,000,000 for each of fiscal years 2012 and 2015.’’. 
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1 Subtitle C—Food and Drug 

2 Administration 

3 PART 1—IN GENERAL 

4 SEC. 2571. NATIONAL MEDICAL DEVICE REGISTRY. 

5 (a) REGISTRY.— 

6 (1) IN GENERAL.—Section 519 of the Federal 

7 Food, Drug, and Cosmetic Act (21 U.S.C. 360i) is 

8 amended— 

9 (A) by redesignating subsection (g) as sub10 section (h); and 

11 (B) by inserting after subsection (f) the 

12 following: 

13 ‘‘National Medical Device Registry 

14 ‘‘(g)(1)(A) The Secretary shall establish a national 

15 medical device registry (in this subsection referred to as 

16 the ‘registry’) to facilitate analysis of postmarket safety 

17 and outcomes data on each covered device. 

18 ‘‘(B) In this subsection, the term ‘covered device’— 

19 ‘‘(i) shall include each class III device; and 

20 ‘‘(ii) may include, as the Secretary determines 

21 appropriate and specifies in regulation, a class II de22 vice that is life-supporting or life-sustaining. 

23 ‘‘(C) Notwithstanding subparagraph (B)(i), the Sec24 retary may by order exempt a class III device from the 

25 provisions of this subsection if the Secretary concludes 
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1 that inclusion of information on the device in the registry 

2 will not provide useful information on safety or effective3 ness. 

4 ‘‘(2) In developing the registry, the Secretary shall, 

5 in consultation with the Commissioner of Food and Drugs, 

6 the Administrator of the Centers for Medicare & Medicaid 

7 Services, the Administrator of the Agency for Healthcare 

8 Research and Quality, the head of the Office of the Na9 tional Coordinator for Health Information Technology, 

10 and the Secretary of Veterans Affairs, determine the best 

11 methods for— 

12 ‘‘(A) including in the registry, in a manner con13 sistent with subsection (f), appropriate information 

14 to identify each covered device by type, model, and 

15 serial number or other unique identifier; 

16 ‘‘(B) validating methods for analyzing patient 

17 safety and outcomes data from multiple sources and 

18 for linking such data with the information included 

19 in the registry as described in subparagraph (A), in20 cluding, to the extent feasible, use of— 

21 ‘‘(i) data provided to the Secretary under 

22 other provisions of this chapter; and 

23 ‘‘(ii) information from public and private 

24 sources identified under paragraph (3); 
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1 ‘‘(C) integrating the activities described in this 

2 subsection (so as to avoid duplication) with— 

3 ‘‘(i) activities under paragraph (3) of sec4 tion 505(k) (relating to active postmarket risk 

5 identification); 

6 ‘‘(ii) activities under paragraph (4) of sec7 tion 505(k) (relating to advanced analysis of 

8 drug safety data); 

9 ‘‘(iii) other postmarket device surveillance 

10 activities of the Secretary authorized by this 

11 chapter; and 

12 ‘‘(iv) registries carried out by or for the 

13 Agency for Healthcare Research and Quality; 

14 and 

15 ‘‘(D) providing public access to the data and 

16 analysis collected or developed through the registry 

17 in a manner and form that protects patient privacy 

18 and proprietary information and is comprehensive, 

19 useful, and not misleading to patients, physicians, 

20 and scientists. 

21 ‘‘(3)(A) To facilitate analyses of postmarket safety 

22 and patient outcomes for covered devices, the Secretary 

23 shall, in collaboration with public, academic, and private 

24 entities, develop methods to— 
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1 ‘‘(i) obtain access to disparate sources of 

2 patient safety and outcomes data, including— 

3 ‘‘(I) Federal health-related electronic 

4 data (such as data from the Medicare pro5 gram under title XVIII of the Social Secu6 rity Act or from the health systems of the 

7 Department of Veterans Affairs); 

8 ‘‘(II) private sector health-related 

9 electronic data (such as pharmaceutical 

10 purchase data and health insurance claims 

11 data); and 

12 ‘‘(III) other data as the Secretary 

13 deems necessary to permit postmarket as14 sessment of device safety and effectiveness; 

15 and 

16 ‘‘(ii) link data obtained under clause (i) 

17 with information in the registry. 

18 ‘‘(B) In this paragraph, the term ‘data’ refers to in19 formation respecting a covered device, including claims 

20 data, patient survey data, standardized analytic files that 

21 allow for the pooling and analysis of data from disparate 

22 data environments, electronic health records, and any 

23 other data deemed appropriate by the Secretary. 
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1 ‘‘(4) The Secretary shall promulgate regulations for 

2 establishment and operation of the registry under para3 graph (1). Such regulations— 

4 ‘‘(A)(i) in the case of covered devices that are 

5 sold on or after the date of the enactment of this 

6 subsection, shall require manufacturers of such de7 vices to submit information to the registry, includ8 ing, for each such device, the type, model, and serial 

9 number or, if required under subsection (f), other 

10 unique device identifier; and 

11 ‘‘(ii) in the case of covered devices that are sold 

12 before such date, may require manufacturers of such 

13 devices to submit such information to the registry, 

14 if deemed necessary by the Secretary to protect the 

15 public health; 

16 ‘‘(B) shall establish procedures— 

17 ‘‘(i) to permit linkage of information sub18 mitted pursuant to subparagraph (A) with pa19 tient safety and outcomes data obtained under 

20 paragraph (3); and 

21 ‘‘(ii) to permit analyses of linked data; 

22 ‘‘(C) may require covered device manufacturers 

23 to submit such other information as is necessary to 

24 facilitate postmarket assessments of device safety 

25 and effectiveness and notification of device risks; 
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1 ‘‘(D) shall establish requirements for regular 

2 and timely reports to the Secretary, which shall be 

3 included in the registry, concerning adverse event 

4 trends, adverse event patterns, incidence and preva5 lence of adverse events, and other information the 

6 Secretary determines appropriate, which may include 

7 data on comparative safety and outcomes trends; 

8 and 

9 ‘‘(E) shall establish procedures to permit public 

10 access to the information in the registry in a manner 

11 and form that protects patient privacy and propri12 etary information and is comprehensive, useful, and 

13 not misleading to patients, physicians, and sci14 entists. 

15 ‘‘(5)(A) The Secretary shall promulgate final regula16 tions under paragraph (4) not later than 36 months after 

17 the date of the enactment of this subsection. 

18 ‘‘(B) Before issuing the notice of proposed rule19 making preceding the final regulations described in sub20 paragraph (A), the Secretary shall hold a public hearing 

21 before an advisory committee on the issue of which class 

22 II devices to include in the definition of covered devices. 

23 ‘‘(C) The Secretary shall include in any regulation 

24 under this subsection an explanation demonstrating that 

25 the requirements of such regulation— 
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1 ‘‘(i) do not duplicate other Federal require2 ments; and 

3 ‘‘(ii) do not impose an undue burden on device 

4 manufacturers. 

5 ‘‘(6) With respect to any entity that submits or is 

6 required to submit a safety report or other information 

7 in connection with the safety of a device under this section 

8 (and any release by the Secretary of that report or infor9 mation), such report or information shall not be construed 

10 to reflect necessarily a conclusion by the entity or the Sec11 retary that the report or information constitutes an admis12 sion that the product involved malfunctioned, caused or 

13 contributed to an adverse experience, or otherwise caused 

14 or contributed to a death, serious injury, or serious illness. 

15 Such an entity need not admit, and may deny, that the 

16 report or information submitted by the entity constitutes 

17 an admission that the product involved malfunctioned, 

18 caused or contributed to an adverse experience, or caused 

19 or contributed to a death, serious injury, or serious illness. 

20 ‘‘(7) To carry out this subsection, there are author21 ized to be appropriated such sums as may be necessary 

22 for each of fiscal years 2011 and 2012.’’. 

23 (2) EFFECTIVE DATE.—The Secretary of 

24 Health and Human Services shall establish and 

25 begin implementation of the registry under section 
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1 519(g) of the Federal Food, Drug, and Cosmetic 

2 Act, as added by paragraph (1), by not later than 

3 the date that is 36 months after the date of the en4 actment of this Act, without regard to whether or 

5 not final regulations to establish and operate the 

6 registry have been promulgated by such date. 

7 (3) CONFORMING AMENDMENT.—Section 

8 303(f)(1)(B)(ii) of the Federal Food, Drug, and 

9 Cosmetic Act (21 U.S.C. 333(f)(1)(B)(ii)) is amend10 ed by striking ‘‘519(g)’’ and inserting ‘‘519(h)’’. 

11 (b) ELECTRONIC EXCHANGE AND USE IN CERTIFIED

12 ELECTRONIC HEALTH RECORDS OF UNIQUE DEVICE

13 IDENTIFIERS.— 

14 (1) RECOMMENDATIONS.—The HIT Policy 

15 Committee established under section 3002 of the 

16 Public Health Service Act (42 U.S.C. 300jj–12) 

17 shall recommend to the head of the Office of the Na18 tional Coordinator for Health Information Tech19 nology standards, implementation specifications, and 

20 certification criteria for the electronic exchange and 

21 use in certified electronic health records of a unique 

22 device identifier for each covered device (as defined 

23 under section 519(g)(1)(B) of the Federal Food, 

24 Drug, and Cosmetic Act, as added by subsection 

25 (a)). 
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1 (2) STANDARDS, IMPLEMENTATION CRITERIA, 

2 AND CERTIFICATION CRITERIA.—The Secretary of 

3 Health and Human Services, acting through the 

4 head of the Office of the National Coordinator for 

5 Health Information Technology, shall adopt stand6 ards, implementation specifications, and certification 

7 criteria for the electronic exchange and use in cer8 tified electronic health records of a unique device 

9 identifier for each covered device referred to in para10 graph (1), if such an identifier is required by section 

11 519(f) of the Federal Food, Drug, and Cosmetic Act 

12 (21 U.S.C. 360i(f)) for the device. 

13 (c) UNIQUE DEVICE IDENTIFICATION SYSTEM.—The 

14 Secretary of Health and Human Services, acting through 

15 the Commissioner of Food and Drugs, shall issue proposed 

16 regulations to implement section 519(f) of the Federal 

17 Food, Drug, and Cosmetic Act (21 U.S.C. 360i(f)) not 

18 later than 6 months after the date of the enactment of 

19 this Act. 
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1 SEC. 2572. NUTRITION LABELING OF STANDARD MENU 

2 ITEMS AT CHAIN RESTAURANTS AND OF AR3 TICLES OF FOOD SOLD FROM VENDING MA4 CHINES. 

5 (a) TECHNICAL AMENDMENTS.—Section 

6 403(q)(5)(A) of the Federal Food, Drug, and Cosmetic 

7 Act (21 U.S.C. 343(q)(5)(A)) is amended— 

8 (1) in subclause (i), by inserting ‘‘except as pro9 vided in clause (H)(ii)(III),’’ after ‘‘(i)’’ ; and 

10 (2) in subclause (ii), by inserting ‘‘except as 

11 provided in clause (H)(ii)(III),’’ after ‘‘(ii)’’. 

12 (b) LABELING REQUIREMENTS.—Section 403(q)(5) 

13 of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 

14 343(q)(5)) is amended by adding at the end the following: 

15 ‘‘(H) RESTAURANTS, RETAIL FOOD ESTABLISH16 MENTS, AND VENDING MACHINES.— 

17 ‘‘(i) GENERAL REQUIREMENTS FOR RES18 TAURANTS AND SIMILAR RETAIL FOOD ESTABLISH19 MENTS.—Except for food described in subclause 

20 (vii), in the case of food that is a standard menu 

21 item that is offered for sale in a restaurant or simi22 lar retail food establishment that is part of a chain 

23 with 20 or more locations doing business under the 

24 same name (regardless of the type of ownership of 

25 the locations) and offering for sale substantially the 

26 same menu items, the restaurant or similar retail 
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1 food establishment shall disclose the information de2 scribed in subclauses (ii) and (iii). 

3 ‘‘(ii) INFORMATION REQUIRED TO BE DIS4 CLOSED BY RESTAURANTS AND RETAIL FOOD ES5 TABLISHMENTS.—Except as provided in subclause 

6 (vii), the restaurant or similar retail food establish7 ment shall disclose in a clear and conspicuous man8 ner— 

9 ‘‘(I)(aa) in a nutrient content disclosure 

10 statement adjacent to the name of the standard 

11 menu item, so as to be clearly associated with 

12 the standard menu item, on the menu listing 

13 the item for sale, the number of calories con14 tained in the standard menu item, as usually 

15 prepared and offered for sale; and 

16 ‘‘(bb) a succinct statement concerning sug17 gested daily caloric intake, as specified by the 

18 Secretary by regulation and posted prominently 

19 on the menu and designed to enable the public 

20 to understand, in the context of a total daily 

21 diet, the significance of the caloric information 

22 that is provided on the menu; 

23 ‘‘(II)(aa) in a nutrient content disclosure 

24 statement adjacent to the name of the standard 

25 menu item, so as to be clearly associated with 
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1 the standard menu item, on the menu board, 

2 including a drive-through menu board, the 

3 number of calories contained in the standard 

4 menu item, as usually prepared and offered for 

5 sale; and 

6 ‘‘(bb) a succinct statement concerning sug7 gested daily caloric intake, as specified by the 

8 Secretary by regulation and posted prominently 

9 on the menu board, designed to enable the pub10 lic to understand, in the context of a total daily 

11 diet, the significance of the nutrition informa12 tion that is provided on the menu board; 

13 ‘‘(III) in a written form, available on the 

14 premises of the restaurant or similar retail es15 tablishment and to the consumer upon request, 

16 the nutrition information required under 

17 clauses (C) and (D) of subparagraph (1); and 

18 ‘‘(IV) on the menu or menu board, a 

19 prominent, clear, and conspicuous statement re20 garding the availability of the information de21 scribed in item (III). 

22 ‘‘(iii) SELF-SERVICE FOOD AND FOOD ON DIS23 PLAY.—Except as provided in subclause (vii), in the 

24 case of food sold at a salad bar, buffet line, cafeteria 

25 line, or similar self-service facility, and for self-serv-
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1 ice beverages or food that is on display and that is 

2 visible to customers, a restaurant or similar retail 

3 food establishment shall place adjacent to each food 

4 offered a sign that lists calories per displayed food 

5 item or per serving. 

6 ‘‘(iv) REASONABLE BASIS.—For the purposes of 

7 this clause, a restaurant or similar retail food estab8 lishment shall have a reasonable basis for its nutri9 ent content disclosures, including nutrient databases, 

10 cookbooks, laboratory analyses, and other reasonable 

11 means, as described in section 101.10 of title 21, 

12 Code of Federal Regulations (or any successor regu13 lation) or in a related guidance of the Food and 

14 Drug Administration. 

15 ‘‘(v) MENU VARIABILITY AND COMBINATION

16 MEALS.—The Secretary shall establish by regulation 

17 standards for determining and disclosing the nutri18 ent content for standard menu items that come in 

19 different flavors, varieties, or combinations, but 

20 which are listed as a single menu item, such as soft 

21 drinks, ice cream, pizza, doughnuts, or children’s 

22 combination meals, through means determined by 

23 the Secretary, including ranges, averages, or other 

24 methods. 
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1 ‘‘(vi) ADDITIONAL INFORMATION.—If the Sec2 retary determines that a nutrient, other than a nu3 trient required under subclause (ii)(III), should be 

4 disclosed for the purpose of providing information to 

5 assist consumers in maintaining healthy dietary 

6 practices, the Secretary may require, by regulation, 

7 disclosure of such nutrient in the written form re8 quired under subclause (ii)(III). 

9 ‘‘(vii) NONAPPLICABILITY TO CERTAIN FOOD.— 

10 ‘‘(I) IN GENERAL.—Subclauses (i) through 

11 (vi) do not apply to— 

12 ‘‘(aa) items that are not listed on a 

13 menu or menu board (such as condiments 

14 and other items placed on the table or 

15 counter for general use); 

16 ‘‘(bb) daily specials, temporary menu 

17 items appearing on the menu for less than 

18 60 days per calendar year, or custom or19 ders; or 

20 ‘‘(cc) such other food that is part of 

21 a customary market test appearing on the 

22 menu for less than 90 days, under terms 

23 and conditions established by the Sec24 retary. 
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1 ‘‘(II) WRITTEN FORMS.—Clause (C) shall 

2 apply to any regulations promulgated under 

3 subclauses (ii)(III) and (vi). 

4 ‘‘(viii) VENDING MACHINES.—In the case of an 

5 article of food sold from a vending machine that— 

6 ‘‘(I) does not permit a prospective pur7 chaser to examine the Nutrition Facts Panel 

8 before purchasing the article or does not other9 wise provide visible nutrition information at the 

10 point of purchase; and 

11 ‘‘(II) is operated by a person who is en12 gaged in the business of owning or operating 20 

13 or more vending machines, 

14 the vending machine operator shall provide a sign in 

15 close proximity to each article of food or the selec16 tion button that includes a clear and conspicuous 

17 statement disclosing the number of calories con18 tained in the article. 

19 ‘‘(ix) VOLUNTARY PROVISION OF NUTRITION IN20 FORMATION.— 

21 ‘‘(I) IN GENERAL.—An authorized official 

22 of any restaurant or similar retail food estab23 lishment or vending machine operator not sub24 ject to the requirements of this clause may elect 

25 to be subject to the requirements of such 
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1 clause, by registering biannually the name and 

2 address of such restaurant or similar retail food 

3 establishment or vending machine operator with 

4 the Secretary, as specified by the Secretary by 

5 regulation. 

6 ‘‘(II) REGISTRATION.—Within 120 days of 

7 the enactment of this clause, the Secretary shall 

8 publish a notice in the Federal Register speci9 fying the terms and conditions for implementa10 tion of item (I), pending promulgation of regu11 lations. 

12 ‘‘(III) RULE OF CONSTRUCTION.—Nothing 

13 in this subclause shall be construed to authorize 

14 the Secretary to require an application, review, 

15 or licensing process for any entity to register 

16 with the Secretary, as described in such item. 

17 ‘‘(x) REGULATIONS.— 

18 ‘‘(I) PROPOSED REGULATION.—Not later 

19 than 1 year after the date of the enactment of 

20 this clause, the Secretary shall promulgate pro21 posed regulations to carry out this clause. 

22 ‘‘(II) CONTENTS.—In promulgating regula23 tions, the Secretary shall— 

24 ‘‘(aa) consider standardization of rec25 ipes and methods of preparation, reason-
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•HR 3962 EH

1 able variation in serving size and formula2 tion of menu items, space on menus and 

3 menu boards, inadvertent human error, 

4 training of food service workers, variations 

5 in ingredients, and other factors, as the 

6 Secretary determines; and 

7 ‘‘(bb) specify the format and manner 

8 of the nutrient content disclosure require9 ments under this subclause. 

10 ‘‘(III) REPORTING.—The Secretary shall 

11 submit to the Committee on Health, Education, 

12 Labor, and Pensions of the Senate and the 

13 Committee on Energy and Commerce of the 

14 House of Representatives a quarterly report 

15 that describes the Secretary’s progress toward 

16 promulgating final regulations under this sub17 paragraph. 

18 ‘‘(xi) DEFINITION.—In this clause, the term 

19 ‘menu’ or ‘menu board’ means the primary writing 

20 of the restaurant or other similar retail food estab21 lishment from which a consumer makes an order se22 lection.’’. 

23 (c) NATIONAL UNIFORMITY.—Section 403A(a)(4) of 

24 the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 

25 343–1(a)(4)) is amended by striking ‘‘except a require-
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1 ment for nutrition labeling of food which is exempt under 

2 subclause (i) or (ii) of section 403(q)(5)(A)’’ and inserting 

3 ‘‘except that this paragraph does not apply to food that 

4 is offered for sale in a restaurant or similar retail food 

5 establishment that is not part of a chain with 20 or more 

6 locations doing business under the same name (regardless 

7 of the type of ownership of the locations) and offering for 

8 sale substantially the same menu items unless such res9 taurant or similar retail food establishment complies with 

10 the voluntary provision of nutrition information require11 ments under section 403(q)(5)(H)(ix)’’. 

12 (d) RULE OF CONSTRUCTION.—Nothing in the 

13 amendments made by this section shall be construed— 

14 (1) to preempt any provision of State or local 

15 law, unless such provision establishes or continues 

16 into effect nutrient content disclosures of the type 

17 required under section 403(q)(5)(H) of the Federal 

18 Food, Drug, and Cosmetic Act (as added by sub19 section (b)) and is expressly preempted under sec20 tion 403A(a)(4) of such Act; 

21 (2) to apply to any State or local requirement 

22 respecting a statement in the labeling of food that 

23 provides for a warning concerning the safety of the 

24 food or component of the food; or 
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1 (3) except as provided in section 

2 403(q)(5)(H)(ix) of the Federal Food, Drug, and 

3 Cosmetic Act (as added by subsection (b)), to apply 

4 to any restaurant or similar retail food establish5 ment other than a restaurant or similar retail food 

6 establishment described in section 403(q)(5)(H)(i) of 

7 such Act. 

8 SEC. 2573. PROTECTING CONSUMER ACCESS TO GENERIC 

9 DRUGS. 

10 (a) FINDINGS; PURPOSE.— 

11 (1) FINDINGS.—The Congress finds the fol12 lowing: 

13 (A) In 1984, the Drug Price Competition 

14 and Patent Term Restoration Act (Public Law 

15 98–417; in this subsection referred to as the 

16 ‘‘1984 Act’’) was enacted with the intent of fa17 cilitating the early entry of generic drugs while 

18 preserving incentives for innovation. 

19 (B) Prescription drugs make up 10 percent 

20 of national health care spending, but for the 

21 past decade have been one of the fastest grow22 ing segments of health care expenditures. 

23 (C) Until recently, the 1984 Act was suc24 cessful in facilitating generic competition to the 

25 benefit of consumers and health care payers— 
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1 although 67 percent of all prescriptions dis2 pensed in the United States are generic drugs, 

3 they account for only 20 percent of all expendi4 tures. 

5 (D) In recent years, the intent of the 1984 

6 Act has been subverted by certain settlement 

7 agreements between brand companies and their 

8 potential generic competitors that make reverse 

9 payments, i.e., payments by the brand company 

10 to the generic company. 

11 (E) These settlement agreements have un12 duly delayed the marketing of low-cost generic 

13 drugs contrary to free competition and the in14 terests of consumers. 

15 (F) The state of antitrust law relating to 

16 such settlement agreements is unsettled. 

17 (2) PURPOSE.—The purpose of this section is 

18 to provide an additional means to effectuate the in19 tent of the 1984 Act by enhancing competition in 

20 the pharmaceutical market by stopping agreements 

21 between brand name and generic drug manufactur22 ers that limit, delay, or otherwise prevent competi23 tion from generic drugs. 
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1 (b) IN GENERAL.—Section 505 of the Federal Food, 

2 Drug, and Cosmetic Act (21 U.S.C. 355) is amended by 

3 adding at the end the following: 

4 ‘‘(w) PROTECTING CONSUMER ACCESS TO GENERIC

5 DRUGS.— 

6 ‘‘(1) UNFAIR AND DECEPTIVE ACTS AND PRAC7 TICES RELATED TO NEW DRUG APPLICATIONS.— 

8 ‘‘(A) CONDUCT PROHIBITED.—It shall be 

9 unlawful for any person to directly or indirectly 

10 be a party to any agreement resolving or set11 tling a patent infringement claim in which— 

12 ‘‘(i) an ANDA filer receives anything 

13 of value; and 

14 ‘‘(ii) the ANDA filer agrees to limit or 

15 forego research, development, manufac16 turing, marketing, or sales, for any period 

17 of time, of the drug that is to be manufac18 tured under the ANDA involved and is the 

19 subject of the patent infringement claim. 

20 ‘‘(B) EXCEPTIONS.—Notwithstanding sub21 paragraph (A)(i), subparagraph (A) does not 

22 prohibit a resolution or settlement of a patent 

23 infringement claim in which the value received 

24 by the ANDA filer includes no more than— 
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1 ‘‘(i) the right to market the drug that 

2 is to be manufactured under the ANDA in3 volved and is the subject of the patent in4 fringement claim, before the expiration 

5 of— 

6 ‘‘(I) the patent that is the basis 

7 for the patent infringement claim; or 

8 ‘‘(II) any other statutory exclu9 sivity that would prevent the mar10 keting of such drug; and 

11 ‘‘(ii) the waiver of a patent infringe12 ment claim for damages based on prior 

13 marketing of such drug. 

14 ‘‘(C) ENFORCEMENT.— 

15 ‘‘(i) IN GENERAL.—A violation of sub16 paragraph (A) shall be subject to enforce17 ment by the Federal Trade Commission in 

18 the same manner, by the same means, and 

19 with the same jurisdiction as would an un20 fair and deceptive act or practice in or af21 fecting interstate commerce or an unfair 

22 method of competition in or affecting inter23 state commerce prohibited under section 5 

24 of the Federal Trade Commission Act, as 

25 though all applicable terms and provisions 
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1 of the Federal Trade Commission Act were 

2 incorporated into and made a part of this 

3 subsection. 

4 ‘‘(ii) INAPPLICABILITY.—Subchapter 

5 A of chapter VII shall not apply with re6 spect to this subsection. 

7 ‘‘(D) DEFINITIONS.—In this subsection: 

8 ‘‘(i) AGREEMENT.—The term ‘agree9 ment’ means anything that would con10 stitute an agreement under section 5 of the 

11 Federal Trade Commission Act. 

12 ‘‘(ii) AGREEMENT RESOLVING OR SET13 TLING.—The term ‘agreement resolving or 

14 settling’, in reference to a patent infringe15 ment claim, includes any agreement that is 

16 contingent upon, provides a contingent 

17 condition for, or is otherwise related to the 

18 resolution or settlement of the claim. 

19 ‘‘(iii) ANDA.—The term ‘ANDA’ 

20 means an abbreviated new drug application 

21 for the approval of a new drug under sec22 tion (j). 

23 ‘‘(iv) ANDA FILER.—The term 

24 ‘ANDA filer’ means a party that has filed 
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1 an ANDA with the Food and Drug Admin2 istration. 

3 ‘‘(v) PATENT INFRINGEMENT.—The 

4 term ‘patent infringement’ means infringe5 ment of any patent or of any filed patent 

6 application, extension, reissuance, renewal, 

7 division, continuation, continuation in part, 

8 reexamination, patent term restoration, 

9 patent of addition, or extension thereof. 

10 ‘‘(vi) PATENT INFRINGEMENT

11 CLAIM.—The term ‘patent infringement 

12 claim’ means any allegation made to an 

13 ANDA filer, whether or not included in a 

14 complaint filed with a court of law, that its 

15 ANDA or drug to be manufactured under 

16 such ANDA may infringe any patent. 

17 ‘‘(2) FTC RULEMAKING.—The Federal Trade 

18 Commission may, by rule promulgated under section 

19 553 of title 5, United States Code, exempt certain 

20 agreements described in paragraph (1) from the re21 quirements of this subsection if the Commission 

22 finds such agreements to be for the benefit of con23 sumers. Consistent with the authority of the Com24 mission, such rules may include interpretive rules 
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1 and general statements of policy with respect to the 

2 practices prohibited under paragraph (1).’’. 

3 (c) NOTICE AND CERTIFICATION OF AGREEMENTS.— 

4 (1) NOTICE OF ALL AGREEMENTS.—Section 

5 1112(c)(2) of the Medicare Prescription Drug, Im6 provement, and Modernization Act of 2003 (21 

7 U.S.C. 3155 note) is amended by— 

8 (A) striking ‘‘the Commission the’’ and in9 serting the following: ‘‘the Commission— 

10 ‘‘(A) the’’; 

11 (B) striking the period at the end and in12 serting ‘‘; and’’; and 

13 (C) adding at the end the following: 

14 ‘‘(B) any other agreement the parties enter 

15 into within 30 days of entering into an agree16 ment covered by subsection (a) or (b).’’. 

17 (2) CERTIFICATION OF AGREEMENTS.—Section 

18 1112 of such Act is amended by adding at the end 

19 the following: 

20 ‘‘(d) CERTIFICATION.—The chief executive officer or 

21 the company official responsible for negotiating any agree22 ment required to be filed under subsection (a), (b), or (c) 

23 shall execute and file with the Assistant Attorney General 

24 and the Commission a certification as follows: ‘I declare 

25 under penalty of perjury that the following is true and 
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1 correct: The materials filed with the Federal Trade Com2 mission and the Department of Justice under section 1112 

3 of subtitle B of title XI of the Medicare Prescription Drug, 

4 Improvement, and Modernization Act of 2003, with re5 spect to the agreement referenced in this certification: (1) 

6 represent the complete, final, and exclusive agreement be7 tween the parties; (2) include any ancillary agreements 

8 that are contingent upon, provide a contingent condition 

9 for, or are otherwise related to, the referenced agreement; 

10 and (3) include written descriptions of any oral agree11 ments, representations, commitments, or promises be12 tween the parties that are responsive to subsection (a) or 

13 (b) of such section 1112 and have not been reduced to 

14 writing.’.’’. 

15 (d) GAO STUDY.— 

16 (1) STUDY.—Beginning 2 years after the date 

17 of enactment of this Act, and each year for a period 

18 of 4 years thereafter, the Comptroller General shall 

19 conduct a study on the litigation in United States 

20 courts during the period beginning 5 years prior to 

21 the date of enactment of this Act relating to patent 

22 infringement claims involving generic drugs, the 

23 number of patent challenges initiated by manufac24 turers of generic drugs, and the number of settle25 ments of such litigation. The Comptroller General 
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1 shall transmit to Congress a report of the findings 

2 of such a study and an analysis of the effect of the 

3 amendments made by subsections (b) and (c) on 

4 such litigation, whether such amendments have had 

5 an effect on the number and frequency of claims set6 tled, and whether such amendments resulted in ear7 lier or delayed entry of generic drugs to market, in8 cluding whether any harm or benefit to consumers 

9 has resulted. 

10 (2) DISCLOSURE OF AGREEMENTS.—Notwith11 standing any other law, agreements filed under sec12 tion 1112 of the Medicare Prescription Drug, Im13 provement, and Modernization Act of 2003 (21 

14 U.S.C. 355 note), or unaggregated information from 

15 such agreements, shall be disclosed to the Comp16 troller General for purposes of the study under para17 graph (1) within 30 days of a request by the Comp18 troller General. 

19 PART 2—BIOSIMILARS 

20 SEC. 2575. LICENSURE PATHWAY FOR BIOSIMILAR BIO21 LOGICAL PRODUCTS. 

22 (a) LICENSURE OF BIOLOGICAL PRODUCTS AS BIO23 SIMILAR OR INTERCHANGEABLE.—Section 351 of the 

24 Public Health Service Act (42 U.S.C. 262) is amended— 
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1 (1) in subsection (a)(1)(A), by inserting ‘‘under 

2 this subsection or subsection (k)’’ after ‘‘biologics li3 cense’’; and 

4 (2) by adding at the end the following: 

5 ‘‘(k) LICENSURE OF BIOLOGICAL PRODUCTS AS BIO6 SIMILAR OR INTERCHANGEABLE.— 

7 ‘‘(1) IN GENERAL.—Any person may submit an 

8 application for licensure of a biological product 

9 under this subsection. 

10 ‘‘(2) CONTENT.— 

11 ‘‘(A) IN GENERAL.— 

12 ‘‘(i) REQUIRED INFORMATION.—An 

13 application submitted under this subsection 

14 shall include information demonstrating 

15 that— 

16 ‘‘(I) the biological product is bio17 similar to a reference product based 

18 upon data derived from— 

19 ‘‘(aa) analytical studies that 

20 demonstrate that the biological 

21 product is highly similar to the 

22 reference product notwith23 standing minor differences in 

24 clinically inactive components; 
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1 ‘‘(bb) animal studies (includ2 ing the assessment of toxicity); 

3 and 

4 ‘‘(cc) a clinical study or 

5 studies (including the assessment 

6 of immunogenicity and phar7 macokinetics or 

8 pharmacodynamics) that are suf9 ficient to demonstrate safety, pu10 rity, and potency in 1 or more 

11 appropriate conditions of use for 

12 which the reference product is li13 censed and intended to be used 

14 and for which licensure is sought 

15 for the biological product; 

16 ‘‘(II) the biological product and 

17 reference product utilize the same 

18 mechanism or mechanisms of action 

19 for the condition or conditions of use 

20 prescribed, recommended, or sug21 gested in the proposed labeling, but 

22 only to the extent the mechanism or 

23 mechanisms of action are known for 

24 the reference product; 
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1 ‘‘(III) the condition or conditions 

2 of use prescribed, recommended, or 

3 suggested in the labeling proposed for 

4 the biological product have been pre5 viously approved for the reference 

6 product; 

7 ‘‘(IV) the route of administra8 tion, the dosage form, and the 

9 strength of the biological product are 

10 the same as those of the reference 

11 product; and 

12 ‘‘(V) the facility in which the bio13 logical product is manufactured, proc14 essed, packed, or held meets stand15 ards designed to assure that the bio16 logical product continues to be safe, 

17 pure, and potent. 

18 ‘‘(ii) DETERMINATION BY SEC19 RETARY.—The Secretary may determine, 

20 in the Secretary’s discretion, that an ele21 ment described in clause (i)(I) is unneces22 sary in an application submitted under this 

23 subsection. 
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•HR 3962 EH

1 ‘‘(iii) ADDITIONAL INFORMATION.— 

2 An application submitted under this sub3 section— 

4 ‘‘(I) shall include publicly avail5 able information regarding the Sec6 retary’s previous determination that 

7 the reference product is safe, pure, 

8 and potent; and 

9 ‘‘(II) may include any additional 

10 information in support of the applica11 tion, including publicly available infor12 mation with respect to the reference 

13 product or another biological product. 

14 ‘‘(B) INTERCHANGEABILITY.—An applica15 tion (or a supplement to an application) sub16 mitted under this subsection may include infor17 mation demonstrating that the biological prod18 uct meets the standards described in paragraph 

19 (4). 

20 ‘‘(3) EVALUATION BY SECRETARY.—Upon re21 view of an application (or a supplement to an appli22 cation) submitted under this subsection, the Sec23 retary shall license the biological product under this 

24 subsection if— 
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1 ‘‘(A) the Secretary determines that the in2 formation submitted in the application (or the 

3 supplement) is sufficient to show that the bio4 logical product— 

5 ‘‘(i) is biosimilar to the reference 

6 product; or 

7 ‘‘(ii) meets the standards described in 

8 paragraph (4), and therefore is inter9 changeable with the reference product; and 

10 ‘‘(B) the applicant (or other appropriate 

11 person) consents to the inspection of the facility 

12 that is the subject of the application, in accord13 ance with subsection (c). 

14 ‘‘(4) SAFETY STANDARDS FOR DETERMINING

15 INTERCHANGEABILITY.—Upon review of an applica16 tion submitted under this subsection or any supple17 ment to such application, the Secretary shall deter18 mine the biological product to be interchangeable 

19 with the reference product if the Secretary deter20 mines that the information submitted in the applica21 tion (or a supplement to such application) is suffi22 cient to show that— 

23 ‘‘(A) the biological product— 

24 ‘‘(i) is biosimilar to the reference 

25 product; and 
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1 ‘‘(ii) can be expected to produce the 

2 same clinical result as the reference prod3 uct in any given patient; and 

4 ‘‘(B) for a biological product that is ad5 ministered more than once to an individual, the 

6 risk in terms of safety or diminished efficacy of 

7 alternating or switching between use of the bio8 logical product and the reference product is not 

9 greater than the risk of using the reference 

10 product without such alternation or switch. 

11 ‘‘(5) GENERAL RULES.— 

12 ‘‘(A) ONE REFERENCE PRODUCT PER AP13 PLICATION.—A biological product, in an appli14 cation submitted under this subsection, may not 

15 be evaluated against more than 1 reference 

16 product. 

17 ‘‘(B) REVIEW.—An application submitted 

18 under this subsection shall be reviewed by the 

19 division within the Food and Drug Administra20 tion that is responsible for the review and ap21 proval of the application under which the ref22 erence product is licensed. 

23 ‘‘(C) RISK EVALUATION AND MITIGATION

24 STRATEGIES.—The authority of the Secretary 

25 with respect to risk evaluation and mitigation 
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1 strategies under the Federal Food, Drug, and 

2 Cosmetic Act shall apply to biological products 

3 licensed under this subsection in the same man4 ner as such authority applies to biological prod5 ucts licensed under subsection (a). 

6 ‘‘(D) RESTRICTIONS ON BIOLOGICAL PROD7 UCTS CONTAINING DANGEROUS INGREDI8 ENTS.—If information in an application sub9 mitted under this subsection, in a supplement 

10 to such an application, or otherwise available to 

11 the Secretary shows that a biological product— 

12 ‘‘(i) is, bears, or contains a select 

13 agent or toxin listed in section 73.3 or 

14 73.4 of title 42, section 121.3 or 121.4 of 

15 title 9, or section 331.3 of title 7, Code of 

16 Federal Regulations (or any successor reg17 ulations); or 

18 ‘‘(ii) is, bears, or contains a controlled 

19 substance in schedule I or II of section 

20 202 of the Controlled Substances Act, as 

21 listed in part 1308 of title 21, Code of 

22 Federal Regulations (or any successor reg23 ulations); 

24 the Secretary shall not license the biological 

25 product under this subsection unless the Sec-
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1 retary determines, after consultation with ap2 propriate national security and drug enforce3 ment agencies, that there would be no increased 

4 risk to the security or health of the public from 

5 licensing such biological product under this sub6 section. 

7 ‘‘(6) EXCLUSIVITY FOR FIRST INTERCHANGE8 ABLE BIOLOGICAL PRODUCT.—Upon review of an 

9 application submitted under this subsection relying 

10 on the same reference product for which a prior bio11 logical product has received a determination of inter12 changeability for any condition of use, the Secretary 

13 shall not make a determination under paragraph (4) 

14 that the second or subsequent biological product is 

15 interchangeable for any condition of use until the 

16 earlier of— 

17 ‘‘(A) 1 year after the first commercial 

18 marketing of the first interchangeable bio19 similar biological product to be approved as 

20 interchangeable for that reference product; 

21 ‘‘(B) 18 months after— 

22 ‘‘(i) a final court decision on all pat23 ents in suit in an action instituted under 

24 subsection (l)(5) against the applicant that 

25 submitted the application for the first ap-
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1 proved interchangeable biosimilar biological 

2 product; or 

3 ‘‘(ii) the dismissal with or without 

4 prejudice of an action instituted under sub5 section (l)(5) against the applicant that 

6 submitted the application for the first ap7 proved interchangeable biosimilar biological 

8 product; or 

9 ‘‘(C)(i) 42 months after approval of the 

10 first interchangeable biosimilar biological prod11 uct if the applicant that submitted such appli12 cation has been sued under subsection (l)(5) 

13 and such litigation is still ongoing within such 

14 42-month period; or 

15 ‘‘(ii) 18 months after approval of the first 

16 interchangeable biosimilar biological product if 

17 the applicant that submitted such application 

18 has not been sued under subsection (l)(5). 

19 For purposes of this paragraph, the term ‘final court 

20 decision’ means a final decision of a court from 

21 which no appeal (other than a petition to the United 

22 States Supreme Court for a writ of certiorari) has 

23 been or can be taken. 

24 ‘‘(7) EXCLUSIVITY FOR REFERENCE PROD25 UCT.— 
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1 ‘‘(A) EFFECTIVE DATE OF BIOSIMILAR AP2 PLICATION APPROVAL.—Approval of an applica3 tion under this subsection may not be made ef4 fective by the Secretary until the date that is 

5 12 years after the date on which the reference 

6 product was first licensed under subsection (a). 

7 ‘‘(B) FILING PERIOD.—An application 

8 under this subsection may not be submitted to 

9 the Secretary until the date that is 4 years 

10 after the date on which the reference product 

11 was first licensed under subsection (a). 

12 ‘‘(C) FIRST LICENSURE.—Subparagraphs 

13 (A) and (B) shall not apply to a license for or 

14 approval of— 

15 ‘‘(i) a supplement for the biological 

16 product that is the reference product; or 

17 ‘‘(ii) a subsequent application filed by 

18 the same sponsor or manufacturer of the 

19 biological product that is the reference 

20 product (or a licensor, predecessor in inter21 est, or other related entity) for— 

22 ‘‘(I) a change (not including a 

23 modification to the structure of the bi24 ological product) that results in a new 

25 indication, route of administration, 
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1 dosing schedule, dosage form, delivery 

2 system, delivery device, or strength; or 

3 ‘‘(II) a modification to the struc4 ture of the biological product that 

5 does not result in a change in safety, 

6 purity, or potency. 

7 ‘‘(8) PEDIATRIC STUDIES.— 

8 ‘‘(A) EXCLUSIVITY.—If, before or after li9 censure of the reference product under sub10 section (a) of this section, the Secretary deter11 mines that information relating to the use of 

12 such product in the pediatric population may 

13 produce health benefits in that population, the 

14 Secretary makes a written request for pediatric 

15 studies (which shall include a timeframe for 

16 completing such studies), the applicant or hold17 er of the approved application agrees to the re18 quest, such studies are completed using appro19 priate formulations for each age group for 

20 which the study is requested within any such 

21 timeframe, and the reports thereof are sub22 mitted and accepted in accordance with section 

23 505A(d)(3) of the Federal Food, Drug, and 

24 Cosmetic Act the period referred to in para-
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1 graph (7)(A) of this subsection is deemed to be 

2 12 years and 6 months rather than 12 years. 

3 ‘‘(B) EXCEPTION.—The Secretary shall 

4 not extend the period referred to in subpara5 graph (A) of this paragraph if the determina6 tion under section 505A(d)(3) of the Federal 

7 Food, Drug, and Cosmetic Act is made later 

8 than 9 months prior to the expiration of such 

9 period. 

10 ‘‘(C) APPLICATION OF CERTAIN PROVI11 SIONS.—The provisions of subsections (a), (d), 

12 (e), (f), (h), (j), (k), and (l) of section 505A of 

13 the Federal Food, Drug, and Cosmetic Act 

14 shall apply with respect to the extension of a 

15 period under subparagraph (A) of this para16 graph to the same extent and in the same man17 ner as such provisions apply with respect to the 

18 extension of a period under subsection (b) or 

19 (c) of section 505A of the Federal Food, Drug, 

20 and Cosmetic Act. 

21 ‘‘(9) GUIDANCE DOCUMENTS.— 

22 ‘‘(A) IN GENERAL.—The Secretary may, 

23 after opportunity for public comment, issue 

24 guidance in accordance, except as provided in 

25 subparagraph (B)(i), with section 701(h) of the 
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1 Federal Food, Drug, and Cosmetic Act with re2 spect to the licensure of a biological product 

3 under this subsection. Any such guidance may 

4 be general or specific. 

5 ‘‘(B) PUBLIC COMMENT.— 

6 ‘‘(i) IN GENERAL.—The Secretary 

7 shall provide the public an opportunity to 

8 comment on any proposed guidance issued 

9 under subparagraph (A) before issuing 

10 final guidance. 

11 ‘‘(ii) INPUT REGARDING MOST VALU12 ABLE GUIDANCE.—The Secretary shall es13 tablish a process through which the public 

14 may provide the Secretary with input re15 garding priorities for issuing guidance. 

16 ‘‘(C) NO REQUIREMENT FOR APPLICATION

17 CONSIDERATION.—The issuance (or non18 issuance) of guidance under subparagraph (A) 

19 shall not preclude the review of, or action on, 

20 an application submitted under this subsection. 

21 ‘‘(D) REQUIREMENT FOR PRODUCT CLASS22 SPECIFIC GUIDANCE.—If the Secretary issues 

23 product class-specific guidance under subpara24 graph (A), such guidance shall include a de25 scription of— 
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1 ‘‘(i) the criteria that the Secretary will 

2 use to determine whether a biological prod3 uct is highly similar to a reference product 

4 in such product class; and 

5 ‘‘(ii) the criteria, if available, that the 

6 Secretary will use to determine whether a 

7 biological product meets the standards de8 scribed in paragraph (4). 

9 ‘‘(E) CERTAIN PRODUCT CLASSES.— 

10 ‘‘(i) GUIDANCE.—The Secretary may 

11 indicate in a guidance document that the 

12 science and experience, as of the date of 

13 such guidance, with respect to a product or 

14 product class (not including any recom15 binant protein) does not allow approval of 

16 an application for a license as provided 

17 under this subsection for such product or 

18 product class. 

19 ‘‘(ii) MODIFICATION OR REVERSAL.— 

20 The Secretary may issue a subsequent 

21 guidance document under subparagraph 

22 (A) to modify or reverse a guidance docu23 ment under clause (i). 

24 ‘‘(iii) NO EFFECT ON ABILITY TO

25 DENY LICENSE.—Clause (i) shall not be 
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1 construed to require the Secretary to ap2 prove a product with respect to which the 

3 Secretary has not indicated in a guidance 

4 document that the science and experience, 

5 as described in clause (i), does not allow 

6 approval of such an application. 

7 ‘‘(10) NAMING.—The Secretary shall ensure 

8 that the labeling and packaging of each biological 

9 product licensed under this subsection bears a name 

10 that uniquely identifies the biological product and 

11 distinguishes it from the reference product and any 

12 other biological products licensed under this sub13 section following evaluation against such reference 

14 product. 

15 ‘‘(l) PATENT NOTICES; RELATIONSHIP TO FINAL AP16 PROVAL.— 

17 ‘‘(1) DEFINITIONS.—For the purposes of this 

18 subsection, the term— 

19 ‘‘(A) ‘biosimilar product’ means the bio20 logical product that is the subject of the appli21 cation under subsection (k); 

22 ‘‘(B) ‘relevant patent’ means a patent 

23 that— 
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1 ‘‘(i) expires after the date specified in 

2 subsection (k)(7)(A) that applies to the 

3 reference product; and 

4 ‘‘(ii) could reasonably be asserted 

5 against the applicant due to the unauthor6 ized making, use, sale, or offer for sale 

7 within the United States, or the importa8 tion into the United States of the bio9 similar product, or materials used in the 

10 manufacture of the biosimilar product, or 

11 due to a use of the biosimilar product in 

12 a method of treatment that is indicated in 

13 the application; 

14 ‘‘(C) ‘reference product sponsor’ means the 

15 holder of an approved application or license for 

16 the reference product; and 

17 ‘‘(D) ‘interested third party’ means a per18 son other than the reference product sponsor 

19 that owns a relevant patent, or has the right to 

20 commence or participate in an action for in21 fringement of a relevant patent. 

22 ‘‘(2) HANDLING OF CONFIDENTIAL INFORMA23 TION.—Any entity receiving confidential information 

24 pursuant to this subsection shall designate one or 

25 more individuals to receive such information. Each 
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1 individual so designated shall execute an agreement 

2 in accordance with regulations promulgated by the 

3 Secretary. The regulations shall require each such 

4 individual to take reasonable steps to maintain the 

5 confidentiality of information received pursuant to 

6 this subsection and use the information solely for 

7 purposes authorized by this subsection. The obliga8 tions imposed on an individual who has received con9 fidential information pursuant to this subsection 

10 shall continue until the individual returns or de11 stroys the confidential information, a court imposes 

12 a protective order that governs the use or handling 

13 of the confidential information, or the party pro14 viding the confidential information agrees to other 

15 terms or conditions regarding the handling or use of 

16 the confidential information. 

17 ‘‘(3) PUBLIC NOTICE BY SECRETARY.—Within 

18 30 days of acceptance by the Secretary of an appli19 cation filed under subsection (k), the Secretary shall 

20 publish a notice identifying— 

21 ‘‘(A) the reference product identified in the 

22 application; and 

23 ‘‘(B) the name and address of an agent 

24 designated by the applicant to receive notices 

25 pursuant to paragraph (4)(B). 
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1 ‘‘(4) EXCHANGES CONCERNING PATENTS.— 

2 ‘‘(A) EXCHANGES WITH REFERENCE

3 PRODUCT SPONSOR.— 

4 ‘‘(i) Within 30 days of the date of ac5 ceptance of the application by the Sec6 retary, the applicant shall provide the ref7 erence product sponsor with a copy of the 

8 application and information concerning the 

9 biosimilar product and its production. This 

10 information shall include a detailed de11 scription of the biosimilar product, its 

12 method of manufacture, and the materials 

13 used in the manufacture of the product. 

14 ‘‘(ii) Within 60 days of the date of re15 ceipt of the information required to be pro16 vided under clause (i), the reference prod17 uct sponsor shall provide to the applicant 

18 a list of relevant patents owned by the ref19 erence product sponsor, or in respect of 

20 which the reference product sponsor has 

21 the right to commence an action of in22 fringement or otherwise has an interest in 

23 the patent as such patent concerns the bio24 similar product. 
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1 ‘‘(iii) If the reference product sponsor 

2 is issued or acquires an interest in a rel3 evant patent after the date on which the 

4 reference product sponsor provides the list 

5 required by clause (ii) to the applicant, the 

6 reference product sponsor shall identify 

7 that patent to the applicant within 30 days 

8 of the date of issue of the patent, or the 

9 date of acquisition of the interest in the 

10 patent, as applicable. 

11 ‘‘(B) EXCHANGES WITH INTERESTED

12 THIRD PARTIES.— 

13 ‘‘(i) At any time after the date on 

14 which the Secretary publishes a notice for 

15 an application under paragraph (3), any 

16 interested third party may provide notice 

17 to the designated agent of the applicant 

18 that the interested third party owns or has 

19 rights under 1 or more patents that may 

20 be relevant patents. The notice shall iden21 tify at least 1 patent and shall designate 

22 an individual who has executed an agree23 ment in accordance with paragraph (2) to 

24 receive confidential information from the 

25 applicant. 
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1 ‘‘(ii) Within 30 days of the date of re2 ceiving notice pursuant to clause (i), the 

3 applicant shall send to the individual des4 ignated by the interested third party the 

5 information specified in subparagraph 

6 (A)(i), unless the applicant and interested 

7 third party otherwise agree. 

8 ‘‘(iii) Within 90 days of the date of 

9 receiving information pursuant to clause 

10 (ii), the interested third party shall provide 

11 to the applicant a list of relevant patents 

12 which the interested third party owns, or 

13 in respect of which the interested third 

14 party has the right to commence or partici15 pate in an action for infringement. 

16 ‘‘(iv) If the interested third party is 

17 issued or acquires an interest in a relevant 

18 patent after the date on which the inter19 ested third party provides the list required 

20 by clause (iii), the interested third party 

21 shall identify that patent within 30 days of 

22 the date of issue of the patent, or the date 

23 of acquisition of the interest in the patent, 

24 as applicable. 
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1 ‘‘(C) IDENTIFICATION OF BASIS FOR IN2 FRINGEMENT.—For any patent identified under 

3 clause (ii) or (iii) of subparagraph (A) or under 

4 clause (iii) or (iv) of subparagraph (B), the ref5 erence product sponsor or the interested third 

6 party, as applicable— 

7 ‘‘(i) shall explain in writing why the 

8 sponsor or the interested third party be9 lieves the relevant patent would be in10 fringed by the making, use, sale, or offer 

11 for sale within the United States, or im12 portation into the United States, of the 

13 biosimilar product or by a use of the bio14 similar product in treatment that is indi15 cated in the application; 

16 ‘‘(ii) may specify whether the relevant 

17 patent is available for licensing; and 

18 ‘‘(iii) shall specify the number and 

19 date of expiration of the relevant patent. 

20 ‘‘(D) CERTIFICATION BY APPLICANT CON21 CERNING IDENTIFIED RELEVANT PATENTS.— 

22 Not later than 45 days after the date on which 

23 a patent is identified under clause (ii) or (iii) of 

24 subparagraph (A) or under clause (iii) or (iv) of 

25 subparagraph (B), the applicant shall send a 
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1 written statement regarding each identified pat2 ent to the party that identified the patent. Such 

3 statement shall either— 

4 ‘‘(i) state that the applicant will not 

5 commence marketing of the biosimilar 

6 product and has requested the Secretary to 

7 not grant final approval of the application 

8 before the date of expiration of the noticed 

9 patent; or 

10 ‘‘(ii) provide a detailed written expla11 nation setting forth the reasons why the 

12 applicant believes— 

13 ‘‘(I) the making, use, sale, or 

14 offer for sale within the United 

15 States, or the importation into the 

16 United States, of the biosimilar prod17 uct, or the use of the biosimilar prod18 uct in a treatment indicated in the ap19 plication, would not infringe the pat20 ent; or 

21 ‘‘(II) the patent is invalid or un22 enforceable. 

23 ‘‘(5) ACTION FOR INFRINGEMENT INVOLVING

24 REFERENCE PRODUCT SPONSOR.—If an action for 

25 infringement concerning a relevant patent identified 
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1 by the reference product sponsor under clause (ii) or 

2 (iii) of paragraph (4)(A), or by an interested third 

3 party under clause (iii) or (iv) of paragraph (4)(B), 

4 is brought within 60 days of the date of receipt of 

5 a statement under paragraph (4)(D)(ii), and the 

6 court in which such action has been commenced de7 termines the patent is infringed prior to the date ap8 plicable under subsection (k)(7)(A) or (k)(8), the 

9 Secretary shall make approval of the application ef10 fective on the day after the date of expiration of the 

11 patent that has been found to be infringed. If more 

12 than one such patent is found to be infringed by the 

13 court, the approval of the application shall be made 

14 effective on the day after the date that the last such 

15 patent expires. 

16 ‘‘(6) NOTIFICATION OF AGREEMENTS.— 

17 ‘‘(A) REQUIREMENTS.— 

18 ‘‘(i) AGREEMENT BETWEEN BIO19 SIMILAR PRODUCT APPLICANT AND REF20 ERENCE PRODUCT SPONSOR.—If a bio21 similar product applicant under subsection 

22 (k) and the reference product sponsor 

23 enter into an agreement described in sub24 paragraph (B), the applicant and sponsor 
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1 shall each file the agreement in accordance 

2 with subparagraph (C). 

3 ‘‘(ii) AGREEMENT BETWEEN BIO4 SIMILAR PRODUCT APPLICANTS.—If 2 or 

5 more biosimilar product applicants submit 

6 an application under subsection (k) for bio7 similar products with the same reference 

8 product and enter into an agreement de9 scribed in subparagraph (B), the appli10 cants shall each file the agreement in ac11 cordance with subparagraph (C). 

12 ‘‘(B) SUBJECT MATTER OF AGREEMENT.— 

13 An agreement described in this subparagraph— 

14 ‘‘(i) is an agreement between the bio15 similar product applicant under subsection 

16 (k) and the reference product sponsor or 

17 between 2 or more biosimilar product ap18 plicants under subsection (k) regarding the 

19 manufacture, marketing, or sale of— 

20 ‘‘(I) the biosimilar product (or 

21 biosimilar products) for which an ap22 plication was submitted; or 

23 ‘‘(II) the reference product; 

24 ‘‘(ii) includes any agreement between 

25 the biosimilar product applicant under sub-
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1 section (k) and the reference product spon2 sor or between 2 or more biosimilar prod3 uct applicants under subsection (k) that is 

4 contingent upon, provides a contingent 

5 condition for, or otherwise relates to an 

6 agreement described in clause (i); and 

7 ‘‘(iii) excludes any agreement that 

8 solely concerns— 

9 ‘‘(I) purchase orders for raw ma10 terial supplies; 

11 ‘‘(II) equipment and facility con12 tracts; 

13 ‘‘(III) employment or consulting 

14 contracts; or 

15 ‘‘(IV) packaging and labeling 

16 contracts. 

17 ‘‘(C) FILING.— 

18 ‘‘(i) IN GENERAL.—The text of an 

19 agreement required to be filed by subpara20 graph (A) shall be filed with the Assistant 

21 Attorney General and the Federal Trade 

22 Commission not later than— 

23 ‘‘(I) 10 business days after the 

24 date on which the agreement is exe25 cuted; and 
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1 ‘‘(II) prior to the date of the first 

2 commercial marketing of, for agree3 ments described in subparagraph 

4 (A)(i), the biosimilar product that is 

5 the subject of the application or, for 

6 agreements described in subparagraph 

7 (A)(ii), any biosimilar product that is 

8 the subject of an application described 

9 in such subparagraph. 

10 ‘‘(ii) IF AGREEMENT NOT REDUCED

11 TO TEXT.—If an agreement required to be 

12 filed by subparagraph (A) has not been re13 duced to text, the persons required to file 

14 the agreement shall each file written de15 scriptions of the agreement that are suffi16 cient to disclose all the terms and condi17 tions of the agreement. 

18 ‘‘(iii) CERTIFICATION.—The chief ex19 ecutive officer or the company official re20 sponsible for negotiating any agreement re21 quired to be filed by subparagraph (A) 

22 shall include in any filing under this para23 graph a certification as follows: ‘I declare 

24 under penalty of perjury that the following 

25 is true and correct: The materials filed 
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1 with the Federal Trade Commission and 

2 the Department of Justice under section 

3 351(l)(6) of the Public Health Service Act, 

4 with respect to the agreement referenced in 

5 this certification: (1) represent the com6 plete, final, and exclusive agreement be7 tween the parties; (2) include any ancillary 

8 agreements that are contingent upon, pro9 vide a contingent condition for, or are oth10 erwise related to, the referenced agree11 ment; and (3) include written descriptions 

12 of any oral agreements, representations, 

13 commitments, or promises between the 

14 parties that are responsive to such section 

15 and have not been reduced to writing.’. 

16 ‘‘(D) DISCLOSURE EXEMPTION.—Any in17 formation or documentary material filed with 

18 the Assistant Attorney General or the Federal 

19 Trade Commission pursuant to this paragraph 

20 shall be exempt from disclosure under section 

21 552 of title 5, United States Code, and no such 

22 information or documentary material may be 

23 made public, except as may be relevant to any 

24 administrative or judicial action or proceeding. 

25 Nothing in this subparagraph prevents disclo-
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1 sure of information or documentary material to 

2 either body of the Congress or to any duly au3 thorized committee or subcommittee of the Con4 gress. 

5 ‘‘(E) ENFORCEMENT.— 

6 ‘‘(i) CIVIL PENALTY.—Any person 

7 that violates a provision of this paragraph 

8 shall be liable for a civil penalty of not 

9 more than $11,000 for each day on which 

10 the violation occurs. Such penalty may be 

11 recovered in a civil action— 

12 ‘‘(I) brought by the United 

13 States; or 

14 ‘‘(II) brought by the Federal 

15 Trade Commission in accordance with 

16 the procedures established in section 

17 16(a)(1) of the Federal Trade Com18 mission Act. 

19 ‘‘(ii) COMPLIANCE AND EQUITABLE

20 RELIEF.—If any person violates any provi21 sion of this paragraph, the United States 

22 district court may order compliance, and 

23 may grant such other equitable relief as 

24 the court in its discretion determines nec25 essary or appropriate, upon application of 
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1 the Assistant Attorney General or the Fed2 eral Trade Commission. 

3 ‘‘(F) RULEMAKING.—The Federal Trade 

4 Commission, with the concurrence of the Assist5 ant Attorney General and by rule in accordance 

6 with section 553 of title 5, United States Code, 

7 consistent with the purposes of this para8 graph— 

9 ‘‘(i) may define the terms used in this 

10 paragraph; 

11 ‘‘(ii) may exempt classes of persons or 

12 agreements from the requirements of this 

13 paragraph; and 

14 ‘‘(iii) may prescribe such other rules 

15 as may be necessary and appropriate to 

16 carry out the purposes of this paragraph. 

17 ‘‘(G) SAVINGS CLAUSE.—Any action taken 

18 by the Assistant Attorney General or the Fed19 eral Trade Commission, or any failure of the 

20 Assistant Attorney General or the Commission 

21 to take action, under this paragraph shall not 

22 at any time bar any proceeding or any action 

23 with respect to any agreement between a bio24 similar product applicant under subsection (k) 

25 and the reference product sponsor, or any 
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1 agreement between biosimilar product appli2 cants under subsection (k), under any other 

3 provision of law, nor shall any filing under this 

4 paragraph constitute or create a presumption of 

5 any violation of any competition laws.’’. 

6 (b) DEFINITIONS.—Section 351(i) of the Public 

7 Health Service Act (42 U.S.C. 262(i)) is amended— 

8 (1) by striking ‘‘In this section, the term ‘bio9 logical product’ means’’ and inserting the following: 

10 ‘‘In this section: 

11 ‘‘(1) The term ‘biological product’ means’’; 

12 (2) in paragraph (1), as so designated, by in13 serting ‘‘protein (except any chemically synthesized 

14 polypeptide),’’ after ‘‘allergenic product,’’; and 

15 (3) by adding at the end the following: 

16 ‘‘(2) The term ‘biosimilar’ or ‘biosimilarity’, in 

17 reference to a biological product that is the subject 

18 of an application under subsection (k), means— 

19 ‘‘(A) that the biological product is highly 

20 similar to the reference product notwith21 standing minor differences in clinically inactive 

22 components; and 

23 ‘‘(B) there are no clinically meaningful dif24 ferences between the biological product and the 
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1 reference product in terms of the safety, purity, 

2 and potency of the product. 

3 ‘‘(3) The term ‘interchangeable’ or ‘inter4 changeability’, in reference to a biological product 

5 that is shown to meet the standards described in 

6 subsection (k)(4), means that the biological product 

7 may be substituted for the reference product without 

8 the intervention of the health care provider who pre9 scribed the reference product. 

10 ‘‘(4) The term ‘reference product’ means the 

11 single biological product licensed under subsection 

12 (a) against which a biological product is evaluated in 

13 an application submitted under subsection (k).’’. 

14 (c) PRODUCTS PREVIOUSLY APPROVED UNDER SEC15 TION 505.— 

16 (1) REQUIREMENT TO FOLLOW SECTION 351.— 

17 Except as provided in paragraph (2), an application 

18 for a biological product shall be submitted under 

19 section 351 of the Public Health Service Act (42 

20 U.S.C. 262) (as amended by this Act). 

21 (2) EXCEPTION.—An application for a biologi22 cal product may be submitted under section 505 of 

23 the Federal Food, Drug, and Cosmetic Act (21 

24 U.S.C. 355) if— 
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1 (A) such biological product is in a product 

2 class for which a biological product in such 

3 product class is the subject of an application 

4 approved under such section 505 not later than 

5 the date of enactment of this Act; and 

6 (B) such application— 

7 (i) has been submitted to the Sec8 retary of Health and Human Services (re9 ferred to in this Act as the ‘‘Secretary’’) 

10 before the date of enactment of this Act; 

11 or 

12 (ii) is submitted to the Secretary not 

13 later than the date that is 10 years after 

14 the date of enactment of this Act. 

15 (3) LIMITATION.—Notwithstanding paragraph 

16 (2), an application for a biological product may not 

17 be submitted under section 505 of the Federal Food, 

18 Drug, and Cosmetic Act (21 U.S.C. 355) if there is 

19 another biological product approved under sub20 section (a) of section 351 of the Public Health Serv21 ice Act that could be a reference product with re22 spect to such application (within the meaning of 

23 such section 351) if such application were submitted 

24 under subsection (k) of such section 351. 
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1 (4) DEEMED APPROVED UNDER SECTION 351.— 

2 An approved application for a biological product 

3 under section 505 of the Federal Food, Drug, and 

4 Cosmetic Act (21 U.S.C. 355) shall be deemed to be 

5 a license for the biological product under such sec6 tion 351 on the date that is 10 years after the date 

7 of enactment of this Act. 

8 (5) DEFINITIONS.—For purposes of this sub9 section, the term ‘‘biological product’’ has the mean10 ing given such term under section 351 of the Public 

11 Health Service Act (42 U.S.C. 262) (as amended by 

12 this Act). 

13 SEC. 2576. FEES RELATING TO BIOSIMILAR BIOLOGICAL 

14 PRODUCTS. 

15 Subparagraph (B) of section 735(1) of the Federal 

16 Food, Drug, and Cosmetic Act (21 U.S.C. 379g(1)) is 

17 amended by inserting ‘‘, including licensure of a biological 

18 product under section 351(k) of such Act’’ before the pe19 riod at the end. 

20 SEC. 2577. AMENDMENTS TO CERTAIN PATENT PROVI21 SIONS. 

22 (a) Section 271(e)(2) of title 35, United States Code, 

23 is amended— 

24 (1) in subparagraph (A), by striking ‘‘or’’ after 

25 ‘‘patent,’’; 
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1 (2) in subparagraph (B), by adding ‘‘or’’ after 

2 the comma at the end; 

3 (3) by inserting the following after subpara4 graph (B): 

5 ‘‘(C) a statement under section 

6 351(l)(4)(D)(ii) of the Public Health Service 

7 Act,’’; and 

8 (4) in the matter following subparagraph (C) 

9 (as added by paragraph (3)), by inserting before the 

10 period the following: ‘‘, or if the statement described 

11 in subparagraph (C) is provided in connection with 

12 an application to obtain a license to engage in the 

13 commercial manufacture, use, or sale of a biological 

14 product claimed in a patent or the use of which is 

15 claimed in a patent before the expiration of such 

16 patent’’. 

17 (b) Section 271(e)(4) of title 35, United States Code, 

18 is amended by striking ‘‘in paragraph (2)’’ in both places 

19 it appears and inserting ‘‘in paragraph (2)(A) or (2)(B)’’. 
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1 Subtitle D—Community Living 

2 Assistance Services and Supports 

3 SEC. 2581. ESTABLISHMENT OF NATIONAL VOLUNTARY IN4 SURANCE PROGRAM FOR PURCHASING COM5 MUNITY LIVING ASSISTANCE SERVICES AND 

6 SUPPORT (CLASS PROGRAM). 

7 (a) ESTABLISHMENT OF CLASS PROGRAM.—The 

8 Public Health Service Act (42 U.S.C. 201 et seq.), as 

9 amended by section 2301, is amended by adding at the 

10 end the following: 

11 ‘‘TITLE XXXII—COMMUNITY LIV12 ING ASSISTANCE SERVICES 

13 AND SUPPORTS 

14 ‘‘SEC. 3201. PURPOSE. 

15 ‘‘The purpose of this title is to establish a national 

16 voluntary insurance program for purchasing community 

17 living assistance services and supports in order to— 

18 ‘‘(1) provide individuals with functional limita19 tions with tools that will allow them to maintain 

20 their personal and financial independence and live in 

21 the community through a new financing strategy for 

22 community living assistance services and supports; 

23 ‘‘(2) establish an infrastructure that will help 

24 address the Nation’s community living assistance 

25 services and supports needs; 
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1 ‘‘(3) alleviate burdens on family caregivers; and 

2 ‘‘(4) address institutional bias by providing a fi3 nancing mechanism that supports personal choice 

4 and independence to live in the community. 

5 ‘‘SEC. 3202. DEFINITIONS. 

6 ‘‘In this title: 

7 ‘‘(1) ACTIVE ENROLLEE.—The term ‘active en8 rollee’ means an individual who is enrolled in the 

9 CLASS program in accordance with section 3204 

10 and who has paid any premiums due to maintain 

11 such enrollment. 

12 ‘‘(2) ACTIVELY EMPLOYED.—The term ‘actively 

13 employed’ means an individual who— 

14 ‘‘(A) is reporting for work at the individ15 ual’s usual place of employment or at another 

16 location to which the individual is required to 

17 travel because of the individual’s employment 

18 (or in the case of an individual who is a mem19 ber of the uniformed services, is on active duty 

20 and is physically able to perform the duties of 

21 the individual’s position); and 

22 ‘‘(B) is able to perform all the usual and 

23 customary duties of the individual’s employment 

24 on the individual’s regular work schedule. 
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1 ‘‘(3) ACTIVITIES OF DAILY LIVING.—The term 

2 ‘activities of daily living’ has the meaning given the 

3 term in section 7702B(c)(2)(B) of the Internal Rev4 enue Code of 1986. 

5 ‘‘(4) CLASS PROGRAM.—The term ‘CLASS 

6 program’ means the program established under this 

7 title. 

8 ‘‘(5) ELIGIBILITY ASSESSMENT SYSTEM.—The 

9 term ‘Eligibility Assessment System’ means the enti10 ty designated by the Secretary under section 

11 3205(a)(2)(A)(i). 

12 ‘‘(6) ELIGIBLE BENEFICIARY.— 

13 ‘‘(A) IN GENERAL.—The term ‘eligible 

14 beneficiary’ means any individual who is an ac15 tive enrollee in the CLASS program and, as of 

16 the date described in subparagraph (B)— 

17 ‘‘(i) has paid premiums for enrollment 

18 in such program for at least 60 months; 

19 ‘‘(ii) has earned, for each calendar 

20 year that occurs during the first 60 

21 months for which the individual has paid 

22 premiums for enrollment in the program, 

23 at least an amount equal to the amount of 

24 wages and self-employment income which 

25 an individual must have in order to be 
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1 credited with a quarter of coverage under 

2 section 213(d) of the Social Security Act 

3 for that year; and 

4 ‘‘(iii) has paid premiums for enroll5 ment in such program for at least 24 con6 secutive months, if a lapse in premium 

7 payments of more than 3 months has oc8 curred during the period that begins on the 

9 date of the individual’s enrollment and 

10 ends on the date of such determination. 

11 ‘‘(B) DATE DESCRIBED.—For purposes of 

12 subparagraph (A), the date described in this 

13 subparagraph is the date on which the indi14 vidual is determined to have a functional limita15 tion described in section 3203(a)(1)(C) that is 

16 expected to last for a continuous period of more 

17 than 90 days. 

18 ‘‘(C) REGULATIONS.—The Secretary shall 

19 promulgate regulations specifying exceptions to 

20 the minimum earnings requirements under sub21 paragraph (A)(ii) for purposes of being consid22 ered an eligible beneficiary for certain popu23 lations. 

24 ‘‘(7) HOSPITAL; NURSING FACILITY; INTER25 MEDIATE CARE FACILITY FOR THE MENTALLY RE-
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1 TARDED; INSTITUTION FOR MENTAL DISEASES.— 

2 The terms ‘hospital’, ‘nursing facility’, ‘intermediate 

3 care facility for the mentally retarded’, and ‘institu4 tion for mental diseases’ have the meanings given 

5 such terms for purposes of Medicaid. 

6 ‘‘(8) CLASS INDEPENDENCE ADVISORY COUN7 CIL.—The term ‘CLASS Independence Advisory 

8 Council’ or ‘Council’ means the Advisory Council es9 tablished under section 3207 to advise the Secretary. 

10 ‘‘(9) CLASS INDEPENDENCE BENEFIT PLAN.— 

11 The term ‘CLASS Independence Benefit Plan’ 

12 means the benefit plan developed and designated by 

13 the Secretary in accordance with section 3203. 

14 ‘‘(10) CLASS INDEPENDENCE FUND.—The 

15 term ‘CLASS Independence Fund’ or ‘Fund’ means 

16 the fund established under section 3206. 

17 ‘‘(11) MEDICAID.—The term ‘Medicaid’ means 

18 the program established under title XIX of the So19 cial Security Act. 

20 ‘‘(12) PROTECTION AND ADVOCACY SYSTEM.— 

21 The term ‘Protection and Advocacy System’ means 

22 the system for each State established under section 

23 143 of the Developmental Disabilities Assistance 

24 and Bill of Rights Act of 2000. 
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1 ‘‘SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN. 

2 ‘‘(a) PROCESS FOR DEVELOPMENT.— 

3 ‘‘(1) IN GENERAL.—The Secretary, in consulta4 tion with appropriate actuaries and other experts, 

5 shall develop at least 3 actuarially sound benefit 

6 plans as alternatives for consideration for designa7 tion by the Secretary as the CLASS Independence 

8 Benefit Plan under which eligible beneficiaries shall 

9 receive benefits under this title. Each of the plan al10 ternatives developed shall be designed to provide eli11 gible beneficiaries with the benefits described in sec12 tion 3205 consistent with the following require13 ments: 

14 ‘‘(A) PREMIUMS.—Beginning with the first 

15 year of the CLASS program, and for each year 

16 thereafter, the Secretary shall establish all pre17 miums to be paid by enrollees for the year 

18 based on an actuarial analysis of the 75-year 

19 costs of the program that ensures solvency 

20 throughout such 75-year period. 

21 ‘‘(B) VESTING PERIOD.—A 5-year vesting 

22 period for eligibility for benefits. 

23 ‘‘(C) BENEFIT TRIGGERS.—A benefit trig24 ger for provision of benefits that requires a de25 termination that an individual has a functional 

26 limitation, as certified by a licensed health care 
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1 practitioner, described in any of the following 

2 clauses that is expected to last for a continuous 

3 period of more than 90 days: 

4 ‘‘(i) The individual is determined to 

5 be unable to perform at least the minimum 

6 number (which may be 2 or 3) of activities 

7 of daily living as are required under the 

8 plan for the provision of benefits without 

9 substantial assistance (as defined by the 

10 Secretary) from another individual. 

11 ‘‘(ii) The individual requires substan12 tial supervision to protect the individual 

13 from threats to health and safety due to 

14 substantial cognitive impairment. 

15 ‘‘(iii) The individual has a level of 

16 functional limitation similar (as determined 

17 under regulations prescribed by the Sec18 retary) to the level of functional limitation 

19 described in clause (i) or (ii). 

20 ‘‘(D) CASH BENEFIT.—Payment of a cash 

21 benefit that satisfies the following requirements: 

22 ‘‘(i) MINIMUM REQUIRED AMOUNT.— 

23 The benefit amount provides an eligible 

24 beneficiary with not less than an average 

25 of $50 per day (as determined based on 
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1 the reasonably expected distribution of 

2 beneficiaries receiving benefits at various 

3 benefit levels). 

4 ‘‘(ii) AMOUNT SCALED TO FUNC5 TIONAL ABILITY.—The benefit amount is 

6 varied based on a scale of functional abil7 ity, with not less than 2, and not more 

8 than 6, benefit level amounts. 

9 ‘‘(iii) DAILY OR WEEKLY.—The ben10 efit is paid on a daily or weekly basis. 

11 ‘‘(iv) NO LIFETIME OR AGGREGATE

12 LIMIT.—The benefit is not subject to any 

13 lifetime or aggregate limit. 

14 ‘‘(2) REVIEW AND RECOMMENDATION BY THE

15 CLASS INDEPENDENCE ADVISORY COUNCIL.—The 

16 CLASS Independence Advisory Council shall— 

17 ‘‘(A) evaluate the alternative benefit plans 

18 developed under paragraph (1); and 

19 ‘‘(B) recommend for designation as the 

20 CLASS Independence Benefit Plan for offering 

21 to the public the plan that the Council deter22 mines best balances price and benefits to meet 

23 enrollees’ needs in an actuarially sound manner, 

24 while optimizing the probability of the long25 term sustainability of the CLASS program. 
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1 ‘‘(3) DESIGNATION BY THE SECRETARY.—Not 

2 later than October 1, 2012, the Secretary, taking 

3 into consideration the recommendation of the 

4 CLASS Independence Advisory Council under para5 graph (2)(B), shall designate a benefit plan as the 

6 CLASS Independence Benefit Plan. The Secretary 

7 shall publish such designation, along with details of 

8 the plan and the reasons for the selection by the 

9 Secretary, in a final rule that allows for a period of 

10 public comment. 

11 ‘‘(b) ADDITIONAL PREMIUM REQUIREMENTS.— 

12 ‘‘(1) ADJUSTMENT OF PREMIUMS.— 

13 ‘‘(A) IN GENERAL.—Except as provided in 

14 subparagraphs (B), (C), (D), and (E), the 

15 amount of the monthly premium determined for 

16 an individual upon such individual’s enrollment 

17 in the CLASS program shall remain the same 

18 for as long as the individual is an active en19 rollee in the program. 

20 ‘‘(B) RECALCULATED PREMIUM IF RE21 QUIRED FOR PROGRAM SOLVENCY.— 

22 ‘‘(i) IN GENERAL.—Subject to clause 

23 (ii), if the Secretary determines, based on 

24 the most recent report of the Board of 

25 Trustees of the CLASS Independence 
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1 Fund, the advice of the CLASS Independ2 ence Advisory Council, and the annual re3 port of the Inspector General of the De4 partment of Health and Human Services, 

5 and waste, fraud, and abuse, or such other 

6 information as the Secretary determines 

7 appropriate, that the monthly premiums 

8 and income to the CLASS Independence 

9 Fund for a year are projected to be insuffi10 cient with respect to the 20-year period 

11 that begins with that year, the Secretary 

12 shall adjust the monthly premiums for in13 dividuals enrolled in the CLASS program 

14 as necessary. 

15 ‘‘(ii) EXEMPTION FROM INCREASE.— 

16 Any increase in a monthly premium im17 posed as result of a determination de18 scribed in clause (i) shall not apply with 

19 respect to the monthly premium of any ac20 tive enrollee who— 

21 ‘‘(I) has attained age 65; 

22 ‘‘(II) has paid premiums for en23 rollment in the program for at least 

24 20 years; and 

25 ‘‘(III) is not actively employed. 
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1 ‘‘(C) RECALCULATED PREMIUM IF RE2 ENROLLMENT AFTER MORE THAN A 3-MONTH

3 LAPSE.— 

4 ‘‘(i) IN GENERAL.—The reenrollment 

5 of an individual after a 90-day period dur6 ing which the individual failed to pay the 

7 monthly premium required to maintain the 

8 individual’s enrollment in the CLASS pro9 gram shall be treated as an initial enroll10 ment for purposes of age-adjusting the 

11 premium for enrollment in the program. 

12 ‘‘(ii) CREDIT FOR PRIOR MONTHS IF

13 REENROLLED WITHIN 5 YEARS.—An indi14 vidual who reenrolls in the CLASS pro15 gram after such a 90-day period and be16 fore the end of the 5-year period that be17 gins with the first month for which the in18 dividual failed to pay the monthly premium 

19 required to maintain the individual’s en20 rollment in the program shall be— 

21 ‘‘(I) credited with any months of 

22 paid premiums that accrued prior to 

23 the individual’s lapse in enrollment; 

24 and 
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1 ‘‘(II) notwithstanding the total 

2 amount of any such credited months, 

3 required to satisfy section 

4 3202(6)(A)(ii) before being eligible to 

5 receive benefits. 

6 ‘‘(D) PENALTY FOR REENROLLMENT

7 AFTER 5-YEAR LAPSE.—In the case of an indi8 vidual who reenrolls in the CLASS program 

9 after the end of the 5-year period described in 

10 subparagraph (C)(ii), the monthly premium re11 quired for the individual shall be the age-ad12 justed premium that would be applicable to an 

13 initially enrolling individual who is the same age 

14 as the reenrolling individual, increased by the 

15 greater of— 

16 ‘‘(i) an amount that the Secretary de17 termines is actuarially sound for each 

18 month that occurs during the period that 

19 begins with the first month for which the 

20 individual failed to pay the monthly pre21 mium required to maintain the individual’s 

22 enrollment in the CLASS program and 

23 ends with the month preceding the month 

24 in which the reenrollment is effective; or 
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1 ‘‘(ii) 1 percent of the applicable age2 adjusted premium for each such month oc3 curring in such period. 

4 ‘‘(2) ADMINISTRATIVE EXPENSES.—In deter5 mining the monthly premiums for the CLASS pro6 gram, the Secretary may factor in costs for admin7 istering the program, not to exceed— 

8 ‘‘(A) in the case of the first 5 years in 

9 which the program is in effect under this title, 

10 an amount equal to 3 percent of all premiums 

11 paid during each such year; and 

12 ‘‘(B) in the case of subsequent years, an 

13 amount equal to 5 percent of the total amount 

14 of all expenditures (including benefits paid) 

15 under this title with respect to that year. 

16 ‘‘(3) NO UNDERWRITING REQUIREMENTS.—No 

17 underwriting (other than on the basis of age in ac18 cordance with paragraph (2)) shall be used to— 

19 ‘‘(A) determine the monthly premium for 

20 enrollment in the CLASS program; or 

21 ‘‘(B) prevent an individual from enrolling 

22 in the program. 

23 ‘‘SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIRE24 MENTS. 

25 ‘‘(a) AUTOMATIC ENROLLMENT.— 
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1 ‘‘(1) IN GENERAL.—Subject to paragraph (2), 

2 the Secretary shall establish procedures under which 

3 each individual described in subsection (c) shall be 

4 automatically enrolled in the CLASS program by an 

5 employer of such individual under rules similar to 

6 the rules of sections 401(k)(13) and 414(w) of the 

7 Internal Revenue Code of 1986. 

8 ‘‘(2) ALTERNATIVE ENROLLMENT PROCE9 DURES.—The procedures established under para10 graph (1) shall provide for an alternative enrollment 

11 process for an individual described in subsection (c) 

12 in the case of such an individual— 

13 ‘‘(A) who is self-employed; 

14 ‘‘(B) who has more than 1 employer; 

15 ‘‘(C) whose employer does not elect to par16 ticipate in the automatic enrollment process es17 tablished by the Secretary; or 

18 ‘‘(D) who is a spouse described in sub19 section (c)(2) of who is not subject to automatic 

20 enrollment. 

21 ‘‘(3) ADMINISTRATION.— 

22 ‘‘(A) IN GENERAL.—The Secretary shall, 

23 by regulation, establish procedures to— 
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1 ‘‘(i) ensure that an individual is not 

2 automatically enrolled in the CLASS pro3 gram by more than 1 employer; and 

4 ‘‘(ii) allow for an individual’s em5 ployer to deduct a premium for a spouse 

6 described in subsection (c)(1)(B) who is 

7 not subject to automatic enrollment. 

8 ‘‘(B) FORM.—Enrollment in the CLASS 

9 program shall be made in such manner as the 

10 Secretary may prescribe in order to ensure ease 

11 of administration. 

12 ‘‘(b) ELECTION TO OPT-OUT.—An individual de13 scribed in subsection (c) may elect to waive enrollment in 

14 the CLASS program at any time in such form and manner 

15 as the Secretary shall prescribe. 

16 ‘‘(c) INDIVIDUAL DESCRIBED.—For purposes of en17 rolling in the CLASS program, an individual described in 

18 this paragraph is— 

19 ‘‘(1) an individual— 

20 ‘‘(A) who has attained age 18; 

21 ‘‘(B) who receives wages on which there is 

22 imposed a tax under section 3101(a) or 3201(a) 

23 of the Internal Revenue Code of 1986; 

24 ‘‘(C) who is actively employed; and 

25 ‘‘(D) who is not— 
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1 ‘‘(i) a patient in a hospital or nursing 

2 facility, an intermediate care facility for 

3 the mentally retarded, or an institution for 

4 mental diseases and receiving medical as5 sistance under Medicaid; or 

6 ‘‘(ii) confined in a jail, prison, other 

7 penal institution or correctional facility, or 

8 by court order pursuant to conviction of a 

9 criminal offense or in connection with a 

10 verdict or finding described in section 

11 202(x)(1)(A)(ii) of the Social Security Act; 

12 or 

13 ‘‘(2) the spouse of an individual described in 

14 paragraph (1) and who would be an individual so de15 scribed but for subparagraph (B) or (C) of that 

16 paragraph. 

17 ‘‘(d) RULE OF CONSTRUCTION.—Nothing in this title 

18 shall be construed as requiring an active enrollee to con19 tinue to satisfy subparagraph (B) or (C) of subsection 

20 (c)(1) in order to maintain enrollment in the CLASS pro21 gram. 

22 ‘‘(e) PAYMENT.— 

23 ‘‘(1) PAYROLL DEDUCTION.—An amount equal 

24 to the monthly premium for the enrollment in the 

25 CLASS program of an individual shall be deducted 
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1 from the wages of such individual in accordance with 

2 such procedures as the Secretary shall establish for 

3 employers who elect to deduct and withhold such 

4 premiums on behalf of enrolled employees. 

5 ‘‘(2) ALTERNATIVE PAYMENT MECHANISM.— 

6 The Secretary shall establish alternative procedures 

7 for the payment of monthly premiums by an indi8 vidual enrolled in the CLASS program who does not 

9 have an employer who elects to deduct and withhold 

10 premiums in accordance with subparagraph (A). 

11 ‘‘(f) TRANSFER OF PREMIUMS COLLECTED.— 

12 ‘‘(1) IN GENERAL.—During each calendar year 

13 the Secretary of the Treasury shall deposit into the 

14 CLASS Independence Fund a total amount equal, in 

15 the aggregate, to 100 percent of the premiums col16 lected during that year. 

17 ‘‘(2) TRANSFERS BASED ON ESTIMATES.—The 

18 amount deposited pursuant to paragraph (1) shall be 

19 transferred in at least monthly payments to the 

20 CLASS Independence Fund on the basis of esti21 mates by the Secretary and certified to the Sec22 retary of the Treasury of the amounts collected in 

23 accordance with this section. Proper adjustments 

24 shall be made in amounts subsequently transferred 
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1 to the Fund to the extent prior estimates were in ex2 cess of, or were less than, actual amounts collected. 

3 ‘‘(g) OTHER ENROLLMENT AND DISENROLLMENT

4 OPPORTUNITIES.—The Secretary shall establish proce5 dures under which— 

6 ‘‘(1) an individual who, in the year of the indi7 vidual’s initial eligibility to enroll in the CLASS pro8 gram, has elected to waive enrollment in the pro9 gram, is eligible to elect to enroll in the program, in 

10 such form and manner as the Secretary shall estab11 lish, only during an open enrollment period estab12 lished by the Secretary that is specific to the indi13 vidual and that may not occur more frequently than 

14 biennially after the date on which the individual first 

15 elected to waive enrollment in the program; and 

16 ‘‘(2) an individual shall only be permitted to 

17 disenroll from the program during an annual 

18 disenrollment period established by the Secretary 

19 and in such form and manner as the Secretary shall 

20 establish. 

21 ‘‘SEC. 3205. BENEFITS. 

22 ‘‘(a) DETERMINATION OF ELIGIBILITY.— 

23 ‘‘(1) APPLICATION FOR RECEIPT OF BENE24 FITS.—The Secretary shall establish procedures 

25 under which an active enrollee shall apply for receipt 
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1 of benefits under the CLASS Independence Benefit 

2 Plan. 

3 ‘‘(2) ELIGIBILITY ASSESSMENTS.— 

4 ‘‘(A) IN GENERAL.—Not later than Janu5 ary 1, 2012, the Secretary shall— 

6 ‘‘(i) designate an entity (other than a 

7 service with which the Commissioner of So8 cial Security has entered into an agree9 ment, with respect to any State, to make 

10 disability determinations for purposes of 

11 title II or XVI of the Social Security Act) 

12 to serve as an Eligibility Assessment Sys13 tem by providing for eligibility assessments 

14 of active enrollees who apply for receipt of 

15 benefits; 

16 ‘‘(ii) enter into an agreement with the 

17 Protection and Advocacy System for each 

18 State to provide advocacy services in ac19 cordance with subsection (d); and 

20 ‘‘(iii) enter into an agreement with 

21 public and private entities to provide ad22 vice and assistance counseling in accord23 ance with subsection (e). 

24 ‘‘(B) REGULATIONS.—The Secretary shall 

25 promulgate regulations to develop an expedited 
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1 nationally equitable eligibility determination 

2 process, as certified by a licensed health care 

3 practitioner, an appeals process, and a redeter4 mination process, as certified by a licensed 

5 health care practitioner, including whether an 

6 applicant is eligible for a cash benefit under the 

7 program and if so, the amount of the cash ben8 efit (in accordance the sliding scale established 

9 under the plan). 

10 ‘‘(C) PRESUMPTIVE ELIGIBILITY FOR CER11 TAIN INSTITUTIONALIZED ENROLLEES PLAN12 NING TO DISCHARGE.—An active enrollee shall 

13 be deemed presumptively eligible if the en14 rollee— 

15 ‘‘(i) has applied for, and attests is eli16 gible for, the maximum cash benefit avail17 able under the sliding scale established 

18 under the CLASS Independence Benefit 

19 Plan; 

20 ‘‘(ii) is a patient in a hospital (but 

21 only if the hospitalization is for long-term 

22 care), nursing facility, intermediate care 

23 facility for the mentally retarded, or an in24 stitution for mental diseases; and 
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1 ‘‘(iii) is in the process of, or about to 

2 being the process of, planning to discharge 

3 from the hospital, facility, or institution, or 

4 within 60 days from the date of discharge 

5 from the hospital, facility, or institution. 

6 ‘‘(D) APPEALS.—The Secretary shall es7 tablish procedures under which an applicant for 

8 benefits under the CLASS Independence Ben9 efit Plan shall be guaranteed the right to ap10 peal an adverse determination. 

11 ‘‘(b) BENEFITS.—An eligible beneficiary shall receive 

12 the following benefits under the CLASS Independence 

13 Benefit Plan: 

14 ‘‘(1) CASH BENEFIT.—A cash benefit estab15 lished by the Secretary in accordance with the re16 quirements of section 3203(a)(1)(D) that— 

17 ‘‘(A) the first year in which beneficiaries 

18 receive the benefits under the plan, is not less 

19 than the average dollar amount specified in 

20 clause (i) of such section; and 

21 ‘‘(B) for any subsequent year, is not less 

22 than the average per day dollar limit applicable 

23 under this subparagraph for the preceding year, 

24 increased by the percentage increase in the con25 sumer price index for all urban consumers 
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1 (United States city average) over the previous 

2 year. 

3 ‘‘(2) ADVOCACY SERVICES.—Advocacy services 

4 in accordance with subsection (d). 

5 ‘‘(3) ADVICE AND ASSISTANCE COUNSELING.— 

6 Advice and assistance counseling in accordance with 

7 subsection (e). 

8 ‘‘(4) ADMINISTRATIVE EXPENSES.—Advocacy 

9 services and advise and assistance counseling serv10 ices under paragraphs (2) and (3) of this subsection 

11 shall be included as administrative expenses under 

12 section 3203(b)(2). 

13 ‘‘(c) PAYMENT OF BENEFITS.— 

14 ‘‘(1) LIFE INDEPENDENCE ACCOUNT.— 

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

16 establish procedures for administering the pro17 vision of benefits to eligible beneficiaries under 

18 the CLASS Independence Benefit Plan, includ19 ing the payment of the cash benefit for the ben20 eficiary into a Life Independence Account es21 tablished by the Secretary on behalf of each eli22 gible beneficiary. 

23 ‘‘(B) USE OF CASH BENEFITS.—Cash ben24 efits paid into a Life Independence Account of 

25 an eligible beneficiary shall be used to purchase 
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1 nonmedical services and supports that the bene2 ficiary needs to maintain his or her independ3 ence at home or in another residential setting 

4 of their choice in the community, including (but 

5 not limited to) home modifications, assistive 

6 technology, accessible transportation, home7 maker services, respite care, personal assistance 

8 services, home care aides, and nursing support. 

9 Nothing in the preceding sentence shall prevent 

10 an eligible beneficiary from using cash benefits 

11 paid into a Life Independence Account for ob12 taining assistance with decisionmaking con13 cerning medical care, including the right to ac14 cept or refuse medical or surgical treatment 

15 and the right to formulate advance directives or 

16 other written instructions recognized under 

17 State law, such as a living will or durable power 

18 of attorney for health care, in the case that an 

19 injury or illness causes the individual to be un20 able to make health care decisions. 

21 ‘‘(C) ELECTRONIC MANAGEMENT OF

22 FUNDS.—The Secretary shall establish proce23 dures for— 
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1 ‘‘(i) crediting an account established 

2 on behalf of a beneficiary with the bene3 ficiary’s cash daily benefit; 

4 ‘‘(ii) allowing the beneficiary to access 

5 such account through debit cards; and 

6 ‘‘(iii) accounting for withdrawals by 

7 the beneficiary from such account. 

8 ‘‘(D) PRIMARY PAYOR RULES FOR BENE9 FICIARIES WHO ARE ENROLLED IN MEDICAID.— 

10 In the case of an eligible beneficiary who is en11 rolled in Medicaid, the following payment rules 

12 shall apply: 

13 ‘‘(i) INSTITUTIONALIZED BENE14 FICIARY.—If the beneficiary is a patient in 

15 a hospital, nursing facility, intermediate 

16 care facility for the mentally retarded, or 

17 an institution for mental diseases, the ben18 eficiary shall retain an amount equal to 5 

19 percent of the beneficiary’s daily or weekly 

20 cash benefit (as applicable) (which shall be 

21 in addition to the amount of the bene22 ficiary’s personal needs allowance provided 

23 under Medicaid), and the remainder of 

24 such benefit shall be applied toward the fa25 cility’s cost of providing the beneficiary’s 
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1 care, and Medicaid shall provide secondary 

2 coverage for such care. 

3 ‘‘(ii) BENEFICIARIES RECEIVING

4 HOME AND COMMUNITY-BASED SERV5 ICES.— 

6 ‘‘(I) 50 PERCENT OF BENEFIT

7 RETAINED BY BENEFICIARY.—Subject 

8 to subclause (II), if a beneficiary is 

9 receiving medical assistance under 

10 Medicaid for home and community11 based services, the beneficiary shall 

12 retain an amount equal to 50 percent 

13 of the beneficiary’s daily or weekly 

14 cash benefit (as applicable), and the 

15 remainder of the daily or weekly cash 

16 benefit shall be applied toward the 

17 cost to the State of providing such as18 sistance (and shall not be used to 

19 claim Federal matching funds under 

20 Medicaid), and Medicaid shall provide 

21 secondary coverage for the remainder 

22 of any costs incurred in providing 

23 such assistance. 

24 ‘‘(II) REQUIREMENT FOR STATE

25 OFFSET.—A State shall be paid the 
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1 remainder of a beneficiary’s daily or 

2 weekly cash benefit under subclause 

3 (I) only if the State home and com4 munity-based waiver under section 

5 1115 of the Social Security Act or 

6 subsection (c) or (d) of section 1915 

7 of such Act, or the State plan amend8 ment under subsection (i) of such sec9 tion does not include a waiver of the 

10 requirements of section 1902(a)(1) of 

11 the Social Security Act (relating to 

12 statewideness) or of section 

13 1902(a)(10)(B) of such Act (relating 

14 to comparability) and the State offers 

15 at a minimum case management serv16 ices, personal care services, habili17 tation services, and respite care under 

18 such a waiver or State plan amend19 ment. 

20 ‘‘(III) DEFINITION OF HOME AND

21 COMMUNITY-BASED SERVICES.—In 

22 this clause, the term ‘home and com23 munity-based services’ means any 

24 services which may be offered under a 

25 home and community-based waiver 
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1 authorized for a State under section 

2 1115 of the Social Security Act or 

3 subsection (c) or (d) of section 1915 

4 of such Act or under a State plan 

5 amendment under subsection (i) of 

6 such section. 

7 ‘‘(iii) BENEFICIARIES ENROLLED IN

8 PROGRAMS OF ALL-INCLUSIVE CARE FOR

9 THE ELDERLY (PACE).— 

10 ‘‘(I) IN GENERAL.—Subject to 

11 subclause (II), if a beneficiary is re12 ceiving medical assistance under Med13 icaid for PACE program services 

14 under section 1934 of the Social Secu15 rity Act, the beneficiary shall retain 

16 an amount equal to 50 percent of the 

17 beneficiary’s daily or weekly cash ben18 efit (as applicable), and the remainder 

19 of the daily or weekly cash benefit 

20 shall be applied toward the cost to the 

21 State of providing such assistance 

22 (and shall not be used to claim Fed23 eral matching funds under Medicaid), 

24 and Medicaid shall provide secondary 

25 coverage for the remainder of any 
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1 costs incurred in providing such as2 sistance. 

3 ‘‘(II) INSTITUTIONALIZED RE4 CIPIENTS OF PACE PROGRAM SERV5 ICES.—If a beneficiary receiving as6 sistance under Medicaid for PACE 

7 program services is a patient in a hos8 pital, nursing facility, intermediate 

9 care facility for the mentally retarded, 

10 or an institution for mental diseases, 

11 the beneficiary shall be treated as in 

12 institutionalized beneficiary under 

13 clause (i). 

14 ‘‘(2) AUTHORIZED REPRESENTATIVES.— 

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

16 establish procedures to allow access to a bene17 ficiary’s cash benefits by an authorized rep18 resentative of the eligible beneficiary on whose 

19 behalf such benefits are paid. 

20 ‘‘(B) QUALITY ASSURANCE AND PROTEC21 TION AGAINST FRAUD AND ABUSE.—The proce22 dures established under subparagraph (A) shall 

23 ensure that authorized representatives of eligi24 ble beneficiaries comply with standards of con25 duct established by the Secretary, including 
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1 standards requiring that such representatives 

2 provide quality services on behalf of such bene3 ficiaries, do not have conflicts of interest, and 

4 do not misuse benefits paid on behalf of such 

5 beneficiaries or otherwise engage in fraud or 

6 abuse. 

7 ‘‘(3) COMMENCEMENT OF BENEFITS.—Benefits 

8 shall be paid to, or on behalf of, an eligible bene9 ficiary beginning with the first month in which an 

10 application for such benefits is approved. 

11 ‘‘(4) ROLLOVER OPTION FOR LUMP-SUM PAY12 MENT.—An eligible beneficiary may elect to— 

13 ‘‘(A) defer payment of their daily or weekly 

14 benefit and to rollover any such deferred bene15 fits from month-to-month, but not from year-to16 year; and 

17 ‘‘(B) receive a lump-sum payment of such 

18 deferred benefits in an amount that may not 

19 exceed the lesser of— 

20 ‘‘(i) the total amount of the accrued 

21 deferred benefits; or 

22 ‘‘(ii) the applicable annual benefit. 

23 ‘‘(5) PERIOD FOR DETERMINATION OF ANNUAL

24 BENEFITS.— 
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1 ‘‘(A) IN GENERAL.—The applicable period 

2 for determining with respect to an eligible bene3 ficiary the applicable annual benefit and the 

4 amount of any accrued deferred benefits is the 

5 12-month period that commences with the first 

6 month in which the beneficiary began to receive 

7 such benefits, and each 12-month period there8 after. 

9 ‘‘(B) INCLUSION OF INCREASED BENE10 FITS.—The Secretary shall establish procedures 

11 under which cash benefits paid to an eligible 

12 beneficiary that increase or decrease as a result 

13 of a change in the functional status of the bene14 ficiary before the end of a 12-month benefit pe15 riod shall be included in the determination of 

16 the applicable annual benefit paid to the eligible 

17 beneficiary. 

18 ‘‘(C) RECOUPMENT OF UNPAID, ACCRUED

19 BENEFITS.— 

20 ‘‘(i) IN GENERAL.—The Secretary, in 

21 coordination with the Secretary of the 

22 Treasury, shall recoup any accrued bene23 fits in the event of— 

24 ‘‘(I) the death of a beneficiary; or 
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1 ‘‘(II) the failure of a beneficiary 

2 to elect under paragraph (4)(B) to re3 ceive such benefits as a lump-sum 

4 payment before the end of the 12- 

5 month period in which such benefits 

6 accrued. 

7 ‘‘(ii) PAYMENT INTO CLASS INDE8 PENDENCE FUND.—Any benefits recouped 

9 in accordance with clause (i) shall be paid 

10 into the CLASS Independence Fund and 

11 used in accordance with section 3206. 

12 ‘‘(6) REQUIREMENT TO RECERTIFY ELIGIBILITY

13 FOR RECEIPT OF BENEFITS.—An eligible beneficiary 

14 shall periodically, as determined by the Secretary— 

15 ‘‘(A) recertify by submission of medical 

16 evidence the beneficiary’s continued eligibility 

17 for receipt of benefits; and 

18 ‘‘(B) submit records of expenditures attrib19 utable to the aggregate cash benefit received by 

20 the beneficiary during the preceding year. 

21 ‘‘(7) SUPPLEMENT, NOT SUPPLANT OTHER

22 HEALTH CARE BENEFITS.—Subject to the Medicaid 

23 payment rules under paragraph (1)(D), benefits re24 ceived by an eligible beneficiary shall supplement, 

25 but not supplant, other health care benefits for 
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1 which the beneficiary is eligible under Medicaid or 

2 any other Federally funded program that provides 

3 health care benefits or assistance. 

4 ‘‘(d) ADVOCACY SERVICES.—An agreement entered 

5 into under subsection (a)(2)(A)(ii) shall require the Pro6 tection and Advocacy System for the State to— 

7 ‘‘(1) assign, as needed, an advocacy counselor 

8 to each eligible beneficiary that is covered by such 

9 agreement and who shall provide an eligible bene10 ficiary with— 

11 ‘‘(A) information regarding how to access 

12 the appeals process established for the program; 

13 ‘‘(B) assistance with respect to the annual 

14 recertification and notification required under 

15 subsection (c)(6); and 

16 ‘‘(C) such other assistance with obtaining 

17 services as the Secretary, by regulation, shall 

18 require; and 

19 ‘‘(2) ensure that the System and such coun20 selors comply with the requirements of subsection 

21 (h). 

22 ‘‘(e) ADVICE AND ASSISTANCE COUNSELING.—An 

23 agreement entered into under subsection (a)(2)(A)(iii) 

24 shall require the entity to assign, as requested by an eligi25 ble beneficiary that is covered by such agreement, an ad-
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1 vice and assistance counselor who shall provide an eligible 

2 beneficiary with information regarding— 

3 ‘‘(1) accessing and coordinating long-term serv4 ices and supports in the most integrated setting; 

5 ‘‘(2) possible eligibility for other benefits and 

6 services; 

7 ‘‘(3) development of a service and support plan; 

8 ‘‘(4) information about programs established 

9 under the Assistive Technology Act of 1998 and the 

10 services offered under such programs; 

11 ‘‘(5) available assistance with decisionmaking 

12 concerning medical care, including the right to ac13 cept or refuse medical or surgical treatment and the 

14 right to formulate advance directives or other writ15 ten instructions recognized under State law, such as 

16 a living will or durable power of attorney for health 

17 care, in the case that an injury or illness causes the 

18 individual to be unable to make health care deci19 sions; and 

20 ‘‘(6) such other services as the Secretary, by 

21 regulation, may require. 

22 ‘‘(f) NO EFFECT ON ELIGIBILITY FOR OTHER BENE23 FITS.—Benefits paid to an eligible beneficiary under the 

24 CLASS program shall be disregarded for purposes of de25 termining or continuing the beneficiary’s eligibility for re-
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1 ceipt of benefits under any other Federal, State, or locally 

2 funded assistance program, including benefits paid under 

3 titles II, XVI, XVIII, XIX, or XXI of the Social Security 

4 Act, under the laws administered by the Secretary of Vet5 erans Affairs, under low-income housing assistance pro6 grams, or under the supplemental nutrition assistance 

7 program established under the Food and Nutrition Act of 

8 2008. 

9 ‘‘(g) RULE OF CONSTRUCTION.—Nothing in this title 

10 shall be construed as prohibiting benefits paid under the 

11 CLASS Independence Benefit Plan from being used to 

12 compensate a family caregiver for providing community 

13 living assistance services and supports to an eligible bene14 ficiary. 

15 ‘‘(h) PROTECTION AGAINST CONFLICTS OF INTER16 EST.—The Secretary shall establish procedures to ensure 

17 that the Eligibility Assessment System, the Protection and 

18 Advocacy System for a State, advocacy counselors for eli19 gible beneficiaries, and any other entities that provide 

20 services to active enrollees and eligible beneficiaries under 

21 the CLASS program comply with the following: 

22 ‘‘(1) If the entity provides counseling or plan23 ning services, such services are provided in a manner 

24 that fosters the best interests of the active enrollee 

25 or beneficiary. 
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1 ‘‘(2) The entity has established operating proce2 dures that are designed to avoid or minimize con3 flicts of interest between the entity and an active en4 rollee or beneficiary. 

5 ‘‘(3) The entity provides information about all 

6 services and options available to the active enrollee 

7 or beneficiary, to the best of its knowledge, including 

8 services available through other entities or providers. 

9 ‘‘(4) The entity assists the active enrollee or 

10 beneficiary to access desired services, regardless of 

11 the provider. 

12 ‘‘(5) The entity reports the number of active 

13 enrollees and beneficiaries provided with assistance 

14 by age, disability, and whether such enrollees and 

15 beneficiaries received services from the entity or an16 other entity. 

17 ‘‘(6) If the entity provides counseling or plan18 ning services, the entity ensures that an active en19 rollee or beneficiary is informed of any financial in20 terest that the entity has in a service provider. 

21 ‘‘(7) The entity provides an active enrollee or 

22 beneficiary with a list of available service providers 

23 that can meet the needs of the active enrollee or 

24 beneficiary. 
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1 ‘‘SEC. 3206. CLASS INDEPENDENCE FUND. 

2 ‘‘(a) ESTABLISHMENT OF CLASS INDEPENDENCE

3 FUND.—There is established in the Treasury of the 

4 United States a trust fund to be known as the ‘CLASS 

5 Independence Fund’. The Secretary of the Treasury shall 

6 serve as Managing Trustee of such Fund. The Fund shall 

7 consist of all amounts derived from payments into the 

8 Fund under sections 3204(f) and 3205(c)(5)(C)(ii), and 

9 remaining after investment of such amounts under sub10 section (b), including additional amounts derived as in11 come from such investments. The amounts held in the 

12 Fund are appropriated and shall remain available without 

13 fiscal year limitation— 

14 ‘‘(1) to be held for investment on behalf of indi15 viduals enrolled in the CLASS program; 

16 ‘‘(2) to pay the administrative expenses related 

17 to the Fund and to investment under subsection (b); 

18 and 

19 ‘‘(3) to pay cash benefits to eligible bene20 ficiaries under the CLASS Independence Benefit 

21 Plan. 

22 ‘‘(b) INVESTMENT OF FUND BALANCE.—The Sec23 retary of the Treasury shall invest and manage the 

24 CLASS Independence Fund in the same manner, and to 

25 the same extent, as the Federal Supplementary Medical 

26 Insurance Trust Fund may be invested and managed 
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1 under subsections (c), (d), and (e) of section 1841(d) of 

2 the Social Security Act. 

3 ‘‘(c) BOARD OF TRUSTEES.— 

4 ‘‘(1) IN GENERAL.—With respect to the CLASS 

5 Independence Fund, there is hereby created a body 

6 to be known as the Board of Trustees of the CLASS 

7 Independence Fund (hereinafter in this section re8 ferred to as the ‘Board of Trustees’) composed of 

9 the Secretary of the Treasury, the Secretary of 

10 Labor, and the Secretary of Health and Human 

11 Services, all ex officio, and of two members of the 

12 public (both of whom may not be from the same po13 litical party), who shall be nominated by the Presi14 dent for a term of 4 years and subject to confirma15 tion by the Senate. A member of the Board of 

16 Trustees serving as a member of the public and 

17 nominated and confirmed to fill a vacancy occurring 

18 during a term shall be nominated and confirmed 

19 only for the remainder of such term. An individual 

20 nominated and confirmed as a member of the public 

21 may serve in such position after the expiration of 

22 such member’s term until the earlier of the time at 

23 which the member’s successor takes office or the 

24 time at which a report of the Board is first issued 

25 under paragraph (2) after the expiration of the 
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1 member’s term. The Secretary of the Treasury shall 

2 be the Managing Trustee of the Board of Trustees. 

3 The Board of Trustees shall meet not less frequently 

4 than once each calendar year. A person serving on 

5 the Board of Trustees shall not be considered to be 

6 a fiduciary and shall not be personally liable for ac7 tions taken in such capacity with respect to the 

8 Trust Fund. 

9 ‘‘(2) DUTIES.— 

10 ‘‘(A) IN GENERAL.—It shall be the duty of 

11 the Board of Trustees to do the following: 

12 ‘‘(i) Hold the CLASS Independence 

13 Fund. 

14 ‘‘(ii) Report to the Congress not later 

15 than the first day of April of each year on 

16 the operation and status of the CLASS 

17 Independence Fund during the preceding 

18 fiscal year and on its expected operation 

19 and status during the current fiscal year 

20 and the next 2 fiscal years. 

21 ‘‘(iii) Report immediately to the Con22 gress whenever the Board is of the opinion 

23 that the amount of the CLASS Independ24 ence Fund is not actuarially sound in re-
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1 gards to the projections under section 

2 3203(b)(1)(B)(i). 

3 ‘‘(iv) Review the general policies fol4 lowed in managing the CLASS Independ5 ence Fund, and recommend changes in 

6 such policies, including necessary changes 

7 in the provisions of law which govern the 

8 way in which the CLASS Independence 

9 Fund is to be managed. 

10 ‘‘(B) REPORT.—The report provided for in 

11 subparagraph (A)(ii) shall— 

12 ‘‘(i) include— 

13 ‘‘(I) a statement of the assets of, 

14 and the disbursements made from, the 

15 CLASS Independence Fund during 

16 the preceding fiscal year; 

17 ‘‘(II) an estimate of the expected 

18 income to, and disbursements to be 

19 made from, the CLASS Independence 

20 Fund during the current fiscal year 

21 and each of the next 2 fiscal years; 

22 ‘‘(III) a statement of the actu23 arial status of the CLASS Independ24 ence Fund for the current fiscal year, 

25 each of the next 2 fiscal years, and as 
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1 projected over the 75-year period be2 ginning with the current fiscal year; 

3 and 

4 ‘‘(IV) an actuarial opinion certi5 fying that the techniques and meth6 odologies used are generally accepted 

7 within the actuarial profession and 

8 that the assumptions and cost esti9 mates used are reasonable; and 

10 ‘‘(ii) be printed as a House document 

11 of the session of the Congress to which the 

12 report is made. 

13 ‘‘(C) RECOMMENDATIONS.—If the Board 

14 of Trustees determines that enrollment trends 

15 and expected future benefit claims on the 

16 CLASS Independence Fund are not actuarially 

17 sound in regards to the projections under sec18 tion 3203(b)(1)(B)(i) and are unlikely to be re19 solved with reasonable premium increases or 

20 through other means, the Board of Trustees 

21 shall include in the report provided for in sub22 paragraph (A)(ii) recommendations for such 

23 legislative action as the Board of Trustees de24 termine to be appropriate, including whether to 
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1 adjust monthly premiums or impose a tem2 porary moratorium on new enrollments. 

3 ‘‘SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL. 

4 ‘‘(a) ESTABLISHMENT.—There is hereby created an 

5 Advisory Committee to be known as the ‘CLASS Inde6 pendence Advisory Council’. 

7 ‘‘(b) MEMBERSHIP.— 

8 ‘‘(1) IN GENERAL.—The CLASS Independence 

9 Advisory Council shall be composed of not more 

10 than 15 individuals, not otherwise in the employ of 

11 the United States— 

12 ‘‘(A) who shall be appointed by the Presi13 dent without regard to the civil service laws and 

14 regulations; and 

15 ‘‘(B) a majority of whom shall be rep16 resentatives of individuals who participate or 

17 are likely to participate in the CLASS program, 

18 and shall include representatives of older and 

19 younger workers, individuals with disabilities, 

20 family caregivers of individuals who require 

21 services and supports to maintain their inde22 pendence at home or in another residential set23 ting of their choice in the community, individ24 uals with expertise in long-term care or dis25 ability insurance, actuarial science, economics, 
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1 and other relevant disciplines, as determined by 

2 the Secretary. 

3 ‘‘(2) TERMS.— 

4 ‘‘(A) IN GENERAL.—The members of the 

5 CLASS Independence Advisory Council shall 

6 serve overlapping terms of 3 years (unless ap7 pointed to fill a vacancy occurring prior to the 

8 expiration of a term, in which case the indi9 vidual shall serve for the remainder of the 

10 term). 

11 ‘‘(B) LIMITATION.—A member shall not be 

12 eligible to serve for more than 2 consecutive 

13 terms. 

14 ‘‘(3) CHAIR.—The President shall, from time to 

15 time, appoint one of the members of the CLASS 

16 Independence Advisory Council to serve as the 

17 Chair. 

18 ‘‘(c) DUTIES.—The CLASS Independence Advisory 

19 Council shall advise the Secretary on matters of general 

20 policy in the administration of the CLASS program estab21 lished under this title and in the formulation of regula22 tions under this title including with respect to— 

23 ‘‘(1) the development of the CLASS Independ24 ence Benefit Plan under section 3203; and 
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1 ‘‘(2) the determination of monthly premiums 

2 under such plan. 

3 ‘‘(d) APPLICATION OF FACA.—The Federal Advisory 

4 Committee Act, other than section 14 of that Act, shall 

5 apply to the CLASS Independence Advisory Council. 

6 ‘‘(e) AUTHORIZATION OF APPROPRIATIONS.— 

7 ‘‘(1) IN GENERAL.—There are authorized to be 

8 appropriated to the CLASS Independence Advisory 

9 Council to carry out its duties under this section, 

10 such sums as may be necessary for fiscal year 2011 

11 and for each fiscal year thereafter. 

12 ‘‘(2) AVAILABILITY.—Any sums appropriated 

13 under the authorization contained in this section 

14 shall remain available, without fiscal year limitation, 

15 until expended. 

16 ‘‘SEC. 3208. REGULATIONS; ANNUAL REPORT. 

17 ‘‘(a) REGULATIONS.—The Secretary shall promulgate 

18 such regulations as are necessary to carry out the CLASS 

19 program in accordance with this title. Such regulations 

20 shall include provisions to prevent fraud and abuse under 

21 the program. 

22 ‘‘(b) ANNUAL REPORT.—Beginning January 1, 2014, 

23 the Secretary shall submit an annual report to Congress 

24 on the CLASS program. Each report shall include the fol25 lowing: 
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1 ‘‘(1) The total number of enrollees in the pro2 gram. 

3 ‘‘(2) The total number of eligible beneficiaries 

4 during the fiscal year. 

5 ‘‘(3) The total amount of cash benefits provided 

6 during the fiscal year. 

7 ‘‘(4) A description of instances of fraud or 

8 abuse identified during the fiscal year. 

9 ‘‘(5) Recommendations for such administrative 

10 or legislative action as the Secretary determines is 

11 necessary to improve the program or to prevent the 

12 occurrence of fraud or abuse. 

13 ‘‘SEC. 3209. INSPECTOR GENERAL’S REPORT. 

14 ‘‘The Inspector General of the Department of Health 

15 and Human Services shall submit an annual report to the 

16 Secretary and Congress relating to the overall progress of 

17 the CLASS program and of the existence of waste, fraud, 

18 and abuse in the CLASS program. Each such report shall 

19 include findings in the following areas: 

20 ‘‘(1) The eligibility determination process. 

21 ‘‘(2) The provision of cash benefits. 

22 ‘‘(3) Quality assurance and protection against 

23 waste, fraud, and abuse. 

24 ‘‘(4) Recouping of unpaid and accrued bene25 fits.’’. 
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1 (b) CONFORMING AMENDMENTS TO MEDICAID.—For 

2 conforming provisions amending the Medicaid program, 

3 see section 1739. 

4 Subtitle E—Miscellaneous 

5 SEC. 2585. STATES FAILING TO ADHERE TO CERTAIN EM6 PLOYMENT OBLIGATIONS. 

7 A State is eligible for Federal funds under the provi8 sions of the Public Health Service Act (42 U.S.C. 201 et 

9 seq.) only if the State— 

10 (1) agrees to be subject in its capacity as an 

11 employer to each obligation under division A of this 

12 Act and the amendments made by such division ap13 plicable to persons in their capacity as an employer; 

14 and 

15 (2) assures that all political subdivisions in the 

16 State will do the same. 

17 SEC. 2586. HEALTH CENTERS UNDER PUBLIC HEALTH 

18 SERVICE ACT; LIABILITY PROTECTIONS FOR 

19 VOLUNTEER PRACTITIONERS. 

20 (a) IN GENERAL.—Section 224 (42 U.S.C. 233) is 

21 amended— 

22 (1) in subsection (g)(1)(A)— 

23 (A) in the first sentence, by striking ‘‘or 

24 employee’’ and inserting ‘‘employee, or (subject 
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1 to subsection (k)(4)) volunteer practitioner’’; 

2 and 

3 (B) in the second sentence, by inserting 

4 ‘‘and subsection (k)(4)’’ after ‘‘subject to para5 graph (5)’’; and 

6 (2) in each of subsections (g), (i), (j), (l), and 

7 (m), by striking the term ‘‘employee, or contractor’’ 

8 each place such term appears and inserting ‘‘em9 ployee, volunteer practitioner, or contractor’’; 

10 (3) in subsection (g)(1)(H), by striking the 

11 term ‘‘employee, and contractor’’ each place such 

12 term appears and inserting ‘‘employee, volunteer 

13 practitioner, and contractor’’; 

14 (4) in subsection (l), by striking the term ‘‘em15 ployee, or any contractor’’ and inserting ‘‘employee, 

16 volunteer practitioner, or contractor’’; and 

17 (5) in subsections (h)(3) and (k), by striking 

18 the term ‘‘employees, or contractors’’ each place 

19 such term appears and inserting ‘‘employees, volun20 teer practitioners, or contractors’’. 

21 (b) APPLICABILITY; DEFINITION.—Section 224(k) 

22 (42 U.S.C. 233(k)) is amended by adding at the end the 

23 following paragraph: 

24 ‘‘(4)(A) Subsections (g) through (m) apply with re25 spect to volunteer practitioners beginning with the first 
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1 fiscal year for which an appropriations Act provides that 

2 amounts in the fund under paragraph (2) are available 

3 with respect to such practitioners. 

4 ‘‘(B) For purposes of subsections (g) through (m), 

5 the term ‘volunteer practitioner’ means a practitioner who, 

6 with respect to an entity described in subsection (g)(4), 

7 meets the following conditions: 

8 ‘‘(i) The practitioner is a licensed physician, a 

9 licensed clinical psychologist, or other licensed or 

10 certified health care practitioner. 

11 ‘‘(ii) At the request of such entity, the practi12 tioner provides services to patients of the entity, at 

13 a site at which the entity operates or at a site des14 ignated by the entity. The weekly number of hours 

15 of services provided to the patients by the practi16 tioner is not a factor with respect to meeting condi17 tions under this subparagraph. 

18 ‘‘(iii) The practitioner does not for the provision 

19 of such services receive any compensation from such 

20 patients, from the entity, or from third-party payors 

21 (including reimbursement under any insurance pol22 icy or health plan, or under any Federal or State 

23 health benefits program).’’. 
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1 SEC. 2587. REPORT TO CONGRESS ON THE CURRENT STATE 

2 OF PARASITIC DISEASES THAT HAVE BEEN 

3 OVERLOOKED AMONG THE POOREST AMERI4 CANS. 

5 Not later than 12 months after the date of the enact6 ment of this Act, the Secretary of Health and Human 

7 Services shall report to Congress on the epidemiology of, 

8 impact of, and appropriate funding required to address ne9 glected diseases of poverty, including neglected parasitic 

10 diseases identified as Chagas disease, cysticercosis, 

11 toxocariasis, toxoplasmosis, trichomoniasis, the soil-trans12 mitted helminths, and others. The report should provide 

13 the information necessary to enhance health policy to ac14 curately evaluate and address the threat of these diseases. 

15 SEC. 2588. OFFICE OF WOMEN’S HEALTH. 

16 (a) HEALTH AND HUMAN SERVICES OFFICE ON

17 WOMEN’S HEALTH.— 

18 (1) ESTABLISHMENT.—Part A of title II (42 

19 U.S.C. 202 et seq.) is amended by adding at the end 

20 the following: 

21 ‘‘SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON 

22 WOMEN’S HEALTH. 

23 ‘‘(a) ESTABLISHMENT OF OFFICE.—There is estab24 lished within the Office of the Secretary, an Office on 

25 Women’s Health (referred to in this section as the ‘Of26 fice’). The Office shall be headed by a Deputy Assistant 
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1 Secretary for Women’s Health who may report to the Sec2 retary. 

3 ‘‘(b) DUTIES.—The Secretary, acting through the Of4 fice, with respect to the health concerns of women, shall— 

5 ‘‘(1) establish short-range and long-range goals 

6 and objectives within the Department of Health and 

7 Human Services and, as relevant and appropriate, 

8 coordinate with other appropriate offices on activi9 ties within the Department that relate to disease 

10 prevention, health promotion, service delivery, re11 search, and public and health care professional edu12 cation, for issues of particular concern to women 

13 throughout their lifespan; 

14 ‘‘(2) provide expert advice and consultation to 

15 the Secretary concerning scientific, legal, ethical, 

16 and policy issues relating to women’s health; 

17 ‘‘(3) monitor the Department of Health and 

18 Human Services’ offices, agencies, and regional ac19 tivities regarding women’s health and identify needs 

20 regarding the coordination of activities, including in21 tramural and extramural multidisciplinary activities; 

22 ‘‘(4) establish a Department of Health and 

23 Human Services Coordinating Committee on Wom24 en’s Health, which shall be chaired by the Deputy 

25 Assistant Secretary for Women’s Health and com-
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1 posed of senior level representatives from each of the 

2 agencies and offices of the Department of Health 

3 and Human Services; 

4 ‘‘(5) establish a National Women’s Health In5 formation Center to— 

6 ‘‘(A) facilitate the exchange of information 

7 regarding matters relating to health informa8 tion, health promotion, preventive health serv9 ices, research advances, and education in the 

10 appropriate use of health care; 

11 ‘‘(B) facilitate access to such information; 

12 ‘‘(C) assist in the analysis of issues and 

13 problems relating to the matters described in 

14 this paragraph; and 

15 ‘‘(D) provide technical assistance with re16 spect to the exchange of information (including 

17 facilitating the development of materials for 

18 such technical assistance); 

19 ‘‘(6) coordinate efforts to promote women’s 

20 health programs and policies with the private sector; 

21 and 

22 ‘‘(7) through publications and any other means 

23 appropriate, provide for the exchange of information 

24 between the Office and recipients of grants, con25 tracts, and agreements under subsection (c), and be-
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1 tween the Office and health professionals and the 

2 general public. 

3 ‘‘(c) GRANTS AND CONTRACTS REGARDING DU4 TIES.— 

5 ‘‘(1) AUTHORITY.—In carrying out subsection 

6 (b), the Secretary may make grants to, and enter 

7 into cooperative agreements, contracts, and inter8 agency agreements with, public and private entities, 

9 agencies, and organizations. 

10 ‘‘(2) EVALUATION AND DISSEMINATION.—The 

11 Secretary shall directly or through contracts with 

12 public and private entities, agencies, and organiza13 tions, provide for evaluations of projects carried out 

14 with financial assistance provided under paragraph 

15 (1) and for the dissemination of information devel16 oped as a result of such projects. 

17 ‘‘(d) REPORTS.—Not later than 1 year after the date 

18 of enactment of this section, and every second year there19 after, the Secretary shall prepare and submit to the appro20 priate committees of Congress a report describing the ac21 tivities carried out under this section during the period 

22 for which the report is being prepared. 

23 ‘‘(e) REFERENCES.—Except as otherwise specified, 

24 any reference in Federal law to an Office on Women’s 

25 Health (in the Department of Health and Human Serv-
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1 ices) is deemed to be a reference to the Office on Women’s 

2 Health in the Office of the Secretary.’’. 

3 (2) TRANSFER OF FUNCTIONS.—There are 

4 transferred to the Office on Women’s Health (estab5 lished under section 229 of the Public Health Serv6 ice Act, as added by this section), all functions exer7 cised by the Office on Women’s Health of the Public 

8 Health Service prior to the date of enactment of this 

9 section, including all personnel and compensation 

10 authority, all delegation and assignment authority, 

11 and all remaining appropriations. All orders, deter12 minations, rules, regulations, permits, agreements, 

13 grants, contracts, certificates, licenses, registrations, 

14 privileges, and other administrative actions that— 

15 (A) have been issued, made, granted, or al16 lowed to become effective by the President, any 

17 Federal agency or official thereof, or by a court 

18 of competent jurisdiction, in the performance of 

19 functions transferred under this paragraph; and 

20 (B) are in effect at the time this section 

21 takes effect, or were final before the date of en22 actment of this section and are to become effec23 tive on or after such date; 

24 shall continue in effect according to their terms until 

25 modified, terminated, superseded, set aside, or re-
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1 voked in accordance with law by the President, the 

2 Secretary, or other authorized official, a court of 

3 competent jurisdiction, or by operation of law. 

4 (b) CENTERS FOR DISEASE CONTROL AND PREVEN5 TION OFFICE OF WOMEN’S HEALTH.—Part A of title III 

6 (42 U.S.C. 241 et seq.) is amended by adding at the end 

7 the following: 

8 ‘‘SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVEN9 TION OFFICE OF WOMEN’S HEALTH. 

10 ‘‘(a) ESTABLISHMENT.—There is established within 

11 the Office of the Director of the Centers for Disease Con12 trol and Prevention, an office to be known as the Office 

13 of Women’s Health (referred to in this section as the ‘Of14 fice’). The Office shall be headed by a director who shall 

15 be appointed by the Director of such Centers. 

16 ‘‘(b) PURPOSE.—The Director of the Office shall— 

17 ‘‘(1) report to the Director of the Centers for 

18 Disease Control and Prevention on the current level 

19 of the Centers’ activity regarding women’s health 

20 conditions across, where appropriate, age, biological, 

21 and sociocultural contexts, in all aspects of the Cen22 ters’ work, including prevention programs, public 

23 and professional education, services, and treatment; 

24 ‘‘(2) establish short-range and long-range goals 

25 and objectives within the Centers for women’s health 
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1 and, as relevant and appropriate, coordinate with 

2 other appropriate offices on activities within the 

3 Centers that relate to prevention, research, edu4 cation and training, service delivery, and policy de5 velopment, for issues of particular concern to 

6 women; 

7 ‘‘(3) identify projects in women’s health that 

8 should be conducted or supported by the Centers; 

9 ‘‘(4) consult with health professionals, non10 governmental organizations, consumer organizations, 

11 women’s health professionals, and other individuals 

12 and groups, as appropriate, on the policy of the Cen13 ters with regard to women; and 

14 ‘‘(5) serve as a member of the Department of 

15 Health and Human Services Coordinating Com16 mittee on Women’s Health (established under sec17 tion 229(b)(4)). 

18 ‘‘(c) DEFINITION.—As used in this section, the term 

19 ‘women’s health conditions’, with respect to women of all 

20 age, ethnic, and racial groups, means diseases, disorders, 

21 and conditions— 

22 ‘‘(1) unique to, significantly more serious for, 

23 or significantly more prevalent in women; and 

24 ‘‘(2) for which the factors of medical risk or 

25 type of medical intervention are different for women, 
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1 or for which there is reasonable evidence that indi2 cates that such factors or types may be different for 

3 women.’’. 

4 (c) OFFICE OF WOMEN’S HEALTH RESEARCH.—Sec5 tion 486(a) (42 U.S.C. 287d(a)) is amended by inserting 

6 ‘‘and who shall report directly to the Director’’ before the 

7 period at the end thereof. 

8 (d) SUBSTANCE ABUSE AND MENTAL HEALTH

9 SERVICES ADMINISTRATION.—Section 501(f) (42 U.S.C. 

10 290aa(f)) is amended— 

11 (1) in paragraph (1), by inserting ‘‘who shall 

12 report directly to the Administrator’’ before the pe13 riod; 

14 (2) by redesignating paragraph (4) as para15 graph (5); and 

16 (3) by inserting after paragraph (3), the fol17 lowing: 

18 ‘‘(4) OFFICE.—Nothing in this subsection shall 

19 be construed to preclude the Secretary from estab20 lishing within the Substance Abuse and Mental 

21 Health Administration an Office of Women’s 

22 Health.’’. 

23 (e) AGENCY FOR HEALTHCARE RESEARCH AND

24 QUALITY ACTIVITIES REGARDING WOMEN’S HEALTH.— 

25 Part C of title IX (42 U.S.C. 299c et seq.) is amended— 
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1 (1) by redesignating sections 927 and 928 as 

2 sections 928 and 929, respectively; 

3 (2) by inserting after section 926 the following: 

4 ‘‘SEC. 927. ACTIVITIES REGARDING WOMEN’S HEALTH. 

5 ‘‘(a) ESTABLISHMENT.—There is established within 

6 the Office of the Director, an Office of Women’s Health 

7 and Gender-Based Research (referred to in this section 

8 as the ‘Office’). The Office shall be headed by a director 

9 who shall be appointed by the Director of Healthcare and 

10 Research Quality. 

11 ‘‘(b) PURPOSE.—The official designated under sub12 section (a) shall— 

13 ‘‘(1) report to the Director on the current 

14 Agency level of activity regarding women’s health, 

15 across, where appropriate, age, biological, and 

16 sociocultural contexts, in all aspects of Agency work, 

17 including the development of evidence reports and 

18 clinical practice protocols and the conduct of re19 search into patient outcomes, delivery of health care 

20 services, quality of care, and access to health care; 

21 ‘‘(2) establish short-range and long-range goals 

22 and objectives within the Agency for research impor23 tant to women’s health and, as relevant and appro24 priate, coordinate with other appropriate offices on 

25 activities within the Agency that relate to health 
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1 services and medical effectiveness research, for 

2 issues of particular concern to women; 

3 ‘‘(3) identify projects in women’s health that 

4 should be conducted or supported by the Agency; 

5 ‘‘(4) consult with health professionals, non6 governmental organizations, consumer organizations, 

7 women’s health professionals, and other individuals 

8 and groups, as appropriate, on Agency policy with 

9 regard to women; and 

10 ‘‘(5) serve as a member of the Department of 

11 Health and Human Services Coordinating Com12 mittee on Women’s Health (established under sec13 tion 229(b)(4)).’’; and 

14 (3) by adding at the end of section 928 (as re15 designated by paragraph (1)) the following: 

16 ‘‘(e) WOMEN’S HEALTH.—For the purpose of car17 rying out section 927 regarding women’s health, there are 

18 authorized to be appropriated such sums as may be nec19 essary for each of fiscal years 2011 through 2015.’’. 

20 (f) HEALTH RESOURCES AND SERVICES ADMINIS21 TRATION OFFICE OF WOMEN’S HEALTH.—Title VII of 

22 the Social Security Act (42 U.S.C. 901 et seq.) is amended 

23 by adding at the end the following: 
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1 ‘‘SEC. 713. OFFICE OF WOMEN’S HEALTH. 

2 ‘‘(a) ESTABLISHMENT.—The Secretary shall estab3 lish within the Office of the Administrator of the Health 

4 Resources and Services Administration, an office to be 

5 known as the Office of Women’s Health. The Office shall 

6 be headed by a director who shall be appointed by the Ad7 ministrator. 

8 ‘‘(b) PURPOSE.—The Director of the Office shall— 

9 ‘‘(1) report to the Administrator on the current 

10 Administration level of activity regarding women’s 

11 health across, where appropriate, age, biological, and 

12 sociocultural contexts; 

13 ‘‘(2) establish short-range and long-range goals 

14 and objectives within the Health Resources and 

15 Services Administration for women’s health and, as 

16 relevant and appropriate, coordinate with other ap17 propriate offices on activities within the Administra18 tion that relate to health care provider training, 

19 health service delivery, research, and demonstration 

20 projects, for issues of particular concern to women; 

21 ‘‘(3) identify projects in women’s health that 

22 should be conducted or supported by the bureaus of 

23 the Administration; 

24 ‘‘(4) consult with health professionals, non25 governmental organizations, consumer organizations, 

26 women’s health professionals, and other individuals 
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1 and groups, as appropriate, on Administration policy 

2 with regard to women; and 

3 ‘‘(5) serve as a member of the Department of 

4 Health and Human Services Coordinating Com5 mittee on Women’s Health (established under sec6 tion 229(b)(4) of the Public Health Service Act). 

7 ‘‘(c) CONTINUED ADMINISTRATION OF EXISTING

8 PROGRAMS.—The Director of the Office shall assume the 

9 authority for the development, implementation, adminis10 tration, and evaluation of any projects carried out through 

11 the Health Resources and Services Administration relat12 ing to women’s health on the date of enactment of this 

13 section. 

14 ‘‘(d) DEFINITIONS.—For purposes of this section: 

15 ‘‘(1) ADMINISTRATION.—The term ‘Administra16 tion’ means the Health Resources and Services Ad17 ministration. 

18 ‘‘(2) ADMINISTRATOR.—The term ‘Adminis19 trator’ means the Administrator of the Health Re20 sources and Services Administration. 

21 ‘‘(3) OFFICE.—The term ‘Office’ means the Of22 fice of Women’s Health established under this sec23 tion in the Administration.’’. 

24 (g) FOOD AND DRUG ADMINISTRATION OFFICE OF

25 WOMEN’S HEALTH.—Chapter IX of the Federal Food, 
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1 Drug, and Cosmetic Act (21 U.S.C. 391 et seq.) is amend2 ed by adding at the end the following: 

3 ‘‘SEC. 911. OFFICE OF WOMEN’S HEALTH. 

4 ‘‘(a) ESTABLISHMENT.—There is established within 

5 the Office of the Commissioner, an office to be known as 

6 the Office of Women’s Health (referred to in this section 

7 as the ‘Office’). The Office shall be headed by a director 

8 who shall be appointed by the Commissioner of Food and 

9 Drugs. 

10 ‘‘(b) PURPOSE.—The Director of the Office shall— 

11 ‘‘(1) report to the Commissioner of Food and 

12 Drugs on current Food and Drug Administration 

13 (referred to in this section as the ‘Administration’) 

14 levels of activity regarding women’s participation in 

15 clinical trials and the analysis of data by sex in the 

16 testing of drugs, medical devices, and biological 

17 products across, where appropriate, age, biological, 

18 and sociocultural contexts; 

19 ‘‘(2) establish short-range and long-range goals 

20 and objectives within the Administration for issues 

21 of particular concern to women’s health within the 

22 jurisdiction of the Administration, including, where 

23 relevant and appropriate, adequate inclusion of 

24 women and analysis of data by sex in Administration 

25 protocols and policies; 
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1 ‘‘(3) provide information to women and health 

2 care providers on those areas in which differences 

3 between men and women exist; 

4 ‘‘(4) consult with pharmaceutical, biologics, and 

5 device manufacturers, health professionals with ex6 pertise in women’s issues, consumer organizations, 

7 and women’s health professionals on Administration 

8 policy with regard to women; 

9 ‘‘(5) make annual estimates of funds needed to 

10 monitor clinical trials and analysis of data by sex in 

11 accordance with needs that are identified; and 

12 ‘‘(6) serve as a member of the Department of 

13 Health and Human Services Coordinating Com14 mittee on Women’s Health (established under sec15 tion 229(b)(4) of the Public Health Service Act).’’. 

16 (h) NO NEW REGULATORY AUTHORITY.—Nothing in 

17 this section and the amendments made by this section may 

18 be construed as establishing regulatory authority or modi19 fying any existing regulatory authority. 

20 (i) LIMITATION ON TERMINATION.—Notwithstanding 

21 any other provision of law, a Federal office of women’s 

22 health (including the Office of Research on Women’s 

23 Health of the National Institutes of Health) or Federal 

24 appointive position with primary responsibility over wom25 en’s health issues (including the Associate Administrator 
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1 for Women’s Services under the Substance Abuse and 

2 Mental Health Services Administration) that is in exist3 ence on the date of enactment of this section shall not 

4 be terminated, reorganized, or have any of its powers or 

5 duties transferred unless such termination, reorganization, 

6 or transfer is approved by an Act of Congress. 

7 (j) RULE OF CONSTRUCTION.—Nothing in this sec8 tion (or the amendments made by this section) shall be 

9 construed to limit the authority of the Secretary of Health 

10 and Human Services with respect to women’s health, or 

11 with respect to activities carried out through the Depart12 ment of Health and Human Services on the date of enact13 ment of this section. 

14 SEC. 2588A. OFFICES OF MINORITY HEALTH. 

15 (a) EXISTING OFFICE.—Section 1707(a) (42 U.S.C. 

16 300u–6(a)) is amended by striking ‘‘within the Office of 

17 Public Health and Science’’ and inserting ‘‘within the Of18 fice of the Secretary’’. 

19 (b) ADDITIONAL OFFICES.—Title XVII (42 U.S.C. 

20 300u et seq.) is amended by inserting after section 1707 

21 the following: 

22 ‘‘SEC. 1707A. ADDITIONAL OFFICES OF MINORITY HEALTH. 

23 ‘‘(a) ESTABLISHMENT.—In addition to the Office of 

24 Minority Health established within the Office of the Sec25 retary under section 1707, the Secretary shall establish 
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1 an Office of Minority Health in each of the following agen2 cies: 

3 ‘‘(1) The Centers for Disease Control and Pre4 vention. 

5 ‘‘(2) The Substance Abuse and Mental Health 

6 Services Administration. 

7 ‘‘(3) The Agency for Healthcare Research and 

8 Quality. 

9 ‘‘(4) The Health Resources and Services Ad10 ministration. 

11 ‘‘(5) The Food and Drug Administration. 

12 ‘‘(b) DIRECTOR; APPOINTMENT.—Each Office of Mi13 nority Health established in an agency listed in subsection 

14 (a) shall be headed by a director, who shall be appointed 

15 by and report directly to the head of such agency. 

16 ‘‘(c) REFERENCES.—Except as otherwise specified, 

17 any reference in Federal law to an Office of Minority 

18 Health (in the Department of Health and Human Serv19 ices) is deemed to be a reference to the Office of Minority 

20 Health in the Office of the Secretary.’’. 

21 (c) NO NEW REGULATORY AUTHORITY.—Nothing in 

22 this section and the amendments made by this section may 

23 be construed as establishing regulatory authority or modi24 fying any existing regulatory authority. 
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1 (d) LIMITATION ON TERMINATION.—Notwith2 standing any other provision of law, a Federal office of 

3 minority health or Federal appointive position with pri4 mary responsibility over minority health issues that is in 

5 existence in an office or agency of the Department of 

6 Health and Human Services on the date of enactment of 

7 this section shall not be terminated, reorganized, or have 

8 any of its powers or duties transferred unless such termi9 nation, reorganization, or transfer is approved by an Act 

10 of Congress. 

11 SEC. 2589. LONG-TERM CARE AND FAMILY CAREGIVER SUP12 PORT. 

13 (a) AMENDMENTS TO THE OLDER AMERICANS ACT

14 OF 1965.— 

15 (1) PROMOTION OF DIRECT CARE WORK16 FORCE.—Section 202(b)(1) of the Older Americans 

17 Act of 1965 (42 U.S.C. 3012(b)(1)) is amended by 

18 inserting before the semicolon the following: ‘‘, and, 

19 in carrying out the purposes of this paragraph, shall 

20 make recommendations to other Federal entities re21 garding appropriate and effective means of identi22 fying, promoting, and implementing investments in 

23 the direct care workforce necessary to meet the 

24 growing demand for long-term health services and 

25 supports and of assisting States in developing a 
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1 comprehensive State workforce development plan 

2 with respect to such workforce, including assisting 

3 efforts to systematically assess, track, and report on 

4 workforce adequacy and capacity’’. 

5 (2) PERSONAL CARE ATTENDANT WORKFORCE

6 ADVISORY PANEL.—Section 202 of such Act (42 

7 U.S.C. 3012) is amended by adding at the end the 

8 following: 

9 ‘‘(g)(1) Not later than 90 days after the date of the 

10 enactment of this subsection, the Assistant Secretary shall 

11 establish a Personal Care Attendant Workforce Advisory 

12 Panel to examine and formulate recommendations on— 

13 ‘‘(A) working conditions and training for work14 ers providing long-term services and supports, in15 cluding home health aides, certified nurse aides, and 

16 personal care attendants; and 

17 ‘‘(B) other workforce issues related to such 

18 workers, including with respect to the adequacy of 

19 the number of such workers; the salaries, wages, and 

20 benefits of such workers; and access to the services 

21 provided by such workers. 

22 ‘‘(2) The Panel shall include representatives of— 

23 ‘‘(A) relevant home- and community-based serv24 ice providers, health care agencies, and facilities (in25 cluding personal or home care agencies, home health 
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1 care agencies, nursing homes, assisted living facili2 ties, and residential care facilities); 

3 ‘‘(B) the disability community, including indi4 viduals with disabilities and family caregivers; 

5 ‘‘(C) the nursing community; 

6 ‘‘(D) direct care workers (which may include 

7 unions and national organizations); 

8 ‘‘(E) older individuals, including senior individ9 uals and family caregivers; 

10 ‘‘(F) State and Federal health care entities; 

11 and 

12 ‘‘(G) experts in workforce development and 

13 adult learning. 

14 ‘‘(3) Within one year after the establishment of the 

15 Panel, the Panel shall submit a report to the Assistant 

16 Secretary and the Congress on workforce issues related 

17 to providing long-term services and supports, including in18 formation on core competencies for eligible personal or 

19 home care aides necessary to successfully provide long20 term services and supports to eligible consumers, as well 

21 as recommended training curricula and resources. 

22 ‘‘(4) Within 180 days after receipt by the Assistant 

23 Secretary of the report under paragraph (3), the Assistant 

24 Secretary shall establish a 3-year demonstration program 

25 in 4 States to pilot and evaluate the effectiveness of the 
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1 competencies articulated by the Panel and the training 

2 curricula and training methods recommended by the 

3 Panel. 

4 ‘‘(5) Not later than 1 year after the completion of 

5 the demonstration program under paragraph (4), the As6 sistant Secretary shall submit to the Congress a report 

7 containing the results of the evaluations by the Assistant 

8 Secretary pursuant to paragraph (4), together with such 

9 recommendations for legislation or administrative action 

10 as the Assistant Secretary determines appropriate.’’. 

11 (b) AUTHORIZATION OF ADDITIONAL APPROPRIA12 TIONS FOR THE FAMILY CAREGIVER SUPPORT PROGRAM

13 UNDER THE OLDER AMERICANS ACT OF 1965.—Section 

14 303(e)(2) of the Older Americans Act of 1965 (42 U.S.C. 

15 3023(e)(2)) is amended by striking ‘‘, $173,000,000’’ and 

16 all that follows through ‘‘2011’’, and inserting ‘‘and 

17 $250,000,000 for each of fiscal years 2011, 2012, and 

18 2013’’. 

19 SEC. 2590. WEB SITE ON HEALTH CARE LABOR MARKET 

20 AND RELATED EDUCATIONAL AND TRAINING 

21 OPPORTUNITIES. 

22 (a) IN GENERAL.—The Secretary of Labor, in con23 sultation with the National Center for Health Workforce 

24 Analysis, shall establish and maintain a Web site to serve 

25 as a comprehensive source of information, searchable by 
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1 workforce region, on the health care labor market and re2 lated educational and training opportunities. 

3 (b) CONTENTS.—The Web site maintained under this 

4 section shall include the following: 

5 (1) Information on the types of jobs that are 

6 currently or are projected to be in high demand in 

7 the health care field, including— 

8 (A) salary information; and 

9 (B) training requirements, such as require10 ments for educational credentials, licensure, or 

11 certification. 

12 (2) Information on training and educational op13 portunities within each region for the type of jobs 

14 described in paragraph (1), including by— 

15 (A) type of provider or program (such as 

16 public, private nonprofit, or private for-profit); 

17 (B) duration; 

18 (C) cost (such as tuition, fees, books, lab19 oratory expenses, and other mandatory costs); 

20 (D) performance outcomes (such as grad21 uation rates, job placement, average salary, job 

22 retention, and wage progression); 

23 (E) Federal financial aid participation; 

24 (F) average graduate loan debt; 

25 (G) student loan default rates; 
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1 (H) average institutional grant aid pro2 vided; 

3 (I) Federal and State accreditation infor4 mation; and 

5 (J) other information determined by the 

6 Secretary. 

7 (3) A mechanism for searching and comparing 

8 training and educational options for specific health 

9 care occupations to facilitate informed career and 

10 education choices. 

11 (4) Financial aid information, including with 

12 respect to loan forgiveness, loan cancellation, loan 

13 repayment, stipends, scholarships, and grants or 

14 other assistance authorized by this Act or other Fed15 eral or State programs. 

16 (c) PUBLIC ACCESSIBILITY.—The Web site main17 tained under this section shall— 

18 (1) be publicly accessible; 

19 (2) be user friendly and convey information in 

20 a manner that is easily understandable; and 

21 (3) be in English and the second most prevalent 

22 language spoken based on the latest Census informa23 tion. 
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1 SEC. 2591. ONLINE HEALTH WORKFORCE TRAINING PRO2 GRAMS. 

3 Section 171 of the Workforce Investment Act of 1998 

4 (29 U.S.C. 2916) is amended by adding at the end the 

5 following: 

6 ‘‘(f) ONLINE HEALTH WORKFORCE TRAINING PRO7 GRAM.— 

8 ‘‘(1) GRANT PROGRAM.— 

9 ‘‘(A) IN GENERAL.—The Secretary in con10 sultation with the Secretary of Health and 

11 Human Services, shall award National Health 

12 Workforce Online Training Grants on a com13 petitive basis to eligible entities to enable such 

14 entities to carry out training for individuals to 

15 attain or advance in health care occupations. 

16 An entity may leverage such grant with other 

17 Federal, State, local, and private resources, in 

18 order to expand the participation of businesses, 

19 employees, and individuals in such training pro20 grams. 

21 ‘‘(B) ELIGIBILITY.—In order to receive a 

22 grant under the program established under this 

23 paragraph— 

24 ‘‘(i) an entity shall be an educational 

25 institution, community-based organization, 

26 nonprofit organization, workforce invest-
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1 ment board, or local or county government; 

2 and 

3 ‘‘(ii) an entity shall provide online 

4 workforce training for individuals seeking 

5 to attain or advance in health care occupa6 tions, including nursing, nursing assist7 ants, dentistry, pharmacy, health care 

8 management and administration, public 

9 health, health information systems anal10 ysis, medical assistants, and other health 

11 care practitioner and support occupations. 

12 ‘‘(C) PRIORITY.—Priority in awarding 

13 grants under this paragraph shall be given to 

14 entities that— 

15 ‘‘(i) have demonstrated experience in 

16 implementing and operating online worker 

17 skills training and education programs; 

18 ‘‘(ii) have demonstrated experience co19 ordinating activities, where appropriate, 

20 with the workforce investment system; and 

21 ‘‘(iii) conduct training for occupations 

22 with national or local shortages. 

23 ‘‘(D) DATA COLLECTION.—Grantees under 

24 this paragraph shall collect and report informa25 tion on— 
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1 ‘‘(i) the number of participants; 

2 ‘‘(ii) the services received by the par3 ticipants; 

4 ‘‘(iii) program completion rates; 

5 ‘‘(iv) factors determined as signifi6 cantly interfering with program participa7 tion or completion; 

8 ‘‘(v) the rate of job placement; and 

9 ‘‘(vi) other information as determined 

10 as needed by the Secretary. 

11 ‘‘(E) OUTREACH.—Grantees under this 

12 paragraph shall conduct outreach activities to 

13 disseminate information about their program 

14 and results to workforce investment boards, 

15 local governments, educational institutions, and 

16 other workforce training organizations. 

17 ‘‘(F) PERFORMANCE LEVELS.—The Sec18 retary shall establish indicators of performance 

19 that will be used to evaluate the performance of 

20 grantees under this paragraph in carrying out 

21 the activities described in this paragraph. The 

22 Secretary shall negotiate and reach agreement 

23 with each grantee regarding the levels of per24 formance expected to be achieved by the grant25 ee on the indicators of performance. 
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1 ‘‘(G) AUTHORIZATION OF APPROPRIA2 TIONS.—There are authorized to be appro3 priated to the Secretary to carry out this sub4 section $50,000,000 for fiscal years 2011 

5 through 2020. 

6 ‘‘(2) ONLINE HEALTH PROFESSIONS TRAINING

7 PROGRAM CLEARINGHOUSE.— 

8 ‘‘(A) DESCRIPTION OF GRANT.—The Sec9 retary may award one or more grants to eligible 

10 postsecondary educational institutions to pro11 vide the services described in this paragraph. 

12 ‘‘(B) ELIGIBILITY.—To be eligible to re13 ceive a grant under this paragraph, a postsec14 ondary educational institution shall— 

15 ‘‘(i) have demonstrated the ability to 

16 disseminate research on best practices for 

17 implementing workforce investment pro18 grams; and 

19 ‘‘(ii) be a national leader in producing 

20 cutting-edge research on technology related 

21 to workforce investment systems under 

22 subtitle B. 

23 ‘‘(C) SERVICES.—The postsecondary edu24 cational institution that receives a grant under 

25 this paragraph shall use such grant— 
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1 ‘‘(i) to provide technical assistance to 

2 entities that receive grants under para3 graph (1); 

4 ‘‘(ii) to collect and nationally dissemi5 nate the data gathered by entities that re6 ceive grants under paragraph (1); and 

7 ‘‘(iii) to disseminate the best practices 

8 identified by the National Health Work9 force Online Training Grant Program to 

10 other workforce training organizations. 

11 ‘‘(D) AUTHORIZATION OF APPROPRIA12 TIONS.—There are authorized to be appro13 priated to the Secretary to carry out this sub14 section $1,000,000 for fiscal years 2011 

15 through 2020.’’. 

16 SEC. 2592. ACCESS FOR INDIVIDUALS WITH DISABILITIES. 

17 Title V of the Rehabilitation Act of 1973 (29 U.S.C. 

18 791 et seq.) is amended by adding at the end of the fol19 lowing: 

20 ‘‘SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL 

21 DIAGNOSTIC EQUIPMENT. 

22 ‘‘(a) STANDARDS.—Not later than 9 months after the 

23 date of enactment of the Affordable Health Care for 

24 America Act, the Architectural and Transportation Bar25 riers Compliance Board (Access Board) shall issue guide-
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1 lines setting forth the minimum technical criteria for new 

2 medical diagnostic equipment to be purchased for use in 

3 (or in conjunction with) physician’s offices, clinics, emer4 gency rooms, hospitals, and other medical settings. The 

5 guidelines shall ensure that such equipment is accessible 

6 to, and usable by, individuals with disabilities, including 

7 provisions to ensure independent entry to, use of, and exit 

8 from the equipment by such individuals to the maximum 

9 extent possible. 

10 ‘‘(b) MEDICAL DIAGNOSTIC EQUIPMENT COV11 ERED.—The guidelines issued under subsection (a) for 

12 medical diagnostic equipment shall apply to new purchases 

13 of equipment that includes examination tables, examina14 tion chairs (including chairs used for eye examinations or 

15 procedures, and dental examinations or procedures), 

16 weight scales, mammography equipment, x-ray machines, 

17 and other equipment commonly used for diagnostic or ex18 amination purposes by health professionals. 

19 ‘‘(c) REGULATIONS.—Not later than 6 months after 

20 the date of the issuance of the guidelines under subsection 

21 (a), each appropriate Federal agency authorized to pro22 mulgate regulations under this Act or under the Ameri23 cans with Disabilities Act shall— 

24 ‘‘(1) prescribe regulations in an accessible for25 mat as necessary to carry out the provisions of such 
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1 Act and section 504 of this Act that include accessi2 bility standards that are consistent with the guide3 lines issued under subsection (a); and 

4 ‘‘(2) ensure that health care providers and 

5 health care plans covered by the Affordable Health 

6 Care for America Act meet the requirements of the 

7 Americans with Disabilities Act and section 504, in8 cluding provisions ensuring that individuals with dis9 abilities receive equal access to all aspects of the 

10 health care delivery system. 

11 ‘‘(d) REVIEW AND AMEND.—The Architectural and 

12 Transportation Barriers Compliance Board (Access 

13 Board) shall periodically review and, as appropriate, 

14 amend the guidelines as prescribed under subsection (a). 

15 Not later than 6 months after the date of the issuance 

16 of such revised guidelines, revised regulations consistent 

17 with such guidelines shall be promulgated in an accessible 

18 format by the appropriate Federal agencies described in 

19 subsection (c).’’. 

20 SEC. 2593. DUPLICATIVE GRANT PROGRAMS. 

21 (a) STUDY.—The Secretary of Health and Human 

22 Services (in this section referred to as the ‘‘Secretary’’) 

23 shall conduct a study to determine if any new division C 

24 grant program is duplicative of one or more other grant 
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1 programs of the Department of Health and Human Serv2 ices that— 

3 (1) are specifically authorized in the Public 

4 Health Service Act (42 U.S.C. 201 et seq.); or 

5 (2) are receiving appropriations. 

6 (b) DUPLICATIVE PROGRAMS.—If the Secretary de7 termines under subsection (a) that a new division C grant 

8 program is duplicative of one or more other grant pro9 grams described in such subsection, the Secretary shall— 

10 (1) attempt to integrate the new division C 

11 grant program with the duplicative programs; and 

12 (2) if the Secretary determines that such inte13 gration is not appropriate or has not been success14 ful, promulgate a rule eliminating the duplication, 

15 including, if appropriate, by terminating one or more 

16 programs. 

17 (c) CONTINUED AVAILABILITY OF FUNDS.—Any 

18 funds appropriated to carry out a program that is termi19 nated under subsection (b)(2) shall remain available for 

20 obligation for the one or more programs that— 

21 (1) were determined under subsection (a) to be 

22 duplicative of such program; and 

23 (2) remain in effect. 

24 (d) REPORT.—Not later than 1 year after the date 

25 of the enactment of this Act, the Secretary shall submit 
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1 to the Congress and make available to the public a report 

2 that contains the results of the study required under sub3 section (a). 

4 (e) CONGRESSIONAL REVIEW.—Any rule under sub5 section (b)(2) terminating a program is deemed to be a 

6 major rule for purposes of chapter 8 of title 5, United 

7 States Code. 

8 (f) DEFINITION.—In this section, the term ‘‘new divi9 sion C grant program’’— 

10 (1) means a grant program first established by 

11 this division; and 

12 (2) excludes any program whose statutory au13 thorization was in existence before the enactment of 

14 this division. 

15 SEC. 2594. DIABETES SCREENING COLLABORATION AND 

16 OUTREACH PROGRAM. 

17 (a) ESTABLISHMENT.—With respect to diabetes 

18 screening tests and for the purposes of reducing the num19 ber of undiagnosed seniors with diabetes or prediabetes, 

20 the Secretary of Health and Human Services (referred to 

21 in this section as the ‘‘Secretary’’), in collaboration with 

22 the Director of the Centers for Disease Control and Pre23 vention (referred to in this section as the ‘‘Director’’), 

24 shall— 
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1 (1) review uptake and utilization of diabetes 

2 screening benefits, consistent with recommendations 

3 of the Task Force on Clinical Preventive Services 

4 (established under section 3131 of the Public Health 

5 Service Act, as added by section 2301 of this Act), 

6 to identify and address any existing problems with 

7 regard to uptake and utilization and related data 

8 collection mechanisms; and 

9 (2) establish an outreach program to identify 

10 existing efforts by agencies of the Department of 

11 Health and Human Services and by the private and 

12 nonprofit sectors to increase awareness among sen13 iors and providers of diabetes screening benefits. 

14 (b) CONSULTATION.—The Secretary shall carry out 

15 this section in consultation with— 

16 (1) the heads of appropriate health agencies 

17 and offices in the Department of Health and Human 

18 Services, including the Office of Minority Health; 

19 and 

20 (2) entities with an interest in diabetes, includ21 ing industry, voluntary health organizations, trade 

22 associations, and professional societies. 

23 (c) REPORT.—The Secretary shall submit an annual 

24 report to the Congress on the activities carried out under 

25 this section. 
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1 SEC. 2595. IMPROVEMENT OF VITAL STATISTICS COLLEC2 TION. 

3 (a) IN GENERAL.—The Secretary of Health and 

4 Human Services (in this section referred to as the ‘‘Sec5 retary’’), acting through the Director of the Centers for 

6 Disease Control and Prevention and in collaboration with 

7 appropriate agencies and States, shall— 

8 (1) promote the education and training of phy9 sicians on the importance of birth and death certifi10 cate data and how to properly complete these docu11 ments in accordance with State law, including the 

12 collection of such data for diabetes and other chronic 

13 diseases as appropriate; 

14 (2) encourage State adoption of the latest 

15 standard revisions of birth and death certificates; 

16 and 

17 (3) work with States to re-engineer their vital 

18 statistics systems in order to provide cost-effective, 

19 timely, and accurate vital systems data. 

20 (b) DEATH CERTIFICATE ADDITIONAL LANGUAGE.— 

21 In carrying out this section, the Secretary may promote 

22 improvements to the collection of diabetes mortality data, 

23 including, as appropriate, the addition by States of a ques24 tion for the individual certifying the cause of death regard25 ing whether the deceased had diabetes. 
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1 SEC. 2596. NATIONAL HEALTH SERVICES CORPS DEM2 ONSTRATION ON INCENTIVE PAYMENTS. 

3 (a) IN GENERAL.—The Secretary of Health and 

4 Human Services may establish a demonstration program 

5 under which, in addition to the salary and benefits other6 wise owed to a member of the National Health Services 

7 Corps, incentive payments are awarded to any such mem8 ber who is assigned to a health professional shortage area 

9 with extreme need. 

10 (b) REPORT.—The Secretary shall submit to the Con11 gress an annual report on the demonstration program 

12 under subsection (a). 

13 (c) DEFINITIONS.—In this section: 

14 (1) The term ‘‘health professional shortage area 

15 with extreme need’’ means a health professional 

16 shortage area that— 

17 (A) is described in section 333A(a)(1)(A) 

18 of the Public Health Service Act (42 U.S.C. 

19 254f–1(a)(1)(A)); 

20 (B) is described in section 

21 333(a)(1)(D)(ii)(IV) of such Act (42 U.S.C. 

22 254f(a)(1)(D)(ii)(IV)); and 

23 (C) has high rates of untreated disease, in24 cluding chronic conditions. 

25 (3) The term ‘‘Secretary’’ means the Secretary 

26 of Health and Human Services. 
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1 (d) AUTHORIZATION OF APPROPRIATIONS.—To carry 

2 out this section, there are authorized to be appropriated 

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

4 2011 through 2015. 

5 DIVISION D—INDIAN HEALTH 

6 CARE IMPROVEMENT 

7 SEC. 3001. SHORT TITLE; TABLE OF CONTENTS. 

8 (a) SHORT TITLE.—This division may be cited as the 

9 ‘‘Indian Health Care Improvement Act Amendments of 

10 2009’’. 

11 (b) TABLE OF CONTENTS.—The table of contents of 

12 this division is as follows: 

Sec. 3001. Short title; table of contents. 

TITLE I—AMENDMENTS TO INDIAN LAWS 

Sec. 3101. Indian Health Care Improvement Act amended. 

Sec. 3102. Native American Health and Wellness Foundation. 

Sec. 3103. GAO study and report on payments for contract health services. 

TITLE II—IMPROVEMENT OF INDIAN HEALTH CARE PROVIDED 

UNDER THE SOCIAL SECURITY ACT 

Sec. 3201. Expansion of payments under Medicare, Medicaid, and SCHIP for 

all covered services furnished by Indian Health Programs. 

Sec. 3202. Additional provisions to increase outreach to, and enrollment of, Indians in SCHIP and Medicaid. 

Sec. 3203. Solicitation of proposals for safe harbors under the Social Security 

Act for facilities of Indian Health Programs and urban Indian 

organizations. 

Sec. 3204. Annual report on Indians served by Social Security Act health benefit programs. 

Sec. 3205. Development of recommendations to improve interstate coordination 

of Medicaid and SCHIP coverage of Indian children and other 

children who are outside of their State of residency because of 

educational or other needs. 
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1 TITLE I—AMENDMENTS TO 

2 INDIAN LAWS 

3 SEC. 3101. INDIAN HEALTH CARE IMPROVEMENT ACT 

4 AMENDED. 

5 (a) IN GENERAL.—The Indian Health Care Improve6 ment Act (25 U.S.C. 1601 et seq.) is amended to read 

7 as follows: 

8 ‘‘SEC. 1. SHORT TITLE; TABLE OF CONTENTS. 

9 ‘‘(a) SHORT TITLE.—This Act may be cited as the 

10 ‘Indian Health Care Improvement Act’. 

11 ‘‘(b) TABLE OF CONTENTS.—The table of contents 

12 for this Act is as follows: 

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

‘‘Sec. 2. Findings. 

‘‘Sec. 3. Declaration of national Indian health policy. 

‘‘Sec. 4. Definitions. 

‘‘TITLE I—INDIAN HEALTH, HUMAN RESOURCES, AND 

DEVELOPMENT 

‘‘Sec. 101. Purpose. 

‘‘Sec. 102. Health professions recruitment program for Indians. 

‘‘Sec. 103. Health professions preparatory scholarship program for Indians. 

‘‘Sec. 104. Indian health professions scholarships. 

‘‘Sec. 105. American Indians Into Psychology Program. 

‘‘Sec. 106. Scholarship programs for Indian Tribes. 

‘‘Sec. 107. Indian Health Service extern programs. 

‘‘Sec. 108. Continuing education allowances. 

‘‘Sec. 109. Community Health Representative Program. 

‘‘Sec. 110. Indian Health Service Loan Repayment Program. 

‘‘Sec. 111. Scholarship and Loan Repayment Recovery Fund. 

‘‘Sec. 112. Recruitment activities. 

‘‘Sec. 113. Indian recruitment and retention program. 

‘‘Sec. 114. Advanced training and research. 

‘‘Sec. 115. Quentin N. Burdick American Indians Into Nursing Program. 

‘‘Sec. 116. Tribal cultural orientation. 

‘‘Sec. 117. INMED Program. 

‘‘Sec. 118. Health training programs of community colleges. 

‘‘Sec. 119. Retention bonus. 

‘‘Sec. 120. Nursing residency program. 

‘‘Sec. 121. Community Health Aide Program. 
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‘‘Sec. 122. Tribal Health Program administration. 

‘‘Sec. 123. Health professional chronic shortage demonstration programs. 

‘‘Sec. 124. National Health Service Corps. 

‘‘Sec. 125. Substance abuse counselor educational curricula demonstration programs. 

‘‘Sec. 126. Behavioral health training and community education programs. 

‘‘Sec. 127. Exemption from payment of certain fees. 

‘‘Sec. 128. Authorization of appropriations. 

‘‘TITLE II—HEALTH SERVICES 

‘‘Sec. 201. Indian Health Care Improvement Fund. 

‘‘Sec. 202. Health promotion and disease prevention services. 

‘‘Sec. 203. Diabetes prevention, treatment, and control. 

‘‘Sec. 204. Shared services for long-term care. 

‘‘Sec. 205. Health services research. 

‘‘Sec. 206. Mammography and other cancer screening. 

‘‘Sec. 207. Patient travel costs. 

‘‘Sec. 208. Epidemiology centers. 

‘‘Sec. 209. Comprehensive school health education programs. 

‘‘Sec. 210. Indian youth program. 

‘‘Sec. 211. Prevention, control, and elimination of communicable and infectious 

diseases. 

‘‘Sec. 212. Other authority for provision of services. 

‘‘Sec. 213. Indian women’s health care. 

‘‘Sec. 214. Environmental and nuclear health hazards. 

‘‘Sec. 215. Arizona as a contract health service delivery area. 

‘‘Sec. 216. North Dakota and South Dakota as contract health service delivery 

area. 

‘‘Sec. 217. California contract health services program. 

‘‘Sec. 218. California as a contract health service delivery area. 

‘‘Sec. 219. Contract health services for the Trenton Service Area. 

‘‘Sec. 220. Programs operated by Indian Tribes and tribal organizations. 

‘‘Sec. 221. Licensing. 

‘‘Sec. 222. Notification of provision of emergency contract health services. 

‘‘Sec. 223. Prompt action on payment of claims. 

‘‘Sec. 224. Liability for payment. 

‘‘Sec. 225. Office of Indian Men’s Health. 

‘‘Sec. 226. Catastrophic health emergency fund. 

‘‘Sec. 227. Authorization of appropriations. 

‘‘TITLE III—FACILITIES 

‘‘Sec. 301. Consultation; construction and renovation of facilities; reports. 

‘‘Sec. 302. Sanitation facilities. 

‘‘Sec. 303. Preference to Indians and Indian firms. 

‘‘Sec. 304. Expenditure of non-Service funds for renovation. 

‘‘Sec. 305. Funding for the construction, expansion, and modernization of small 

ambulatory care facilities. 

‘‘Sec. 306. Indian health care delivery demonstration project. 

‘‘Sec. 307. Land transfer. 

‘‘Sec. 308. Leases, contracts, and other agreements. 

‘‘Sec. 309. Study on loans, loan guarantees, and loan repayment. 

‘‘Sec. 310. Tribal leasing. 

‘‘Sec. 311. Indian Health Service/tribal facilities joint venture program. 

‘‘Sec. 312. Location of facilities. 
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‘‘Sec. 313. Maintenance and improvement of health care facilities. 

‘‘Sec. 314. Tribal management of federally owned quarters. 

‘‘Sec. 315. Applicability of Buy American Act requirement. 

‘‘Sec. 316. Other funding for facilities. 

‘‘Sec. 317. Authorization of appropriations. 

‘‘TITLE IV—ACCESS TO HEALTH SERVICES 

‘‘Sec. 401. Treatment of payments under Social Security Act health benefits 

programs. 

‘‘Sec. 402. Grants to and contracts with the Service, Indian Tribes, Tribal Organizations, and urban Indian organizations to facilitate outreach, enrollment, and coverage of Indians under Social Security Act health benefit programs. 

‘‘Sec. 403. Reimbursement from certain third parties of costs of health services. 

‘‘Sec. 404. Crediting of reimbursements. 

‘‘Sec. 405. Purchasing health care coverage. 

‘‘Sec. 406. Sharing arrangements with Federal agencies. 

‘‘Sec. 407. Eligible indian veteran services. 

‘‘Sec. 408. Payor of last resort. 

‘‘Sec. 409. Consultation. 

‘‘Sec. 410. State Children’s Health Insurance Program (SCHIP). 

‘‘Sec. 411. Premium and cost sharing protections and eligibility determinations 

under Medicaid and SCHIP and protection of certain Indian 

property from Medicaid estate recovery. 

‘‘Sec. 412. Treatment under Medicaid and SCHIP managed care. 

‘‘Sec. 413. Navajo Nation Medicaid Agency feasibility study. 

‘‘Sec. 414. Exception for excepted benefits. 

‘‘Sec. 415. Authorization of appropriations. 

‘‘TITLE V—HEALTH SERVICES FOR URBAN INDIANS 

‘‘Sec. 501. Purpose. 

‘‘Sec. 502. Contracts with, and grants to, urban Indian organizations. 

‘‘Sec. 503. Contracts and grants for the provision of health care and referral 

services. 

‘‘Sec. 504. Use of Federal Government Facilities and Sources of Supply. 

‘‘Sec. 505. Contracts and grants for the determination of unmet health care 

needs. 

‘‘Sec. 506. Evaluations; renewals. 

‘‘Sec. 507. Other contract and grant requirements. 

‘‘Sec. 508. Reports and records. 

‘‘Sec. 509. Limitation on contract authority. 

‘‘Sec. 510. Facilities. 

‘‘Sec. 511. Division of Urban Indian Health. 

‘‘Sec. 512. Grants for alcohol and substance abuse-related services. 

‘‘Sec. 513. Treatment of certain demonstration projects. 

‘‘Sec. 514. Urban NIAAA transferred programs. 

‘‘Sec. 515. Conferring with urban Indian organizations. 

‘‘Sec. 516. Urban youth treatment center demonstration. 

‘‘Sec. 517. Grants for diabetes prevention, treatment, and control. 

‘‘Sec. 518. Community health representatives. 

‘‘Sec. 519. Effective date. 

‘‘Sec. 520. Eligibility for services. 

‘‘Sec. 521. Authorization of appropriations. 

‘‘Sec. 522. Health information technology. 
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‘‘TITLE VI—ORGANIZATIONAL IMPROVEMENTS 

‘‘Sec. 601. Establishment of the Indian Health Service as an agency of the 

Public Health Service. 

‘‘Sec. 602. Automated management information system. 

‘‘Sec. 603. Authorization of appropriations. 

‘‘TITLE VII—BEHAVIORAL HEALTH PROGRAMS 

‘‘Sec. 701. Behavioral health prevention and treatment services. 

‘‘Sec. 702. Memoranda of agreement with the Department of the Interior. 

‘‘Sec. 703. Comprehensive behavioral health prevention and treatment program. 

‘‘Sec. 704. Mental health technician program. 

‘‘Sec. 705. Licensing requirement for mental health care workers. 

‘‘Sec. 706. Indian women treatment programs. 

‘‘Sec. 707. Indian youth program. 

‘‘Sec. 708. Indian youth telemental health demonstration project. 

‘‘Sec. 709. Inpatient and community-based mental health facilities design, construction, and staffing. 

‘‘Sec. 710. Training and community education. 

‘‘Sec. 711. Behavioral health program. 

‘‘Sec. 712. Fetal alcohol disorder programs. 

‘‘Sec. 713. Child sexual abuse and prevention treatment programs. 

‘‘Sec. 714. Domestic and sexual violence prevention and treatment. 

‘‘Sec. 715. Behavioral health research. 

‘‘Sec. 716. Definitions. 

‘‘Sec. 717. Authorization of appropriations. 

‘‘TITLE VIII—MISCELLANEOUS 

‘‘Sec. 801. Reports. 

‘‘Sec. 802. Regulations. 

‘‘Sec. 803. Plan of implementation. 

‘‘Sec. 804. Limitation on use of funds appropriated to Indian Health Service. 

‘‘Sec. 805. Eligibility of California Indians. 

‘‘Sec. 806. Health services for ineligible persons. 

‘‘Sec. 807. Reallocation of base resources. 

‘‘Sec. 808. Results of demonstration projects. 

‘‘Sec. 809. Moratorium. 

‘‘Sec. 810. Severability provisions. 

‘‘Sec. 811. Use of patient safety organizations. 

‘‘Sec. 812. Confidentiality of medical quality assurance records; qualified immunity for participants. 

‘‘Sec. 813. Claremore Indian Hospital. 

‘‘Sec. 814. Sense of Congress regarding law enforcement and methamphetamine 

issues in Indian country. 

‘‘Sec. 815. Permitting implementation through contracts with Tribal Health 

Programs. 

‘‘Sec. 816. Authorization of appropriations; availability. 

1 ‘‘SEC. 2. FINDINGS. 

2 ‘‘Congress makes the following findings: 
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1 ‘‘(1) Federal health services to maintain and 

2 improve the health of the Indians are consonant 

3 with and required by the Federal Government’s his4 torical and unique legal relationship with, and re5 sulting responsibility to, the American Indian people. 

6 ‘‘(2) A major national goal of the United States 

7 is to provide the resources, processes, and structure 

8 that will enable Indian tribes and tribal members to 

9 obtain the quantity and quality of health care serv10 ices and opportunities that will eradicate the health 

11 disparities between Indians the general population. 

12 ‘‘(3) A major national goal of the United States 

13 is to provide the quantity and quality of health serv14 ices which will permit the health status of Indians 

15 to be raised to the highest possible level and to en16 courage the maximum participation of Indians in the 

17 planning and management of those services. 

18 ‘‘(4) Federal health services to Indians have re19 sulted in a reduction in the prevalence and incidence 

20 of preventable illnesses among, and unnecessary and 

21 premature deaths of, Indians. 

22 ‘‘(5) Despite such services, the unmet health 

23 needs of the American Indian people are severe and 

24 the health status of the Indians is far below that of 

25 the general population of the United States. 
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1 ‘‘SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POL2 ICY. 

3 ‘‘Congress declares that it is the policy of this Nation, 

4 in fulfillment of its special trust responsibilities and legal 

5 obligations to Indians— 

6 ‘‘(1) to assure the highest possible health status 

7 for Indians and Urban Indians and to provide all re8 sources necessary to effect that policy; 

9 ‘‘(2) to raise the health status of Indians and 

10 Urban Indians to at least the levels set forth in the 

11 goals contained within the Health People 2010 or 

12 successor objectives; 

13 ‘‘(3) to the greatest extent possible, to allow In14 dians to set their own health care priorities and es15 tablish goals that reflect their unmet needs; 

16 ‘‘(4) to increase the proportion of all degrees in 

17 the health professions and allied and associated 

18 health professions awarded to Indians so that the 

19 proportion of Indian health professionals in each 

20 Service Area is raised to at least the level of that of 

21 the general population; 

22 ‘‘(5) to require meaningful consultation with In23 dian Tribes, Tribal Organizations, and urban Indian 

24 organizations to implement this Act and the national 

25 policy of Indian self-determination; and 
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1 ‘‘(6) to provide funding for programs and facili2 ties operated by Indian Tribes, Tribal Organizations, 

3 and Urban Indian Organizations in amounts that 

4 are not less than the amounts provided to programs 

5 and facilities operated directly by the Service. 

6 ‘‘SEC. 4. DEFINITIONS. 

7 ‘‘For purposes of this Act: 

8 ‘‘(1) The term ‘accredited and accessible’ means 

9 on or near a reservation and accredited by a na10 tional or regional organization with accrediting au11 thority. 

12 ‘‘(2) The term ‘Area Office’ means an adminis13 trative entity, including a program office, within the 

14 Service through which services and funds are pro15 vided to the Service Units within a defined geo16 graphic area. 

17 ‘‘(3) The term ‘Assistant Secretary’ means the 

18 Assistant Secretary of Indian Health. 

19 ‘‘(4)(A) The term ‘behavioral health’ means the 

20 blending of substance (including alcohol, drugs, 

21 inhalants, and tobacco) abuse and mental health 

22 prevention and treatment, for the purpose of pro23 viding comprehensive services. 

24 ‘‘(B) The term ‘behavioral health’ includes the 

25 joint development of substance abuse and mental 
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1 health treatment planning and coordinated case 

2 management using a multidisciplinary approach. 

3 ‘‘(5) The term ‘California Indians’ means those 

4 Indians who are eligible for health services of the 

5 Service pursuant to section 805. 

6 ‘‘(6) The term ‘community college’ means— 

7 ‘‘(A) a tribal college or university, or 

8 ‘‘(B) a junior or community college. 

9 ‘‘(7) The term ‘contract health service’ means 

10 health services provided at the expense of the Serv11 ice or a Tribal Health Program by public or private 

12 medical providers or hospitals, other than the Serv13 ice Unit or the Tribal Health Program at whose ex14 pense the services are provided. 

15 ‘‘(8) The term ‘Department’ means, unless oth16 erwise designated, the Department of Health and 

17 Human Services. 

18 ‘‘(9) The term ‘disease prevention’ means the 

19 reduction, limitation, and prevention of disease and 

20 its complications and reduction in the consequences 

21 of disease, including— 

22 ‘‘(A) controlling— 

23 ‘‘(i) the development of diabetes; 

24 ‘‘(ii) high blood pressure; 

25 ‘‘(iii) infectious agents; 
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1 ‘‘(iv) injuries; 

2 ‘‘(v) occupational hazards and disabil3 ities; 

4 ‘‘(vi) sexually transmittable diseases; 

5 and 

6 ‘‘(vii) toxic agents; and 

7 ‘‘(B) providing— 

8 ‘‘(i) fluoridation of water; and 

9 ‘‘(ii) immunizations. 

10 ‘‘(10) The term ‘health profession’ means 

11 allopathic medicine, family medicine, internal medi12 cine, pediatrics, geriatric medicine, obstetrics and 

13 gynecology, podiatric medicine, nursing, public 

14 health nursing, dentistry, psychiatry, osteopathy, op15 tometry, pharmacy, psychology, public health, social 

16 work, marriage and family therapy, chiropractic 

17 medicine, environmental health and engineering, al18 lied health professions, naturopathic medicine, and 

19 any other health profession. 

20 ‘‘(11) The term ‘health promotion’ means— 

21 ‘‘(A) fostering social, economic, environ22 mental, and personal factors conducive to 

23 health, including raising public awareness about 

24 health matters and enabling the people to cope 
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1 with health problems by increasing their knowl2 edge and providing them with valid information; 

3 ‘‘(B) encouraging adequate and appro4 priate diet, exercise, and sleep; 

5 ‘‘(C) promoting education and work in con6 formity with physical and mental capacity; 

7 ‘‘(D) making available safe water and sani8 tary facilities; 

9 ‘‘(E) improving the physical, economic, cul10 tural, psychological, and social environment; 

11 ‘‘(F) promoting culturally competent care; 

12 and 

13 ‘‘(G) providing adequate and appropriate 

14 programs, which may include— 

15 ‘‘(i) abuse prevention (mental and 

16 physical); 

17 ‘‘(ii) community health; 

18 ‘‘(iii) community safety; 

19 ‘‘(iv) consumer health education; 

20 ‘‘(v) diet and nutrition; 

21 ‘‘(vi) immunization and other preven22 tion of communicable diseases, including 

23 HIV/AIDS; 

24 ‘‘(vii) environmental health; 

25 ‘‘(viii) exercise and physical fitness; 
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1 ‘‘(ix) avoidance of fetal alcohol dis2 orders; 

3 ‘‘(x) first aid and CPR education; 

4 ‘‘(xi) human growth and development; 

5 ‘‘(xii) injury prevention and personal 

6 safety; 

7 ‘‘(xiii) behavioral health; 

8 ‘‘(xiv) monitoring of disease indicators 

9 between health care provider visits, 

10 through appropriate means, including 

11 Internet-based health care management 

12 systems; 

13 ‘‘(xv) personal health and wellness 

14 practices; 

15 ‘‘(xvi) personal capacity building; 

16 ‘‘(xvii) prenatal, pregnancy, and in17 fant care; 

18 ‘‘(xviii) psychological well-being; 

19 ‘‘(xix) reproductive health and family 

20 planning; 

21 ‘‘(xx) safe and adequate water; 

22 ‘‘(xxi) healthy work environments; 

23 ‘‘(xxii) elimination, reduction, and 

24 prevention of contaminants that create 
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1 unhealthy household conditions (including 

2 mold and other allergens); 

3 ‘‘(xxiii) stress control; 

4 ‘‘(xxiv) substance abuse; 

5 ‘‘(xxv) sanitary facilities; 

6 ‘‘(xxvi) sudden infant death syndrome 

7 prevention; 

8 ‘‘(xxvii) tobacco use cessation and re9 duction; 

10 ‘‘(xxviii) violence prevention; and 

11 ‘‘(xxix) activities to promote achieve12 ment of any of the objectives described in 

13 section 3(2). 

14 ‘‘(12) The term ‘Indian’, unless otherwise des15 ignated, means any person who is a member of an 

16 Indian Tribe or is eligible for health services under 

17 section 805, except that, for the purpose of sections 

18 102 and 103, the term also means any individual 

19 who— 

20 ‘‘(A)(i) irrespective of whether the indi21 vidual lives on or near a reservation, is a mem22 ber of a tribe, band, or other organized group 

23 of Indians, including those tribes, bands, or 

24 groups terminated since 1940 and those recog-
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1 nized now or in the future by the State in 

2 which they reside; or 

3 ‘‘(ii) is a descendant, in the first or second 

4 degree, of any such member; 

5 ‘‘(B) is an Eskimo or Aleut or other Alas6 ka Native; 

7 ‘‘(C) is considered by the Secretary of the 

8 Interior to be an Indian for any purpose; or 

9 ‘‘(D) is determined to be an Indian under 

10 regulations promulgated by the Secretary. 

11 ‘‘(13) The term ‘Indian Health Program’ 

12 means— 

13 ‘‘(A) any health program administered di14 rectly by the Service; 

15 ‘‘(B) any Tribal Health Program; or 

16 ‘‘(C) any Indian Tribe or Tribal Organiza17 tion to which the Secretary provides funding 

18 pursuant to section 23 of the Act of June 25, 

19 1910 (25 U.S.C. 47) (commonly known as the 

20 ‘Buy Indian Act’). 

21 ‘‘(14) The term ‘Indian Tribe’ has the meaning 

22 given the term in the Indian Self-Determination and 

23 Education Assistance Act (25 U.S.C. 450 et seq.). 

24 ‘‘(15) The term ‘junior or community college’ 

25 has the meaning given the term by section 312(f) of 
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1 the Higher Education Act of 1965 (20 U.S.C. 

2 1058(f)). 

3 ‘‘(16) The term ‘reservation’ means any feder4 ally recognized Indian Tribe’s reservation, Pueblo, or 

5 colony, including former reservations in Oklahoma, 

6 Indian allotments, and Alaska Native Regions estab7 lished pursuant to the Alaska Native Claims Settle8 ment Act (43 U.S.C. 1601 et seq.). 

9 ‘‘(17) The term ‘Secretary’, unless otherwise 

10 designated, means the Secretary of Health and 

11 Human Services. 

12 ‘‘(18) The term ‘Service’ means the Indian 

13 Health Service. 

14 ‘‘(19) The term ‘Service Area’ means the geo15 graphical area served by each Area Office. 

16 ‘‘(20) The term ‘Service Unit’ means an admin17 istrative entity of the Service, or a Tribal Health 

18 Program through which services are provided, di19 rectly or by contract, to eligible Indians within a de20 fined geographic area. 

21 ‘‘(21) The term ‘telehealth’ has the meaning 

22 given the term in section 330K(a) of the Public 

23 Health Service Act (42 U.S.C. 254c–16(a)). 

24 ‘‘(22) The term ‘telemedicine’ means a tele25 communications link to an end user through the use 
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1 of eligible equipment that electronically links health 

2 professionals or patients and health professionals at 

3 separate sites in order to exchange health care infor4 mation in audio, video, graphic, or other format for 

5 the purpose of providing improved health care serv6 ices. 

7 ‘‘(23) The term ‘tribal college or university’ has 

8 the meaning given the term in section 316(b)(3) of 

9 the Higher Education Act (20 U.S.C. 1059c(b)(3)). 

10 ‘‘(24) The term ‘Tribal Health Program’ means 

11 an Indian Tribe or Tribal Organization that oper12 ates any health program, service, function, activity, 

13 or facility funded, in whole or part, by the Service 

14 through, or provided for in, a contract or compact 

15 with the Service under the Indian Self-Determina16 tion and Education Assistance Act (25 U.S.C. 450 

17 et seq.). 

18 ‘‘(25) The term ‘Tribal Organization’ has the 

19 meaning given the term in the Indian Self-Deter20 mination and Education Assistance Act (25 U.S.C. 

21 450 et seq.). 

22 ‘‘(26) The term ‘Urban Center’ means any com23 munity which has a sufficient Urban Indian popu24 lation with unmet health needs to warrant assistance 
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1 under title V of this Act, as determined by the Sec2 retary. 

3 ‘‘(27) The term ‘Urban Indian’ means any indi4 vidual who resides in an Urban Center and who 

5 meets 1 or more of the following criteria: 

6 ‘‘(A) Irrespective of whether the individual 

7 lives on or near a reservation, the individual is 

8 a member of a tribe, band, or other organized 

9 group of Indians, including those tribes, bands, 

10 or groups terminated since 1940 and those 

11 tribes, bands, or groups that are recognized by 

12 the States in which they reside, or who is a de13 scendant in the first or second degree of any 

14 such member. 

15 ‘‘(B) The individual is an Eskimo, Aleut, 

16 or other Alaska Native. 

17 ‘‘(C) The individual is considered by the 

18 Secretary of the Interior to be an Indian for 

19 any purpose. 

20 ‘‘(D) The individual is determined to be an 

21 Indian under regulations promulgated by the 

22 Secretary. 

23 ‘‘(28) The term ‘urban Indian organization’ 

24 means a nonprofit corporate body that (A) is situ25 ated in an Urban Center; (B) is governed by an 
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1 Urban Indian-controlled board of directors; (C) pro2 vides for the participation of all interested Indian 

3 groups and individuals; and (D) is capable of legally 

4 cooperating with other public and private entities for 

5 the purpose of performing the activities described in 

6 section 503(a). 

7 ‘‘TITLE I—INDIAN HEALTH, 

8 HUMAN RESOURCES, AND DE9 VELOPMENT 

10 ‘‘SEC. 101. PURPOSE. 

11 ‘‘The purpose of this title is to increase, to the max12 imum extent feasible, the number of Indians entering the 

13 health professions and providing health services, and to 

14 assure an optimum supply of health professionals to the 

15 Indian Health Programs and urban Indian organizations 

16 involved in the provision of health services to Indians. 

17 ‘‘SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM 

18 FOR INDIANS. 

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

20 the Service, shall make grants to public or nonprofit pri21 vate health or educational entities, Tribal Health Pro22 grams, or urban Indian organizations to assist such enti23 ties in meeting the costs of— 
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1 ‘‘(1) identifying Indians with a potential for 

2 education or training in the health professions and 

3 encouraging and assisting them— 

4 ‘‘(A) to enroll in courses of study in such 

5 health professions; or 

6 ‘‘(B) if they are not qualified to enroll in 

7 any such courses of study, to undertake such 

8 postsecondary education or training as may be 

9 required to qualify them for enrollment; 

10 ‘‘(2) publicizing existing sources of financial aid 

11 available to Indians enrolled in any course of study 

12 referred to in paragraph (1) or who are undertaking 

13 training necessary to qualify them to enroll in any 

14 such course of study; or 

15 ‘‘(3) establishing other programs which the Sec16 retary determines will enhance and facilitate the en17 rollment of Indians in, and the subsequent pursuit 

18 and completion by them of, courses of study referred 

19 to in paragraph (1). 

20 ‘‘(b) GRANTS.— 

21 ‘‘(1) APPLICATION.—No grant may be made 

22 under this section unless an application has been 

23 submitted to, and approved by, the Secretary. Such 

24 application shall be in such form, submitted in such 

25 manner, and contain such information, as the Sec-
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1 retary shall by regulation prescribe pursuant to this 

2 Act. The Secretary shall give a preference to appli3 cations submitted by Tribal Health Programs or 

4 urban Indian organizations. 

5 ‘‘(2) AMOUNT OF GRANTS; PAYMENT.—The 

6 amount of a grant under this section shall be deter7 mined by the Secretary. Payments pursuant to this 

8 section may be made in advance or by way of reim9 bursement, and at such intervals and on such condi10 tions as provided for in regulations issued pursuant 

11 to this Act. To the extent not otherwise prohibited 

12 by law, grants shall be for 3 years, as provided in 

13 regulations issued pursuant to this Act. 

14 ‘‘SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOL15 ARSHIP PROGRAM FOR INDIANS. 

16 ‘‘(a) SCHOLARSHIPS AUTHORIZED.—The Secretary, 

17 acting through the Service, shall provide scholarship 

18 grants to Indians who— 

19 ‘‘(1) have successfully completed their high 

20 school education or high school equivalency; and 

21 ‘‘(2) have demonstrated the potential to suc22 cessfully complete courses of study in the health pro23 fessions. 

24 ‘‘(b) PURPOSES.—Scholarship grants provided pursu25 ant to this section shall be for the following purposes: 
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1 ‘‘(1) Compensatory preprofessional education of 

2 any recipient, such scholarship not to exceed 2 years 

3 on a full-time basis (or the part-time equivalent 

4 thereof, as determined by the Secretary pursuant to 

5 regulations issued under this Act). 

6 ‘‘(2) Pregraduate education of any recipient 

7 leading to a baccalaureate degree in an approved 

8 course of study preparatory to a field of study in a 

9 health profession, such scholarship not to exceed 4 

10 years. An extension of up to 2 years (or the part11 time equivalent thereof, as determined by the Sec12 retary pursuant to regulations issued pursuant to 

13 this Act) may be approved. 

14 ‘‘(c) OTHER CONDITIONS.—Scholarships under this 

15 section— 

16 ‘‘(1) may cover costs of tuition, books, trans17 portation, board, and other necessary related ex18 penses of a recipient while attending school; 

19 ‘‘(2) shall not be denied solely on the basis of 

20 the applicant’s scholastic achievement if such appli21 cant has been admitted to, or maintained good 

22 standing at, an accredited institution; and 

23 ‘‘(3) shall not be denied solely by reason of such 

24 applicant’s eligibility for assistance or benefits under 

25 any other Federal program. 
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1 ‘‘SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS. 

2 ‘‘(a) IN GENERAL.— 

3 ‘‘(1) AUTHORITY.—The Secretary, acting 

4 through the Service, shall make scholarship grants 

5 to Indians who are enrolled full or part time in ac6 credited schools pursuing courses of study in the 

7 health professions. Such scholarships shall be des8 ignated Indian Health Scholarships and shall be 

9 made in accordance with section 338A of the Public 

10 Health Services Act (42 U.S.C. 254l), except as pro11 vided in subsection (b) of this section. 

12 ‘‘(2) DETERMINATIONS BY SECRETARY.—The 

13 Secretary, acting through the Service, shall deter14 mine— 

15 ‘‘(A) who shall receive scholarship grants 

16 under subsection (a); and 

17 ‘‘(B) the distribution of the scholarships 

18 among health professions on the basis of the 

19 relative needs of Indians for additional service 

20 in the health professions. 

21 ‘‘(3) CERTAIN DELEGATION NOT ALLOWED.— 

22 The administration of this section shall be a respon23 sibility of the Assistant Secretary and shall not be 

24 delegated in a contract or compact under the Indian 

25 Self-Determination and Education Assistance Act 

26 (25 U.S.C. 450 et seq.). 
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1 ‘‘(b) ACTIVE DUTY SERVICE OBLIGATION.— 

2 ‘‘(1) OBLIGATION MET.—The active duty serv3 ice obligation under a written contract with the Sec4 retary under this section that an Indian has entered 

5 into shall, if that individual is a recipient of an In6 dian Health Scholarship, be met in full-time practice 

7 equal to 1 year for each school year for which the 

8 participant receives a scholarship award under this 

9 part, or 2 years, whichever is greater, by service in 

10 1 or more of the following: 

11 ‘‘(A) In an Indian Health Program. 

12 ‘‘(B) In a program assisted under title V 

13 of this Act. 

14 ‘‘(C) In the private practice of the applica15 ble profession if, as determined by the Sec16 retary, in accordance with guidelines promul17 gated by the Secretary, such practice is situated 

18 in a physician or other health professional 

19 shortage area and addresses the health care 

20 needs of a substantial number of Indians. 

21 ‘‘(D) In a teaching capacity in a tribal col22 lege or university nursing program (or a related 

23 health profession program) if, as determined by 

24 the Secretary, the health service provided to In25 dians would not decrease. 
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1 ‘‘(2) OBLIGATION DEFERRED.—At the request 

2 of any individual who has entered into a contract re3 ferred to in paragraph (1) and who receives a health 

4 professions degree requiring postgraduate training 

5 for licensure or to improve clinical skills, the Sec6 retary shall defer the active duty service obligation 

7 of that individual under that contract, in order that 

8 such individual may complete any internship, resi9 dency, or other advanced clinical training that is re10 quired for the practice of that health profession, for 

11 an appropriate period (in years, as determined by 

12 the Secretary), subject to the following conditions: 

13 ‘‘(A) No period of internship, residency, or 

14 other advanced clinical training shall be counted 

15 as satisfying any period of obligated service 

16 under this subsection. 

17 ‘‘(B) The active duty service obligation of 

18 that individual shall commence not later than 

19 90 days after the completion of that advanced 

20 clinical training (or by a date specified by the 

21 Secretary). 

22 ‘‘(C) The active duty service obligation will 

23 be served in the health profession of that indi24 vidual in a manner consistent with paragraph 

25 (1). 
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1 ‘‘(D) A recipient of a scholarship under 

2 this section may, at the election of the recipient, 

3 meet the active duty service obligation described 

4 in paragraph (1) by service in a program speci5 fied under that paragraph that— 

6 ‘‘(i) is located on the reservation of 

7 the Indian Tribe in which the recipient is 

8 enrolled; or 

9 ‘‘(ii) serves the Indian Tribe in which 

10 the recipient is enrolled. 

11 ‘‘(3) PRIORITY WHEN MAKING ASSIGNMENTS.— 

12 Subject to paragraph (2), the Secretary, in making 

13 assignments of Indian Health Scholarship recipients 

14 required to meet the active duty service obligation 

15 described in paragraph (1), shall give priority to as16 signing individuals to service in those programs 

17 specified in paragraph (1) that have a need for 

18 health professionals to provide health care services 

19 as a result of individuals having breached contracts 

20 entered into under this section. 

21 ‘‘(c) PART-TIME STUDENTS.—In the case of an indi22 vidual receiving a scholarship under this section who is 

23 enrolled part time in an approved course of study— 
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1 ‘‘(1) such scholarship shall be for a period of 

2 years not to exceed the part-time equivalent of 4 

3 years, as determined by the Secretary; 

4 ‘‘(2) the period of obligated service described in 

5 subsection (b)(1) shall be equal to the greater of— 

6 ‘‘(A) the part-time equivalent of 1 year for 

7 each year for which the individual was provided 

8 a scholarship (as determined by the Secretary); 

9 or 

10 ‘‘(B) 2 years; and 

11 ‘‘(3) the amount of the monthly stipend speci12 fied in section 338A(g)(1)(B) of the Public Health 

13 Service Act (42 U.S.C. 254l(g)(1)(B)) shall be re14 duced pro rata (as determined by the Secretary) 

15 based on the number of hours such student is en16 rolled. 

17 ‘‘(d) BREACH OF CONTRACT.— 

18 ‘‘(1) SPECIFIED BREACHES.—An individual 

19 shall be liable to the United States for the amount 

20 which has been paid to the individual, or on behalf 

21 of the individual, under a contract entered into with 

22 the Secretary under this section on or after the date 

23 of enactment of the Indian Health Care Improve24 ment Act Amendments of 2009 if that individual— 
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1 ‘‘(A) fails to maintain an acceptable level 

2 of academic standing in the educational institu3 tion in which he or she is enrolled (such level 

4 determined by the educational institution under 

5 regulations of the Secretary); 

6 ‘‘(B) is dismissed from such educational 

7 institution for disciplinary reasons; 

8 ‘‘(C) voluntarily terminates the training in 

9 such an educational institution for which he or 

10 she is provided a scholarship under such con11 tract before the completion of such training; or 

12 ‘‘(D) fails to accept payment, or instructs 

13 the educational institution in which he or she is 

14 enrolled not to accept payment, in whole or in 

15 part, of a scholarship under such contract, in 

16 lieu of any service obligation arising under such 

17 contract. 

18 ‘‘(2) OTHER BREACHES.—If for any reason not 

19 specified in paragraph (1) an individual breaches a 

20 written contract by failing either to begin such indi21 vidual’s service obligation required under such con22 tract or to complete such service obligation, the 

23 United States shall be entitled to recover from the 

24 individual an amount determined in accordance with 
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1 the formula specified in subsection (l) of section 110 

2 in the manner provided for in such subsection. 

3 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI4 ENT.—Upon the death of an individual who receives 

5 an Indian Health Scholarship, any outstanding obli6 gation of that individual for service or payment that 

7 relates to that scholarship shall be canceled. 

8 ‘‘(4) WAIVERS AND SUSPENSIONS.—The Sec9 retary shall provide for the partial or total waiver or 

10 suspension of any obligation of service or payment of 

11 a recipient of an Indian Health Scholarship if the 

12 Secretary determines that— 

13 ‘‘(A) it is not possible for the recipient to 

14 meet that obligation or make that payment; 

15 ‘‘(B) requiring that recipient to meet that 

16 obligation or make that payment would result 

17 in extreme hardship to the recipient; or 

18 ‘‘(C) the enforcement of the requirement to 

19 meet the obligation or make the payment would 

20 be unconscionable. 

21 ‘‘(5) EXTREME HARDSHIP.—Notwithstanding 

22 any other provision of law, in any case of extreme 

23 hardship or for other good cause shown, the Sec24 retary may waive, in whole or in part, the right of 
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1 the United States to recover funds made available 

2 under this section. 

3 ‘‘(6) BANKRUPTCY.—Notwithstanding any 

4 other provision of law, with respect to a recipient of 

5 an Indian Health Scholarship, no obligation for pay6 ment may be released by a discharge in bankruptcy 

7 under title 11, United States Code, unless that dis8 charge is granted after the expiration of the 5-year 

9 period beginning on the initial date on which that 

10 payment is due, and only if the bankruptcy court 

11 finds that the nondischarge of the obligation would 

12 be unconscionable. 

13 ‘‘SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PRO14 GRAM. 

15 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

16 through the Service, shall make grants of not more than 

17 $300,000 to each of 9 colleges and universities for the pur18 pose of developing and maintaining Indian psychology ca19 reer recruitment programs as a means of encouraging In20 dians to enter the behavioral health field. These programs 

21 shall be located at various locations throughout the coun22 try to maximize their availability to Indian students and 

23 new programs shall be established in different locations 

24 from time to time. 
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1 ‘‘(b) QUENTIN N. BURDICK PROGRAM GRANT.—The 

2 Secretary shall provide a grant authorized under sub3 section (a) to develop and maintain a program at the Uni4 versity of North Dakota to be known as the ‘Quentin N. 

5 Burdick American Indians Into Psychology Program’. 

6 Such program shall, to the maximum extent feasible, co7 ordinate with the Quentin N. Burdick Indian Health Pro8 grams authorized under section 117(b), the Quentin N. 

9 Burdick American Indians Into Nursing Program author10 ized under section 115(e), and existing university research 

11 and communications networks. 

12 ‘‘(c) REGULATIONS.—The Secretary shall issue regu13 lations pursuant to this Act for the competitive awarding 

14 of grants provided under this section. 

15 ‘‘(d) CONDITIONS OF GRANT.—Applicants under this 

16 section shall agree to provide a program which, at a min17 imum— 

18 ‘‘(1) provides outreach and recruitment for 

19 health professions to Indian communities including 

20 elementary, secondary, and accredited and accessible 

21 community colleges that will be served by the pro22 gram; 

23 ‘‘(2) incorporates a program advisory board 

24 comprised of representatives from the tribes and 

25 communities that will be served by the program; 
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1 ‘‘(3) provides summer enrichment programs to 

2 expose Indian students to the various fields of psy3 chology through research, clinical, and experimental 

4 activities; 

5 ‘‘(4) provides stipends to undergraduate and 

6 graduate students to pursue a career in psychology; 

7 ‘‘(5) develops affiliation agreements with tribal 

8 colleges and universities, the Service, university af9 filiated programs, and other appropriate accredited 

10 and accessible entities to enhance the education of 

11 Indian students; 

12 ‘‘(6) to the maximum extent feasible, uses exist13 ing university tutoring, counseling, and student sup14 port services; and 

15 ‘‘(7) to the maximum extent feasible, employs 

16 qualified Indians in the program. 

17 ‘‘(e) ACTIVE DUTY SERVICE REQUIREMENT.—The 

18 active duty service obligation prescribed under section 

19 338C of the Public Health Service Act (42 U.S.C. 254m) 

20 shall be met by each graduate who receives a stipend de21 scribed in subsection (d)(4) that is funded under this sec22 tion. Such obligation shall be met by service— 

23 ‘‘(1) in an Indian Health Program; 

24 ‘‘(2) in a program assisted under title V of this 

25 Act; or 
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1 ‘‘(3) in the private practice of psychology if, as 

2 determined by the Secretary, in accordance with 

3 guidelines promulgated by the Secretary, such prac4 tice is situated in a physician or other health profes5 sional shortage area and addresses the health care 

6 needs of a substantial number of Indians. 

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

8 is authorized to be appropriated such sums as may be nec9 essary to carry out this section. 

10 ‘‘SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES. 

11 ‘‘(a) IN GENERAL.— 

12 ‘‘(1) GRANTS AUTHORIZED.—The Secretary, 

13 acting through the Service, shall make grants to 

14 Tribal Health Programs for the purpose of providing 

15 scholarships for Indians to serve as health profes16 sionals in Indian communities. 

17 ‘‘(2) AMOUNT.—Amounts available under para18 graph (1) for any fiscal year shall not exceed 5 per19 cent of the amounts available for each fiscal year for 

20 Indian Health Scholarships under section 104. 

21 ‘‘(3) APPLICATION.—An application for a grant 

22 under paragraph (1) shall be in such form and con23 tain such agreements, assurances, and information 

24 as consistent with this section. 

25 ‘‘(b) REQUIREMENTS.— 
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1 ‘‘(1) IN GENERAL.—A Tribal Health Program 

2 receiving a grant under subsection (a) shall provide 

3 scholarships to Indians in accordance with the re4 quirements of this section. 

5 ‘‘(2) COSTS.—With respect to costs of providing 

6 any scholarship pursuant to subsection (a)— 

7 ‘‘(A) 80 percent of the costs of the scholar8 ship shall be paid from the funds made avail9 able pursuant to subsection (a)(1) provided to 

10 the Tribal Health Program; and 

11 ‘‘(B) 20 percent of such costs may be paid 

12 from any other source of funds. 

13 ‘‘(c) COURSE OF STUDY.—A Tribal Health Program 

14 shall provide scholarships under this section only to Indi15 ans enrolled or accepted for enrollment in a course of 

16 study (approved by the Secretary) in 1 of the health pro17 fessions contemplated by this Act. 

18 ‘‘(d) CONTRACT.— 

19 ‘‘(1) IN GENERAL.—In providing scholarships 

20 under subsection (b), the Secretary and the Tribal 

21 Health Program shall enter into a written contract 

22 with each recipient of such scholarship. 

23 ‘‘(2) REQUIREMENTS.—Such contract shall— 

24 ‘‘(A) obligate such recipient to provide 

25 service in an Indian Health Program or urban 
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1 Indian organization, in the same Service Area 

2 where the Tribal Health Program providing the 

3 scholarship is located, for— 

4 ‘‘(i) a number of years for which the 

5 scholarship is provided (or the part-time 

6 equivalent thereof, as determined by the 

7 Secretary), or for a period of 2 years, 

8 whichever period is greater; or 

9 ‘‘(ii) such greater period of time as 

10 the recipient and the Tribal Health Pro11 gram may agree; 

12 ‘‘(B) provide that the amount of the schol13 arship— 

14 ‘‘(i) may only be expended for— 

15 ‘‘(I) tuition expenses, other rea16 sonable educational expenses, and rea17 sonable living expenses incurred in at18 tendance at the educational institu19 tion; and 

20 ‘‘(II) payment to the recipient of 

21 a monthly stipend of not more than 

22 the amount authorized by section 

23 338(g)(1)(B) of the Public Health 

24 Service Act (42 U.S.C. 

25 254m(g)(1)(B)), with such amount to 
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1 be reduced pro rata (as determined by 

2 the Secretary) based on the number of 

3 hours such student is enrolled, and 

4 not to exceed, for any year of attend5 ance for which the scholarship is pro6 vided, the total amount required for 

7 the year for the purposes authorized 

8 in this clause; and 

9 ‘‘(ii) may not exceed, for any year of 

10 attendance for which the scholarship is 

11 provided, the total amount required for the 

12 year for the purposes authorized in clause 

13 (i); 

14 ‘‘(C) require the recipient of such scholar15 ship to maintain an acceptable level of academic 

16 standing as determined by the educational insti17 tution in accordance with regulations issued 

18 pursuant to this Act; and 

19 ‘‘(D) require the recipient of such scholar20 ship to meet the educational and licensure re21 quirements appropriate to each health profes22 sion. 

23 ‘‘(3) SERVICE IN OTHER SERVICE AREAS.—The 

24 contract may allow the recipient to serve in another 

25 Service Area, provided the Tribal Health Program 
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1 and Secretary approve and services are not dimin2 ished to Indians in the Service Area where the Trib3 al Health Program providing the scholarship is lo4 cated. 

5 ‘‘(e) BREACH OF CONTRACT.— 

6 ‘‘(1) SPECIFIC BREACHES.—An individual who 

7 has entered into a written contract with the Sec8 retary and a Tribal Health Program under sub9 section (d) shall be liable to the United States for 

10 the Federal share of the amount which has been 

11 paid to him or her, or on his or her behalf, under 

12 the contract if that individual— 

13 ‘‘(A) fails to maintain an acceptable level 

14 of academic standing in the educational institu15 tion in which he or she is enrolled (such level 

16 as determined by the educational institution 

17 under regulations of the Secretary); 

18 ‘‘(B) is dismissed from such educational 

19 institution for disciplinary reasons; 

20 ‘‘(C) voluntarily terminates the training in 

21 such an educational institution for which he or 

22 she is provided a scholarship under such con23 tract before the completion of such training; or 

24 ‘‘(D) fails to accept payment, or instructs 

25 the educational institution in which he or she is 
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1 enrolled not to accept payment, in whole or in 

2 part, of a scholarship under such contract, in 

3 lieu of any service obligation arising under such 

4 contract. 

5 ‘‘(2) OTHER BREACHES.—If for any reason not 

6 specified in paragraph (1), an individual breaches a 

7 written contract by failing to either begin such indi8 vidual’s service obligation required under such con9 tract or to complete such service obligation, the 

10 United States shall be entitled to recover from the 

11 individual an amount determined in accordance with 

12 the formula specified in subsection (l) of section 110 

13 in the manner provided for in such subsection. 

14 ‘‘(3) CANCELLATION UPON DEATH OF RECIPI15 ENT.—Upon the death of an individual who receives 

16 an Indian Health Scholarship, any outstanding obli17 gation of that individual for service or payment that 

18 relates to that scholarship shall be canceled. 

19 ‘‘(4) INFORMATION.—The Secretary may carry 

20 out this subsection on the basis of information re21 ceived from Tribal Health Programs involved or on 

22 the basis of information collected through such other 

23 means as the Secretary deems appropriate. 

24 ‘‘(f) RELATION TO SOCIAL SECURITY ACT.—The re25 cipient of a scholarship under this section shall agree, in 
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1 providing health care pursuant to the requirements here2 in— 

3 ‘‘(1) not to discriminate against an individual 

4 seeking care on the basis of the ability of the indi5 vidual to pay for such care or on the basis that pay6 ment for such care will be made pursuant to a pro7 gram established in title XVIII of the Social Secu8 rity Act or pursuant to the programs established in 

9 title XIX or title XXI of such Act; and 

10 ‘‘(2) to accept assignment under section 

11 1842(b)(3)(B)(ii) of the Social Security Act for all 

12 services for which payment may be made under part 

13 B of title XVIII of such Act, and to enter into an 

14 appropriate agreement with the State agency that 

15 administers the State plan for medical assistance 

16 under title XIX, or the State child health plan under 

17 title XXI, of such Act to provide service to individ18 uals entitled to medical assistance or child health as19 sistance, respectively, under the plan. 

20 ‘‘(g) CONTINUANCE OF FUNDING.—The Secretary 

21 shall make payments under this section to a Tribal Health 

22 Program for any fiscal year subsequent to the first fiscal 

23 year of such payments unless the Secretary determines 

24 that, for the immediately preceding fiscal year, the Tribal 
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1 Health Program has not complied with the requirements 

2 of this section. 

3 ‘‘SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS. 

4 ‘‘(a) EMPLOYMENT PREFERENCE.—Any individual 

5 who receives a scholarship pursuant to section 104 or 106 

6 shall be given preference for employment in the Service, 

7 or may be employed by a Tribal Health Program or an 

8 urban Indian organization, or other agencies of the De9 partment as available, during any nonacademic period of 

10 the year. 

11 ‘‘(b) NOT COUNTED TOWARD ACTIVE DUTY SERVICE

12 OBLIGATION.—Periods of employment pursuant to this 

13 subsection shall not be counted in determining fulfillment 

14 of the service obligation incurred as a condition of the 

15 scholarship. 

16 ‘‘(c) TIMING; LENGTH OF EMPLOYMENT.—Any indi17 vidual enrolled in a program, including a high school pro18 gram, authorized under section 102(a) may be employed 

19 by the Service or by a Tribal Health Program or an urban 

20 Indian organization during any nonacademic period of the 

21 year. Any such employment shall not exceed 120 days dur22 ing any calendar year. 

23 ‘‘(d) NONAPPLICABILITY OF COMPETITIVE PER24 SONNEL SYSTEM.—Any employment pursuant to this sec25 tion shall be made without regard to any competitive per-
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1 sonnel system or agency personnel limitation and to a po2 sition which will enable the individual so employed to re3 ceive practical experience in the health profession in which 

4 he or she is engaged in study. Any individual so employed 

5 shall receive payment for his or her services comparable 

6 to the salary he or she would receive if he or she were 

7 employed in the competitive system. Any individual so em8 ployed shall not be counted against any employment ceil9 ing affecting the Service or the Department. 

10 ‘‘SEC. 108. CONTINUING EDUCATION ALLOWANCES. 

11 ‘‘In order to encourage scholarship and stipend re12 cipients under sections 104, 105, 106, and 115 and health 

13 professionals, including community health representatives 

14 and emergency medical technicians, to join or continue in 

15 an Indian Health Program and to provide their services 

16 in the rural and remote areas where a significant portion 

17 of Indians reside, the Secretary, acting through the Serv18 ice, may— 

19 ‘‘(1) provide programs or allowances to transi20 tion into an Indian Health Program, including li21 censing, board or certification examination assist22 ance, and technical assistance in fulfilling service ob23 ligations under sections 104, 105, 106, and 115; and 

24 ‘‘(2) provide programs or allowances to health 

25 professionals employed in an Indian Health Program 
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1 to enable them for a period of time each year pre2 scribed by regulation of the Secretary to take leave 

3 of their duty stations for professional consultation, 

4 management, leadership, and refresher training 

5 courses. 

6 ‘‘SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PRO7 GRAM. 

8 ‘‘(a) IN GENERAL.—Under the authority of the Act 

9 of November 2, 1921 (25 U.S.C. 13) (commonly known 

10 as the ‘Snyder Act’), the Secretary, acting through the 

11 Service, shall maintain a Community Health Representa12 tive Program under which Indian Health Programs— 

13 ‘‘(1) provide for the training of Indians as com14 munity health representatives; and 

15 ‘‘(2) use such community health representatives 

16 in the provision of health care, health promotion, 

17 and disease prevention services to Indian commu18 nities. 

19 ‘‘(b) DUTIES.—The Community Health Representa20 tive Program of the Service, shall— 

21 ‘‘(1) provide a high standard of training for 

22 community health representatives to ensure that the 

23 community health representatives provide quality 

24 health care, health promotion, and disease preven-
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1 tion services to the Indian communities served by 

2 the Program; 

3 ‘‘(2) in order to provide such training, develop 

4 and maintain a curriculum that— 

5 ‘‘(A) combines education in the theory of 

6 health care with supervised practical experience 

7 in the provision of health care; and 

8 ‘‘(B) provides instruction and practical ex9 perience in health promotion and disease pre10 vention activities, with appropriate consider11 ation given to lifestyle factors that have an im12 pact on Indian health status, such as alco13 holism, family dysfunction, and poverty; 

14 ‘‘(3) maintain a system which identifies the 

15 needs of community health representatives for con16 tinuing education in health care, health promotion, 

17 and disease prevention and develop programs that 

18 meet the needs for continuing education; 

19 ‘‘(4) maintain a system that provides close su20 pervision of Community Health Representatives; 

21 ‘‘(5) maintain a system under which the work 

22 of Community Health Representatives is reviewed 

23 and evaluated; and 

24 ‘‘(6) promote traditional health care practices 

25 of the Indian Tribes served consistent with the Serv-
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1 ice standards for the provision of health care, health 

2 promotion, and disease prevention. 

3 ‘‘SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT 

4 PROGRAM. 

5 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

6 through the Service, shall establish and administer a pro7 gram to be known as the Service Loan Repayment Pro8 gram (hereinafter referred to as the ‘Loan Repayment 

9 Program’) in order to ensure an adequate supply of 

10 trained health professionals necessary to maintain accredi11 tation of, and provide health care services to Indians 

12 through, Indian Health Programs and urban Indian orga13 nizations. 

14 ‘‘(b) ELIGIBLE INDIVIDUALS.—To be eligible to par15 ticipate in the Loan Repayment Program, an individual 

16 must— 

17 ‘‘(1)(A) be enrolled— 

18 ‘‘(i) in a course of study or program in an 

19 accredited educational institution (as deter20 mined by the Secretary under section 

21 338B(b)(1)(c)(i) of the Public Health Service 

22 Act (42 U.S.C. 254l–1(b)(1)(c)(i))) and be 

23 scheduled to complete such course of study in 

24 the same year such individual applies to partici25 pate in such program; or 
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1 ‘‘(ii) in an approved graduate training pro2 gram in a health profession; or 

3 ‘‘(B) have— 

4 ‘‘(i) a degree in a health profession; and 

5 ‘‘(ii) a license to practice a health profes6 sion; 

7 ‘‘(2)(A) be eligible for, or hold, an appointment 

8 as a commissioned officer in the Regular or Reserve 

9 Corps of the Public Health Service; 

10 ‘‘(B) meet the professional standards for civil 

11 service employment in the Service; or 

12 ‘‘(C) be employed in an Indian Health Program 

13 or urban Indian organization without a service obli14 gation; and 

15 ‘‘(3) submit to the Secretary an application for 

16 a contract described in subsection (e). 

17 ‘‘(c) APPLICATION.— 

18 ‘‘(1) INFORMATION TO BE INCLUDED WITH

19 FORMS.—In disseminating application forms and 

20 contract forms to individuals desiring to participate 

21 in the Loan Repayment Program, the Secretary 

22 shall include with such forms a fair summary of the 

23 rights and liabilities of an individual whose applica24 tion is approved (and whose contract is accepted) by 

25 the Secretary, including in the summary a clear ex-
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1 planation of the damages to which the United States 

2 is entitled under subsection (l) in the case of the in3 dividual’s breach of contract. The Secretary shall 

4 provide such individuals with sufficient information 

5 regarding the advantages and disadvantages of serv6 ice as a commissioned officer in the Regular or Re7 serve Corps of the Public Health Service or a civil8 ian employee of the Service to enable the individual 

9 to make a decision on an informed basis. 

10 ‘‘(2) CLEAR LANGUAGE.—The application form, 

11 contract form, and all other information furnished 

12 by the Secretary under this section shall be written 

13 in a manner calculated to be understood by the aver14 age individual applying to participate in the Loan 

15 Repayment Program. 

16 ‘‘(3) TIMELY AVAILABILITY OF FORMS.—The 

17 Secretary shall make such application forms, con18 tract forms, and other information available to indi19 viduals desiring to participate in the Loan Repay20 ment Program on a date sufficiently early to ensure 

21 that such individuals have adequate time to carefully 

22 review and evaluate such forms and information. 

23 ‘‘(d) PRIORITIES.— 

24 ‘‘(1) LIST.—Consistent with subsection (j), the 

25 Secretary shall annually— 
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1 ‘‘(A) identify the positions in each Indian 

2 Health Program or urban Indian organization 

3 for which there is a need or a vacancy; and 

4 ‘‘(B) rank those positions in order of pri5 ority. 

6 ‘‘(2) APPROVALS.—Consistent with the priority 

7 determined under paragraph (1), the Secretary, in 

8 determining which applications under the Loan Re9 payment Program to approve (and which contracts 

10 to accept), shall— 

11 ‘‘(A) give first priority to applications 

12 made by individual Indians; and 

13 ‘‘(B) after making determinations on all 

14 applications submitted by individual Indians as 

15 required under subparagraph (A), give priority 

16 to— 

17 ‘‘(i) individuals recruited through the 

18 efforts of an Indian Health Program or 

19 urban Indian organization; and 

20 ‘‘(ii) other individuals based on the 

21 priority rankings under paragraph (1). 

22 ‘‘(e) RECIPIENT CONTRACTS.— 

23 ‘‘(1) CONTRACT REQUIRED.—An individual be24 comes a participant in the Loan Repayment Pro25 gram only upon the Secretary and the individual en-
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1 tering into a written contract described in paragraph 

2 (2). 

3 ‘‘(2) CONTENTS OF CONTRACT.—The written 

4 contract referred to in this section between the Sec5 retary and an individual shall contain— 

6 ‘‘(A) an agreement under which— 

7 ‘‘(i) subject to subparagraph (C), the 

8 Secretary agrees— 

9 ‘‘(I) to pay loans on behalf of the 

10 individual in accordance with the pro11 visions of this section; and 

12 ‘‘(II) to accept (subject to the 

13 availability of appropriated funds for 

14 carrying out this section) the indi15 vidual into the Service or place the in16 dividual with a Tribal Health Pro17 gram or urban Indian organization as 

18 provided in clause (ii)(III); and 

19 ‘‘(ii) subject to subparagraph (C), the 

20 individual agrees— 

21 ‘‘(I) to accept loan payments on 

22 behalf of the individual; 

23 ‘‘(II) in the case of an individual 

24 described in subsection (b)(1)— 
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1 ‘‘(aa) to maintain enrollment 

2 in a course of study or training 

3 described in subsection (b)(1)(A) 

4 until the individual completes the 

5 course of study or training; and 

6 ‘‘(bb) while enrolled in such 

7 course of study or training, to 

8 maintain an acceptable level of 

9 academic standing (as deter10 mined under regulations of the 

11 Secretary by the educational in12 stitution offering such course of 

13 study or training); and 

14 ‘‘(III) to serve for a time period 

15 (in this section referred to as the ‘pe16 riod of obligated service’) equal to 2 

17 years or such longer period as the in18 dividual may agree to serve in the 

19 full-time clinical practice of such indi20 vidual’s profession in an Indian 

21 Health Program or urban Indian or22 ganization to which the individual 

23 may be assigned by the Secretary; 

24 ‘‘(B) a provision permitting the Secretary 

25 to extend for such longer additional periods, as 
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1 the individual may agree to, the period of obli2 gated service agreed to by the individual under 

3 subparagraph (A)(ii)(III); 

4 ‘‘(C) a provision that any financial obliga5 tion of the United States arising out of a con6 tract entered into under this section and any 

7 obligation of the individual which is conditioned 

8 thereon is contingent upon funds being appro9 priated for loan repayments under this section; 

10 ‘‘(D) a statement of the damages to which 

11 the United States is entitled under subsection 

12 (k) for the individual’s breach of the contract; 

13 and 

14 ‘‘(E) such other statements of the rights 

15 and liabilities of the Secretary and of the indi16 vidual, not inconsistent with this section. 

17 ‘‘(f) DEADLINE FOR DECISION ON APPLICATION.— 

18 The Secretary shall provide written notice to an individual 

19 within 21 days on— 

20 ‘‘(1) the Secretary’s approving, under sub21 section (e)(1), of the individual’s participation in the 

22 Loan Repayment Program, including extensions re23 sulting in an aggregate period of obligated service in 

24 excess of 4 years; or 
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1 ‘‘(2) the Secretary’s disapproving an individ2 ual’s participation in such Program. 

3 ‘‘(g) PAYMENTS.— 

4 ‘‘(1) IN GENERAL.—A loan repayment provided 

5 for an individual under a written contract under the 

6 Loan Repayment Program shall consist of payment, 

7 in accordance with paragraph (2), on behalf of the 

8 individual of the principal, interest, and related ex9 penses on government and commercial loans received 

10 by the individual regarding the undergraduate or 

11 graduate education of the individual (or both), which 

12 loans were made for— 

13 ‘‘(A) tuition expenses; 

14 ‘‘(B) all other reasonable educational ex15 penses, including fees, books, and laboratory ex16 penses, incurred by the individual; and 

17 ‘‘(C) reasonable living expenses as deter18 mined by the Secretary. 

19 ‘‘(2) AMOUNT.—For each year of obligated 

20 service that an individual contracts to serve under 

21 subsection (e), the Secretary may pay up to $35,000 

22 or an amount equal to the amount specified in sec23 tion 338B(g)(2)(A) of the Public Health Service 

24 Act, whichever is more, on behalf of the individual 

25 for loans described in paragraph (1). In making a 
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1 determination of the amount to pay for a year of 

2 such service by an individual, the Secretary shall 

3 consider the extent to which each such determina4 tion— 

5 ‘‘(A) affects the ability of the Secretary to 

6 maximize the number of contracts that can be 

7 provided under the Loan Repayment Program 

8 from the amounts appropriated for such con9 tracts; 

10 ‘‘(B) provides an incentive to serve in In11 dian Health Programs and urban Indian orga12 nizations with the greatest shortages of health 

13 professionals; and 

14 ‘‘(C) provides an incentive with respect to 

15 the health professional involved remaining in an 

16 Indian Health Program or urban Indian organi17 zation with such a health professional shortage, 

18 and continuing to provide primary health serv19 ices, after the completion of the period of obli20 gated service under the Loan Repayment Pro21 gram. 

22 ‘‘(3) TIMING.—Any arrangement made by the 

23 Secretary for the making of loan repayments in ac24 cordance with this subsection shall provide that any 

25 repayments for a year of obligated service shall be 
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1 made no later than the end of the fiscal year in 

2 which the individual completes such year of service. 

3 ‘‘(4) REIMBURSEMENTS FOR TAX LIABILITY.— 

4 For the purpose of providing reimbursements for tax 

5 liability resulting from a payment under paragraph 

6 (2) on behalf of an individual, the Secretary— 

7 ‘‘(A) in addition to such payments, may 

8 make payments to the individual in an amount 

9 equal to not less than 20 percent and not more 

10 than 39 percent of the total amount of loan re11 payments made for the taxable year involved; 

12 and 

13 ‘‘(B) may make such additional payments 

14 as the Secretary determines to be appropriate 

15 with respect to such purpose. 

16 ‘‘(5) PAYMENT SCHEDULE.—The Secretary 

17 may enter into an agreement with the holder of any 

18 loan for which payments are made under the Loan 

19 Repayment Program to establish a schedule for the 

20 making of such payments. 

21 ‘‘(h) EMPLOYMENT CEILING.—Notwithstanding any 

22 other provision of law, individuals who have entered into 

23 written contracts with the Secretary under this section 

24 shall not be counted against any employment ceiling af-
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1 fecting the Department while those individuals are under2 going academic training. 

3 ‘‘(i) RECRUITMENT.—The Secretary shall conduct re4 cruiting programs for the Loan Repayment Program and 

5 other manpower programs of the Service at educational 

6 institutions training health professionals or specialists 

7 identified in subsection (a). 

8 ‘‘(j) APPLICABILITY OF LAW.—Section 214 of the 

9 Public Health Service Act (42 U.S.C. 215) shall not apply 

10 to individuals during their period of obligated service 

11 under the Loan Repayment Program. 

12 ‘‘(k) ASSIGNMENT OF INDIVIDUALS.—The Secretary, 

13 in assigning individuals to serve in Indian Health Pro14 grams or urban Indian organizations pursuant to con15 tracts entered into under this section, shall— 

16 ‘‘(1) ensure that the staffing needs of Tribal 

17 Health Programs and urban Indian organizations 

18 receive consideration on an equal basis with pro19 grams that are administered directly by the Service; 

20 and 

21 ‘‘(2) give priority to assigning individuals to In22 dian Health Programs and urban Indian organiza23 tions that have a need for health professionals to 

24 provide health care services as a result of individuals 
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1 having breached contracts entered into under this 

2 section. 

3 ‘‘(l) BREACH OF CONTRACT.— 

4 ‘‘(1) SPECIFIC BREACHES.—An individual who 

5 has entered into a written contract with the Sec6 retary under this section and has not received a 

7 waiver under subsection (m) shall be liable, in lieu 

8 of any service obligation arising under such contract, 

9 to the United States for the amount which has been 

10 paid on such individual’s behalf under the contract 

11 if that individual— 

12 ‘‘(A) is enrolled in the final year of a 

13 course of study and— 

14 ‘‘(i) fails to maintain an acceptable 

15 level of academic standing in the edu16 cational institution in which he or she is 

17 enrolled (such level determined by the edu18 cational institution under regulations of 

19 the Secretary); 

20 ‘‘(ii) voluntarily terminates such en21 rollment; or 

22 ‘‘(iii) is dismissed from such edu23 cational institution before completion of 

24 such course of study; or 
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1 ‘‘(B) is enrolled in a graduate training pro2 gram and fails to complete such training pro3 gram. 

4 ‘‘(2) OTHER BREACHES; FORMULA FOR

5 AMOUNT OWED.—If, for any reason not specified in 

6 paragraph (1), an individual breaches his or her 

7 written contract under this section by failing either 

8 to begin, or complete, such individual’s period of ob9 ligated service in accordance with subsection (e)(2), 

10 the United States shall be entitled to recover from 

11 such individual an amount to be determined in ac12 cordance with the following formula: A=3Z(t¥s/t) 

13 in which— 

14 ‘‘(A) ‘A’ is the amount the United States 

15 is entitled to recover; 

16 ‘‘(B) ‘Z’ is the sum of the amounts paid 

17 under this section to, or on behalf of, the indi18 vidual and the interest on such amounts which 

19 would be payable if, at the time the amounts 

20 were paid, they were loans bearing interest at 

21 the maximum legal prevailing rate, as deter22 mined by the Secretary of the Treasury; 

23 ‘‘(C) ‘t’ is the total number of months in 

24 the individual’s period of obligated service; and 
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1 ‘‘(D) ‘s’ is the number of months of such 

2 period served by such individual in accordance 

3 with this section. 

4 ‘‘(3) TIME PERIOD FOR REPAYMENT.—Any 

5 amount of damages which the United States is enti6 tled to recover under this subsection shall be paid to 

7 the United States within the 1-year period beginning 

8 on the date of the breach or such longer period be9 ginning on such date as shall be specified by the 

10 Secretary. 

11 ‘‘(4) DEDUCTIONS IN MEDICARE PAYMENTS.— 

12 Amounts not paid within such period shall be sub13 ject to collection through deductions in Medicare 

14 payments pursuant to section 1892 of the Social Se15 curity Act. 

16 ‘‘(5) RECOVERY OF DELINQUENCY.— 

17 ‘‘(A) IN GENERAL.—If damages described 

18 in paragraph (4) are delinquent for 3 months, 

19 the Secretary shall, for the purpose of recov20 ering such damages— 

21 ‘‘(i) use collection agencies contracted 

22 with by the Administrator of General Serv23 ices; or 
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1 ‘‘(ii) enter into contracts for the re2 covery of such damages with collection 

3 agencies selected by the Secretary. 

4 ‘‘(B) REPORT.—Each contract for recov5 ering damages pursuant to this subsection shall 

6 provide that the contractor will, not less than 

7 once each 6 months, submit to the Secretary a 

8 status report on the success of the contractor in 

9 collecting such damages. Section 3718 of title 

10 31, United States Code, shall apply to any such 

11 contract to the extent not inconsistent with this 

12 subsection. 

13 ‘‘(m) WAIVER OR SUSPENSION OF OBLIGATION.— 

14 ‘‘(1) IN GENERAL.—The Secretary shall by reg15 ulation provide for the partial or total waiver or sus16 pension of any obligation of service or payment by 

17 an individual under the Loan Repayment Program 

18 whenever compliance by the individual is impossible 

19 or would involve extreme hardship to the individual 

20 and if enforcement of such obligation with respect to 

21 any individual would be unconscionable. 

22 ‘‘(2) CANCELED UPON DEATH.—Any obligation 

23 of an individual under the Loan Repayment Pro24 gram for service or payment of damages shall be 

25 canceled upon the death of the individual. 
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1 ‘‘(3) HARDSHIP WAIVER.—The Secretary may 

2 waive, in whole or in part, the rights of the United 

3 States to recover amounts under this section in any 

4 case of extreme hardship or other good cause shown, 

5 as determined by the Secretary. 

6 ‘‘(4) BANKRUPTCY.—Any obligation of an indi7 vidual under the Loan Repayment Program for pay8 ment of damages may be released by a discharge in 

9 bankruptcy under title 11, United States Code, only 

10 if such discharge is granted after the expiration of 

11 the 5-year period beginning on the first date that 

12 payment of such damages is required, and only if 

13 the bankruptcy court finds that nondischarge of the 

14 obligation would be unconscionable. 

15 ‘‘(n) REPORT.—The Secretary shall submit to the 

16 President, for inclusion in the report required to be sub17 mitted to Congress under section 801, a report concerning 

18 the previous fiscal year which sets forth by Service Area 

19 the following: 

20 ‘‘(1) A list of the health professional positions 

21 maintained by Indian Health Programs and urban 

22 Indian organizations for which recruitment or reten23 tion is difficult. 
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1 ‘‘(2) The number of Loan Repayment Program 

2 applications filed with respect to each type of health 

3 profession. 

4 ‘‘(3) The number of contracts described in sub5 section (e) that are entered into with respect to each 

6 health profession. 

7 ‘‘(4) The amount of loan payments made under 

8 this section, in total and by health profession. 

9 ‘‘(5) The number of scholarships that are pro10 vided under sections 104 and 106 with respect to 

11 each health profession. 

12 ‘‘(6) The amount of scholarship grants provided 

13 under sections 104 and 106, in total and by health 

14 profession. 

15 ‘‘(7) The number of providers of health care 

16 that will be needed by Indian Health Programs and 

17 urban Indian organizations, by location and profes18 sion, during the 3 fiscal years beginning after the 

19 date the report is filed. 

20 ‘‘(8) The measures the Secretary plans to take 

21 to fill the health professional positions maintained 

22 by Indian Health Programs or urban Indian organi23 zations for which recruitment or retention is dif24 ficult. 
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1 ‘‘SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOV2 ERY FUND. 

3 ‘‘(a) ESTABLISHMENT.—There is established in the 

4 Treasury of the United States a fund to be known as the 

5 Indian Health Scholarship and Loan Repayment Recovery 

6 Fund (hereafter in this section referred to as the ‘LRRF’). 

7 The LRRF shall consist of such amounts as may be col8 lected from individuals under section 104(d), section 

9 106(e), and section 110(l) for breach of contract, such 

10 funds as may be appropriated to the LRRF, and interest 

11 earned on amounts in the LRRF. All amounts collected, 

12 appropriated, or earned relative to the LRRF shall remain 

13 available until expended. 

14 ‘‘(b) USE OF FUNDS.— 

15 ‘‘(1) BY SECRETARY.—Amounts in the LRRF 

16 may be expended by the Secretary, acting through 

17 the Service, to make payments to an Indian Health 

18 Program— 

19 ‘‘(A) to which a scholarship recipient under 

20 section 104 and 106 or a loan repayment pro21 gram participant under section 110 has been 

22 assigned to meet the obligated service require23 ments pursuant to such sections; and 

24 ‘‘(B) that has a need for a health profes25 sional to provide health care services as a result 

26 of such recipient or participant having breached 
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1 the contract entered into under section 104, 

2 106, or 110. 

3 ‘‘(2) BY TRIBAL HEALTH PROGRAMS.—A Tribal 

4 Health Program receiving payments pursuant to 

5 paragraph (1) may expend the payments to provide 

6 scholarships or recruit and employ, directly or by 

7 contract, health professionals to provide health care 

8 services. 

9 ‘‘(c) INVESTMENT OF FUNDS.—The Secretary of the 

10 Treasury shall invest such amounts of the LRRF as the 

11 Secretary of Health and Human Services determines are 

12 not required to meet current withdrawals from the LRRF. 

13 Such investments may be made only in interest bearing 

14 obligations of the United States. For such purpose, such 

15 obligations may be acquired on original issue at the issue 

16 price, or by purchase of outstanding obligations at the 

17 market price. 

18 ‘‘(d) SALE OF OBLIGATIONS.—Any obligation ac19 quired by the LRRF may be sold by the Secretary of the 

20 Treasury at the market price. 

21 ‘‘SEC. 112. RECRUITMENT ACTIVITIES. 

22 ‘‘(a) REIMBURSEMENT FOR TRAVEL.—The Sec23 retary, acting through the Service, may reimburse health 

24 professionals seeking positions with Indian Health Pro25 grams or urban Indian organizations, including individ-
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1 uals considering entering into a contract under section 

2 110 and their spouses, for actual and reasonable expenses 

3 incurred in traveling to and from their places of residence 

4 to an area in which they may be assigned for the purpose 

5 of evaluating such area with respect to such assignment. 

6 ‘‘(b) RECRUITMENT PERSONNEL.—The Secretary, 

7 acting through the Service, shall assign 1 individual in 

8 each Area Office to be responsible on a full-time basis for 

9 recruitment activities. 

10 ‘‘SEC. 113. INDIAN RECRUITMENT AND RETENTION PRO11 GRAM. 

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

13 the Service, shall fund, on a competitive basis, innovative 

14 demonstration projects for a period not to exceed 3 years 

15 to enable Indian Health Programs and urban Indian orga16 nizations to recruit, place, and retain health professionals 

17 to meet their staffing needs. 

18 ‘‘(b) ELIGIBLE ENTITIES; APPLICATION.—Any In19 dian Health Program or Urban Indian organization may 

20 submit an application for funding of a project pursuant 

21 to this section. 

22 ‘‘SEC. 114. ADVANCED TRAINING AND RESEARCH. 

23 ‘‘(a) DEMONSTRATION PROGRAM.—The Secretary, 

24 acting through the Service, shall establish a demonstration 

25 project to enable health professionals who have worked in 
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1 an Indian Health Program or urban Indian organization 

2 for a substantial period of time to pursue advanced train3 ing or research areas of study for which the Secretary de4 termines a need exists. 

5 ‘‘(b) SERVICE OBLIGATION.—An individual who par6 ticipates in a program under subsection (a), where the 

7 educational costs are borne by the Service, shall incur an 

8 obligation to serve in an Indian Health Program or urban 

9 Indian organization for a period of obligated service equal 

10 to at least the period of time during which the individual 

11 participates in such program. In the event that the indi12 vidual fails to complete such obligated service, the indi13 vidual shall be liable to the United States for the period 

14 of service remaining. In such event, with respect to indi15 viduals entering the program after the date of enactment 

16 of the Indian Health Care Improvement Act Amendments 

17 of 2009, the United States shall be entitled to recover 

18 from such individual an amount to be determined in ac19 cordance with the formula specified in subsection (l) of 

20 section 110 in the manner provided for in such subsection. 

21 ‘‘(c) EQUAL OPPORTUNITY FOR PARTICIPATION.— 

22 Health professionals from Tribal Health Programs and 

23 urban Indian organizations shall be given an equal oppor24 tunity to participate in the program under subsection (a). 
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1 ‘‘SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO 

2 NURSING PROGRAM. 

3 ‘‘(a) GRANTS AUTHORIZED.—For the purpose of in4 creasing the number of nurses, nurse midwives, and nurse 

5 practitioners who deliver health care services to Indians, 

6 the Secretary, acting through the Service, shall provide 

7 grants to the following: 

8 ‘‘(1) Public or private schools of nursing. 

9 ‘‘(2) Tribal colleges or universities. 

10 ‘‘(3) Nurse midwife programs and advanced 

11 practice nurse programs that are provided by any 

12 tribal college or university accredited nursing pro13 gram, or in the absence of such, any other public or 

14 private institutions. 

15 ‘‘(b) USE OF GRANTS.—Grants provided under sub16 section (a) may be used for 1 or more of the following: 

17 ‘‘(1) To recruit individuals for programs which 

18 train individuals to be nurses, nurse midwives, or 

19 advanced practice nurses. 

20 ‘‘(2) To provide scholarships to Indians enrolled 

21 in such programs that may pay the tuition charged 

22 for such program and other expenses incurred in 

23 connection with such program, including books, fees, 

24 room and board, and stipends for living expenses. 

25 ‘‘(3) To provide a program that encourages 

26 nurses, nurse midwives, and advanced practice 
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1 nurses to provide, or continue to provide, health care 

2 services to Indians. 

3 ‘‘(4) To provide a program that increases the 

4 skills of, and provides continuing education to, 

5 nurses, nurse midwives, and advanced practice 

6 nurses. 

7 ‘‘(5) To provide any program that is designed 

8 to achieve the purpose described in subsection (a). 

9 ‘‘(c) APPLICATIONS.—Each application for a grant 

10 under subsection (a) shall include such information as the 

11 Secretary may require to establish the connection between 

12 the program of the applicant and a health care facility 

13 that primarily serves Indians. 

14 ‘‘(d) PREFERENCES FOR GRANT RECIPIENTS.—In 

15 providing grants under subsection (a), the Secretary shall 

16 extend a preference to the following: 

17 ‘‘(1) Programs that provide a preference to In18 dians. 

19 ‘‘(2) Programs that train nurse midwives or ad20 vanced practice nurses. 

21 ‘‘(3) Programs that are interdisciplinary. 

22 ‘‘(4) Programs that are conducted in coopera23 tion with a program for gifted and talented Indian 

24 students. 
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1 ‘‘(5) Programs conducted by tribal colleges and 

2 universities. 

3 ‘‘(e) QUENTIN N. BURDICK PROGRAM GRANT.—The 

4 Secretary shall provide 1 of the grants authorized under 

5 subsection (a) to establish and maintain a program at the 

6 University of North Dakota to be known as the ‘Quentin 

7 N. Burdick American Indians Into Nursing Program’. 

8 Such program shall, to the maximum extent feasible, co9 ordinate with the Quentin N. Burdick Indian Health Pro10 grams established under section 117(b) and the Quentin 

11 N. Burdick American Indians Into Psychology Program 

12 established under section 105(b). 

13 ‘‘(f) ACTIVE DUTY SERVICE OBLIGATION.—The ac14 tive duty service obligation prescribed under section 338C 

15 of the Public Health Service Act (42 U.S.C. 254m) shall 

16 be met by each individual who receives training or assist17 ance described in paragraph (1) or (2) of subsection (b) 

18 that is funded by a grant provided under subsection (a). 

19 Such obligation shall be met by service— 

20 ‘‘(1) in the Service; 

21 ‘‘(2) in a program of an Indian Tribe or Tribal 

22 Organization conducted under the Indian Self-Deter23 mination and Education Assistance Act (25 U.S.C. 

24 450 et seq.) (including programs under agreements 

25 with the Bureau of Indian Affairs); 
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1 ‘‘(3) in a program assisted under title V of this 

2 Act; 

3 ‘‘(4) in the private practice of nursing if, as de4 termined by the Secretary, in accordance with guide5 lines promulgated by the Secretary, such practice is 

6 situated in a physician or other health shortage area 

7 and addresses the health care needs of a substantial 

8 number of Indians; or 

9 ‘‘(5) in a teaching capacity in a tribal college or 

10 university nursing program (or a related health pro11 fession program) if, as determined by the Secretary, 

12 health services provided to Indians would not de13 crease. 

14 ‘‘SEC. 116. TRIBAL CULTURAL ORIENTATION. 

15 ‘‘(a) CULTURAL EDUCATION OF EMPLOYEES.—The 

16 Secretary, acting through the Service, shall require that 

17 appropriate employees of the Service who serve Indian 

18 Tribes in each Service Area receive educational instruction 

19 in the history and culture of such Indian Tribes and their 

20 relationship to the Service. 

21 ‘‘(b) PROGRAM.—In carrying out subsection (a), the 

22 Secretary shall establish a program which shall, to the ex23 tent feasible— 
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1 ‘‘(1) be developed in consultation with the af2 fected Indian Tribes, Tribal Organizations, and 

3 urban Indian organizations; 

4 ‘‘(2) be carried out through tribal colleges or 

5 universities; 

6 ‘‘(3) include instruction in American Indian 

7 studies; and 

8 ‘‘(4) describe the use and place of traditional 

9 health care practices of the Indian Tribes in the 

10 Service Area. 

11 ‘‘SEC. 117. INMED PROGRAM. 

12 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

13 through the Service, is authorized to provide grants to col14 leges and universities for the purpose of maintaining and 

15 expanding the Indian health careers recruitment program 

16 known as the ‘Indians Into Medicine Program’ (herein17 after in this section referred to as ‘INMED’) as a means 

18 of encouraging Indians to enter the health professions. 

19 ‘‘(b) QUENTIN N. BURDICK GRANT.—The Secretary 

20 shall provide 1 of the grants authorized under subsection 

21 (a) to maintain the INMED program at the University 

22 of North Dakota, to be known as the ‘Quentin N. Burdick 

23 Indian Health Programs’, unless the Secretary makes a 

24 determination, based upon program reviews, that the pro25 gram is not meeting the purposes of this section. Such 
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•HR 3962 EH

1 program shall, to the maximum extent feasible, coordinate 

2 with the Quentin N. Burdick American Indians Into Psy3 chology Program established under section 105(b) and the 

4 Quentin N. Burdick American Indians Into Nursing Pro5 gram established under section 115. 

6 ‘‘(c) REGULATIONS.—The Secretary, pursuant to this 

7 Act, shall develop regulations to govern grants pursuant 

8 to this section. 

9 ‘‘(d) REQUIREMENTS.—Applicants for grants pro10 vided under this section shall agree to provide a program 

11 which— 

12 ‘‘(1) provides outreach and recruitment for 

13 health professions to Indian communities including 

14 elementary and secondary schools and community 

15 colleges located on reservations which will be served 

16 by the program; 

17 ‘‘(2) incorporates a program advisory board 

18 comprised of representatives from the Indian Tribes 

19 and Indian communities which will be served by the 

20 program; 

21 ‘‘(3) provides summer preparatory programs for 

22 Indian students who need enrichment in the subjects 

23 of math and science in order to pursue training in 

24 the health professions; 
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1 ‘‘(4) provides tutoring, counseling, and support 

2 to students who are enrolled in a health career pro3 gram of study at the respective college or university; 

4 and 

5 ‘‘(5) to the maximum extent feasible, employs 

6 qualified Indians in the program. 

7 ‘‘SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY 

8 COLLEGES. 

9 ‘‘(a) GRANTS TO ESTABLISH PROGRAMS.— 

10 ‘‘(1) IN GENERAL.—The Secretary, acting 

11 through the Service, shall award grants to accredited 

12 and accessible community colleges for the purpose of 

13 assisting such community colleges in the establish14 ment of programs which provide education in a 

15 health profession leading to a degree or diploma in 

16 a health profession for individuals who desire to 

17 practice such profession on or near a reservation or 

18 in an Indian Health Program. 

19 ‘‘(2) AMOUNT OF GRANTS.—The amount of any 

20 grant awarded to a community college under para21 graph (1) for the first year in which such a grant 

22 is provided to the community college shall not exceed 

23 $250,000. 

24 ‘‘(b) GRANTS FOR MAINTENANCE AND RECRUIT25 ING.— 
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1 ‘‘(1) IN GENERAL.—The Secretary, acting 

2 through the Service, shall award grants to accredited 

3 and accessible community colleges that have estab4 lished a program described in subsection (a)(1) for 

5 the purpose of maintaining the program and recruit6 ing students for the program. 

7 ‘‘(2) REQUIREMENTS.—Grants may only be 

8 made under this section to a community college 

9 which— 

10 ‘‘(A) is accredited; 

11 ‘‘(B) has a relationship with a hospital fa12 cility, Service facility, or hospital that could 

13 provide training of nurses or health profes14 sionals; 

15 ‘‘(C) has entered into an agreement with 

16 an accredited college or university medical 

17 school, the terms of which— 

18 ‘‘(i) provide a program that enhances 

19 the transition and recruitment of students 

20 into advanced baccalaureate or graduate 

21 programs that train health professionals; 

22 and 

23 ‘‘(ii) stipulate certifications necessary 

24 to approve internship and field placement 

25 opportunities at Indian Health Programs; 
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1 ‘‘(D) has a qualified staff which has the 

2 appropriate certifications; 

3 ‘‘(E) is capable of obtaining State or re4 gional accreditation of the program described in 

5 subsection (a)(1); and 

6 ‘‘(F) agrees to provide for Indian pref7 erence for applicants for programs under this 

8 section. 

9 ‘‘(c) TECHNICAL ASSISTANCE.—The Secretary shall 

10 encourage community colleges described in subsection 

11 (b)(2) to establish and maintain programs described in 

12 subsection (a)(1) by— 

13 ‘‘(1) entering into agreements with such col14 leges for the provision of qualified personnel of the 

15 Service to teach courses of study in such programs; 

16 and 

17 ‘‘(2) providing technical assistance and support 

18 to such colleges. 

19 ‘‘(d) ADVANCED TRAINING.— 

20 ‘‘(1) REQUIRED.—Any program receiving as21 sistance under this section that is conducted with re22 spect to a health profession shall also offer courses 

23 of study which provide advanced training for any 

24 health professional who— 
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1 ‘‘(A) has already received a degree or di2 ploma in such health profession; and 

3 ‘‘(B) provides clinical services on or near a 

4 reservation or for an Indian Health Program. 

5 ‘‘(2) MAY BE OFFERED AT ALTERNATE SITE.— 

6 Such courses of study may be offered in conjunction 

7 with the college or university with which the commu8 nity college has entered into the agreement required 

9 under subsection (b)(2)(C). 

10 ‘‘(e) PRIORITY.—Where the requirements of sub11 section (b) are met, grant award priority shall be provided 

12 to tribal colleges and universities in Service Areas where 

13 they exist. 

14 ‘‘SEC. 119. RETENTION BONUS. 

15 ‘‘(a) BONUS AUTHORIZED.—The Secretary may pay 

16 a retention bonus to any health professional employed by, 

17 or assigned to, and serving in, an Indian Health Program 

18 or urban Indian organization either as a civilian employee 

19 or as a commissioned officer in the Regular or Reserve 

20 Corps of the Public Health Service who— 

21 ‘‘(1) is assigned to, and serving in, a position 

22 for which recruitment or retention of personnel is 

23 difficult; 
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1 ‘‘(2) the Secretary determines is needed by In2 dian Health Programs and urban Indian organiza3 tions; 

4 ‘‘(3) has— 

5 ‘‘(A) completed 2 years of employment 

6 with an Indian Health Program or urban In7 dian organization; or 

8 ‘‘(B) completed any service obligations in9 curred as a requirement of— 

10 ‘‘(i) any Federal scholarship program; 

11 or 

12 ‘‘(ii) any Federal education loan re13 payment program; and 

14 ‘‘(4) enters into an agreement with an Indian 

15 Health Program or urban Indian organization for 

16 continued employment for a period of not less than 

17 1 year. 

18 ‘‘(b) RATES.—The Secretary may establish rates for 

19 the retention bonus which shall provide for a higher an20 nual rate for multiyear agreements than for single year 

21 agreements referred to in subsection (a)(4), but in no 

22 event shall the annual rate be more than $25,000 per 

23 annum. 

24 ‘‘(c) DEFAULT OF RETENTION AGREEMENT.—Any 

25 health professional failing to complete the agreed upon 
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1 term of service, except where such failure is through no 

2 fault of the individual, shall be obligated to refund to the 

3 Government the full amount of the retention bonus for the 

4 period covered by the agreement, plus interest as deter5 mined by the Secretary in accordance with section 

6 110(l)(2)(B). 

7 ‘‘(d) OTHER RETENTION BONUS.—The Secretary 

8 may pay a retention bonus to any health professional em9 ployed by a Tribal Health Program if such health profes10 sional is serving in a position which the Secretary deter11 mines is— 

12 ‘‘(1) a position for which recruitment or reten13 tion is difficult; and 

14 ‘‘(2) necessary for providing health care services 

15 to Indians. 

16 ‘‘SEC. 120. NURSING RESIDENCY PROGRAM. 

17 ‘‘(a) ESTABLISHMENT OF PROGRAM.—The Sec18 retary, acting through the Service, shall establish a pro19 gram to enable Indians who are licensed practical nurses, 

20 licensed vocational nurses, and registered nurses who are 

21 working in an Indian Health Program or urban Indian 

22 organization, and have done so for a period of not less 

23 than 1 year, to pursue advanced training. Such program 

24 shall include a combination of education and work study 

25 in an Indian Health Program or urban Indian organiza-
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1 tion leading to an associate or bachelor’s degree (in the 

2 case of a licensed practical nurse or licensed vocational 

3 nurse), a bachelor’s degree (in the case of a registered 

4 nurse), or advanced degrees or certifications in nursing 

5 and public health. 

6 ‘‘(b) SERVICE OBLIGATION.—An individual who par7 ticipates in a program under subsection (a), where the 

8 educational costs are paid by the Service, shall incur an 

9 obligation to serve in an Indian Health Program or urban 

10 Indian organization for a period of obligated service equal 

11 to 1 year for every year that nonprofessional employee (li12 censed practical nurses, licensed vocational nurses, nurs13 ing assistants, and various health care technicians), or 2 

14 years for every year that professional nurse (associate de15 gree and bachelor-prepared registered nurses), partici16 pates in such program. In the event that the individual 

17 fails to complete such obligated service, the United States 

18 shall be entitled to recover from such individual an amount 

19 determined in accordance with the formula specified sub20 section (d)(1) of section 104 for individuals failing to 

21 graduate from their degree program and subsection (l) of 

22 Section 110 for individuals failing to start or complete the 

23 obligated service. 
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1 ‘‘SEC. 121. COMMUNITY HEALTH AIDE PROGRAM. 

2 ‘‘(a) GENERAL PURPOSES OF PROGRAM.—Under the 

3 authority of the Act of November 2, 1921 (25 U.S.C. 13) 

4 (commonly known as the ‘Snyder Act’), the Secretary, act5 ing through the Service, shall develop and operate a Com6 munity Health Aide Program in Alaska under which the 

7 Service— 

8 ‘‘(1) provides for the training of Alaska Natives 

9 as health aides or community health practitioners; 

10 ‘‘(2) uses such aides or practitioners in the pro11 vision of health care, health promotion, and disease 

12 prevention services to Alaska Natives living in vil13 lages in rural Alaska; and 

14 ‘‘(3) provides for the establishment of tele15 conferencing capacity in health clinics located in or 

16 near such villages for use by community health aides 

17 or community health practitioners. 

18 ‘‘(b) SPECIFIC PROGRAM REQUIREMENTS.—The Sec19 retary, acting through the Community Health Aide Pro20 gram of the Service, shall— 

21 ‘‘(1) using trainers accredited by the Program, 

22 provide a high standard of training to community 

23 health aides and community health practitioners to 

24 ensure that such aides and practitioners provide 

25 quality health care, health promotion, and disease 
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1 prevention services to the villages served by the Pro2 gram; 

3 ‘‘(2) in order to provide such training, develop 

4 a curriculum that— 

5 ‘‘(A) combines education in the theory of 

6 health care with supervised practical experience 

7 in the provision of health care; 

8 ‘‘(B) provides instruction and practical ex9 perience in the provision of acute care, emer10 gency care, health promotion, disease preven11 tion, and the efficient and effective manage12 ment of clinic pharmacies, supplies, equipment, 

13 and facilities; and 

14 ‘‘(C) promotes the achievement of the 

15 health status objectives specified in section 

16 3(2); 

17 ‘‘(3) establish and maintain a Community 

18 Health Aide Certification Board to certify as com19 munity health aides or community health practi20 tioners individuals who have successfully completed 

21 the training described in paragraph (1) or can dem22 onstrate equivalent experience; 

23 ‘‘(4) develop and maintain a system which iden24 tifies the needs of community health aides and com25 munity health practitioners for continuing education 
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1 in the provision of health care, including the areas 

2 described in paragraph (2)(B), and develop pro3 grams that meet the needs for such continuing edu4 cation; 

5 ‘‘(5) develop and maintain a system that pro6 vides close supervision of community health aides 

7 and community health practitioners; 

8 ‘‘(6) develop a system under which the work of 

9 community health aides and community health prac10 titioners is reviewed and evaluated to assure the pro11 vision of quality health care, health promotion, and 

12 disease prevention services; and 

13 ‘‘(7) ensure that pulpal therapy (not including 

14 pulpotomies on deciduous teeth) or extraction of 

15 adult teeth can be performed by a dental health aide 

16 therapist only after consultation with a licensed den17 tist who determines that the procedure is a medical 

18 emergency that cannot be resolved with palliative 

19 treatment, and further that dental health aide thera20 pists are strictly prohibited from performing all 

21 other oral or jaw surgeries, provided that uncompli22 cated extractions shall not be considered oral sur23 gery under this section. 

24 ‘‘(c) PROGRAM REVIEW.— 

25 ‘‘(1) NEUTRAL PANEL.— 
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1 ‘‘(A) ESTABLISHMENT.—The Secretary, 

2 acting through the Service, shall establish a 

3 neutral panel to carry out the study under 

4 paragraph (2). 

5 ‘‘(B) MEMBERSHIP.—Members of the neu6 tral panel shall be appointed by the Secretary 

7 from among clinicians, economists, community 

8 practitioners, oral epidemiologists, and Alaska 

9 Natives. 

10 ‘‘(2) STUDY.— 

11 ‘‘(A) IN GENERAL.—The neutral panel es12 tablished under paragraph (1) shall conduct a 

13 study of the dental health aide therapist serv14 ices provided by the Community Health Aide 

15 Program under this section to ensure that the 

16 quality of care provided through those services 

17 is adequate and appropriate. 

18 ‘‘(B) PARAMETERS OF STUDY.—The Sec19 retary, in consultation with interested parties, 

20 including professional dental organizations, 

21 shall develop the parameters of the study. 

22 ‘‘(C) INCLUSIONS.—The study shall in23 clude a determination by the neutral panel with 

24 respect to— 
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1 ‘‘(i) the ability of the dental health 

2 aide therapist services under this section to 

3 address the dental care needs of Alaska 

4 Natives; 

5 ‘‘(ii) the quality of care provided 

6 through those services, including any train7 ing, improvement, or additional oversight 

8 required to improve the quality of care; 

9 and 

10 ‘‘(iii) whether safer and less costly al11 ternatives to the dental health aide thera12 pist services exist. 

13 ‘‘(D) CONSULTATION.—In carrying out the 

14 study under this paragraph, the neutral panel 

15 shall consult with Alaska Tribal Organizations 

16 with respect to the adequacy and accuracy of 

17 the study. 

18 ‘‘(3) REPORT.—The neutral panel shall submit 

19 to the Secretary, the Committee on Indian Affairs of 

20 the Senate, and the Committee on Natural Re21 sources of the House of Representatives a report de22 scribing the results of the study under paragraph 

23 (2), including a description of— 

24 ‘‘(A) any determination of the neutral 

25 panel under paragraph (2)(C); and 
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1 ‘‘(B) any comments received from an Alas2 ka Tribal Organization under paragraph 

3 (2)(D). 

4 ‘‘(d) NATIONALIZATION OF PROGRAM.— 

5 ‘‘(1) IN GENERAL.—Except as provided in para6 graph (2), the Secretary, acting through the Service, 

7 may establish a national Community Health Aide 

8 Program in accordance with the program under this 

9 section, as the Secretary determines to be appro10 priate. 

11 ‘‘(2) EXCEPTION.—The national Community 

12 Health Aide Program under paragraph (1) shall not 

13 include dental health aide therapist services. 

14 ‘‘(3) REQUIREMENT.—In establishing a na15 tional program under paragraph (1), the Secretary 

16 shall not reduce the amount of funds provided for 

17 the Community Health Aide Program described in 

18 subsections (a) and (b). 

19 ‘‘SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION. 

20 ‘‘The Secretary shall, by contract or otherwise, pro21 vide training for individuals in the administration and 

22 planning of Tribal Health Programs, with priority to Indi23 ans. 
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1 ‘‘SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE 

2 DEMONSTRATION PROGRAMS. 

3 ‘‘(a) DEMONSTRATION PROGRAMS AUTHORIZED.— 

4 The Secretary, acting through the Service, may fund dem5 onstration programs for Tribal Health Programs to ad6 dress the chronic shortages of health professionals. 

7 ‘‘(b) PURPOSES OF PROGRAMS.—The purposes of 

8 demonstration programs funded under subsection (a) shall 

9 be— 

10 ‘‘(1) to provide direct clinical and practical ex11 perience at a Service Unit to health profession stu12 dents and residents from medical schools; 

13 ‘‘(2) to improve the quality of health care for 

14 Indians by assuring access to qualified health care 

15 professionals; and 

16 ‘‘(3) to provide academic and scholarly opportu17 nities for health professionals serving Indians by 

18 identifying all academic and scholarly resources of 

19 the region. 

20 ‘‘(c) ADVISORY BOARD.—The demonstration pro21 grams established pursuant to subsection (a) shall incor22 porate a program advisory board composed of representa23 tives from the Indian Tribes and Indian communities in 

24 the area which will be served by the program. 
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1 ‘‘SEC. 124. NATIONAL HEALTH SERVICE CORPS. 

2 ‘‘(a) NO REDUCTION IN SERVICES.—The Secretary 

3 shall not— 

4 ‘‘(1) remove a member of the National Health 

5 Service Corps from an Indian Health Program or 

6 urban Indian organization; or 

7 ‘‘(2) withdraw funding used to support such 

8 member, unless the Secretary, acting through the 

9 Service, has ensured that the Indians receiving serv10 ices from such member will experience no reduction 

11 in services. 

12 ‘‘(b) TREATMENT OF INDIAN HEALTH PROGRAMS.— 

13 At the request of an Indian Health Program, the services 

14 of a member of the National Health Service Corps as15 signed to an Indian Health Program may be limited to 

16 the persons who are eligible for services from such Pro17 gram. 

18 ‘‘SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL 

19 CURRICULA DEMONSTRATION PROGRAMS. 

20 ‘‘(a) CONTRACTS AND GRANTS.—The Secretary, act21 ing through the Service, may enter into contracts with, 

22 or make grants to, accredited tribal colleges and univer23 sities and eligible accredited and accessible community col24 leges to establish demonstration programs to develop edu25 cational curricula for substance abuse counseling. 
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1 ‘‘(b) USE OF FUNDS.—Funds provided under this 

2 section shall be used only for developing and providing 

3 educational curriculum for substance abuse counseling (in4 cluding paying salaries for instructors). Such curricula 

5 may be provided through satellite campus programs. 

6 ‘‘(c) TIME PERIOD OF ASSISTANCE; RENEWAL.—A 

7 contract entered into or a grant provided under this sec8 tion shall be for a period of 3 years. Such contract or 

9 grant may be renewed for an additional 2-year period 

10 upon the approval of the Secretary. 

11 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP12 PLICATIONS.—Not later than 180 days after the date of 

13 enactment of the Indian Health Care Improvement Act 

14 Amendments of 2009, the Secretary, after consultation 

15 with Indian Tribes and administrators of tribal colleges 

16 and universities and eligible accredited and accessible com17 munity colleges, shall develop and issue criteria for the 

18 review and approval of applications for funding (including 

19 applications for renewals of funding) under this section. 

20 Such criteria shall ensure that demonstration programs 

21 established under this section promote the development of 

22 the capacity of such entities to educate substance abuse 

23 counselors. 

24 ‘‘(e) ASSISTANCE.—The Secretary shall provide such 

25 technical and other assistance as may be necessary to en-
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1 able grant recipients to comply with the provisions of this 

2 section. 

3 ‘‘(f) REPORT.—Each fiscal year, the Secretary shall 

4 submit to the President, for inclusion in the report which 

5 is required to be submitted under section 801 for that fis6 cal year, a report on the findings and conclusions derived 

7 from the demonstration programs conducted under this 

8 section during that fiscal year. 

9 ‘‘(g) DEFINITION.—For the purposes of this section, 

10 the term ‘educational curriculum’ means 1 or more of the 

11 following: 

12 ‘‘(1) Classroom education. 

13 ‘‘(2) Clinical work experience. 

14 ‘‘(3) Continuing education workshops. 

15 ‘‘SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMU16 NITY EDUCATION PROGRAMS. 

17 ‘‘(a) STUDY; LIST.—The Secretary, acting through 

18 the Service, and the Secretary of the Interior, in consulta19 tion with Indian Tribes and Tribal Organizations, shall 

20 conduct a study and compile a list of the types of staff 

21 positions specified in subsection (b) whose qualifications 

22 include, or should include, training in the identification, 

23 prevention, education, referral, or treatment of mental ill24 ness, or dysfunctional and self-destructive behavior. 
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1 ‘‘(b) POSITIONS.—The positions referred to in sub2 section (a) are— 

3 ‘‘(1) staff positions within the Bureau of Indian 

4 Affairs, including existing positions, in the fields 

5 of— 

6 ‘‘(A) elementary and secondary education; 

7 ‘‘(B) social services and family and child 

8 welfare; 

9 ‘‘(C) law enforcement and judicial services; 

10 and 

11 ‘‘(D) alcohol and substance abuse; 

12 ‘‘(2) staff positions within the Service; and 

13 ‘‘(3) staff positions similar to those identified in 

14 paragraphs (1) and (2) established and maintained 

15 by Indian Tribes, Tribal Organizations (without re16 gard to the funding source), and urban Indian orga17 nizations. 

18 ‘‘(c) TRAINING CRITERIA.— 

19 ‘‘(1) IN GENERAL.—The appropriate Secretary 

20 shall provide training criteria appropriate to each 

21 type of position identified in subsection (b)(1) and 

22 (b)(2) and ensure that appropriate training has 

23 been, or shall be provided to any individual in any 

24 such position. With respect to any such individual in 

25 a position identified pursuant to subsection (b)(3), 
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1 the respective Secretaries shall provide appropriate 

2 training to, or provide funds to, an Indian Tribe, 

3 Tribal Organization, or urban Indian organization 

4 for training of appropriate individuals. In the case of 

5 positions funded under a contract or compact under 

6 the Indian Self-Determination and Education Assist7 ance Act (25 U.S.C. 450 et seq.), the appropriate 

8 Secretary shall ensure that such training costs are 

9 included in the contract or compact, as the Sec10 retary determines necessary. 

11 ‘‘(2) POSITION SPECIFIC TRAINING CRITERIA.— 

12 Position specific training criteria shall be culturally 

13 relevant to Indians and Indian Tribes and shall en14 sure that appropriate information regarding tradi15 tional health care practices is provided. 

16 ‘‘(d) COMMUNITY EDUCATION ON MENTAL ILL17 NESS.—The Service shall develop and implement, on re18 quest of an Indian Tribe, Tribal Organization, or urban 

19 Indian organization, or assist the Indian Tribe, Tribal Or20 ganization, or urban Indian organization to develop and 

21 implement, a program of community education on mental 

22 illness. In carrying out this subsection, the Service shall, 

23 upon request of an Indian Tribe, Tribal Organization, or 

24 urban Indian organization, provide technical assistance to 

25 the Indian Tribe, Tribal Organization, or urban Indian or-
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1 ganization to obtain and develop community educational 

2 materials on the identification, prevention, referral, and 

3 treatment of mental illness and dysfunctional and self-de4 structive behavior. 

5 ‘‘(e) PLAN.—Not later than 90 days after the date 

6 of enactment of the Indian Health Care Improvement Act 

7 Amendments of 2009, the Secretary shall develop a plan 

8 under which the Service will increase the health care staff 

9 providing behavioral health services by at least 500 posi10 tions within 5 years after the date of enactment of this 

11 section, with at least 200 of such positions devoted to 

12 child, adolescent, and family services. The plan developed 

13 under this subsection shall be implemented under the Act 

14 of November 2, 1921 (25 U.S.C. 13) (commonly known 

15 as the ‘Snyder Act’). 

16 ‘‘SEC. 127. EXEMPTION FROM PAYMENT OF CERTAIN FEES. 

17 ‘‘Employees of a Tribal Health Program or an Urban 

18 Indian Organization shall be exempt from payment of li19 censing, registration, and other fees imposed by a Federal 

20 agency to the same extent that Commissioned Corps Offi21 cers or other employees of the Indian Health Service are 

22 exempt from such fees. 

23 ‘‘SEC. 128. AUTHORIZATION OF APPROPRIATIONS. 

24 ‘‘There are authorized to be appropriated such sums 

25 as may be necessary to carry out this title. 
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1 ‘‘TITLE II—HEALTH SERVICES 

2 ‘‘SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND. 

3 ‘‘(a) USE OF FUNDS.—The Secretary, acting through 

4 the Service, is authorized to expend funds, directly or 

5 under the authority of the Indian Self-Determination and 

6 Education Assistance Act (25 U.S.C. 450 et seq.), which 

7 are appropriated under the authority of this section, for 

8 the purposes of— 

9 ‘‘(1) eliminating the deficiencies in health sta10 tus and health resources of all Indian Tribes; 

11 ‘‘(2) eliminating backlogs in the provision of 

12 health care services to Indians; 

13 ‘‘(3) meeting the health needs of Indians in an 

14 efficient and equitable manner, including the use of 

15 telehealth and telemedicine when appropriate; 

16 ‘‘(4) eliminating inequities in funding for both 

17 direct care and contract health service programs; 

18 and 

19 ‘‘(5) augmenting the ability of the Service to 

20 meet the following health service responsibilities with 

21 respect to those Indian Tribes with the highest levels 

22 of health status deficiencies and resource defi23 ciencies: 

24 ‘‘(A) Clinical care, including inpatient care, 

25 outpatient care (including audiology, clinical 
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1 eye, and vision care), primary care, secondary 

2 and tertiary care, and long-term care. 

3 ‘‘(B) Preventive health, including mam4 mography and other cancer screening in accord5 ance with section 207. 

6 ‘‘(C) Dental care. 

7 ‘‘(D) Mental health, including community 

8 mental health services, inpatient mental health 

9 services, dormitory mental health services, 

10 therapeutic and residential treatment centers, 

11 and training of traditional health care practi12 tioners. 

13 ‘‘(E) Emergency medical services. 

14 ‘‘(F) Treatment and control of, and reha15 bilitative care related to, alcoholism and drug 

16 abuse (including fetal alcohol syndrome) among 

17 Indians. 

18 ‘‘(G) Injury prevention programs, includ19 ing data collection and evaluation, demonstra20 tion projects, training, and capacity building. 

21 ‘‘(H) Home health care. 

22 ‘‘(I) Community health representatives. 

23 ‘‘(J) Maintenance and improvement. 

24 ‘‘(b) NO OFFSET OR LIMITATION.—Any funds appro25 priated under the authority of this section shall not be 
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1 used to offset or limit any other appropriations made to 

2 the Service under this Act or the Act of November 2, 1921 

3 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

4 or any other provision of law. 

5 ‘‘(c) ALLOCATION; USE.— 

6 ‘‘(1) IN GENERAL.—Funds appropriated under 

7 the authority of this section shall be allocated to 

8 Service Units, Indian Tribes, or Tribal Organiza9 tions. The funds allocated to each Indian Tribe, 

10 Tribal Organization, or Service Unit under this 

11 paragraph shall be used by the Indian Tribe, Tribal 

12 Organization, or Service Unit under this paragraph 

13 to improve the health status and reduce the resource 

14 deficiency of each Indian Tribe served by such Serv15 ice Unit, Indian Tribe, or Tribal Organization. 

16 ‘‘(2) APPORTIONMENT OF ALLOCATED

17 FUNDS.—The apportionment of funds allocated to a 

18 Service Unit, Indian Tribe, or Tribal Organization 

19 under paragraph (1) among the health service re20 sponsibilities described in subsection (a)(5) shall be 

21 determined by the Service in consultation with, and 

22 with the active participation of, the affected Indian 

23 Tribes and Tribal Organizations. 
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1 ‘‘(d) PROVISIONS RELATING TO HEALTH STATUS

2 AND RESOURCE DEFICIENCIES.—For the purposes of this 

3 section, the following definitions apply: 

4 ‘‘(1) DEFINITION.—The term ‘health status 

5 and resource deficiency’ means the extent to 

6 which— 

7 ‘‘(A) the health status objectives set forth 

8 in section 3(2) are not being achieved; and 

9 ‘‘(B) the Indian Tribe or Tribal Organiza10 tion does not have available to it the health re11 sources it needs, taking into account the actual 

12 cost of providing health care services given local 

13 geographic, climatic, rural, or other cir14 cumstances. 

15 ‘‘(2) AVAILABLE RESOURCES.—The health re16 sources available to an Indian Tribe or Tribal Orga17 nization include health resources provided by the 

18 Service as well as health resources used by the In19 dian Tribe or Tribal Organization, including services 

20 and financing systems provided by any Federal pro21 grams, private insurance, and programs of State or 

22 local governments. 

23 ‘‘(3) PROCESS FOR REVIEW OF DETERMINA24 TIONS.—The Secretary shall establish procedures 

25 which allow any Indian Tribe or Tribal Organization 
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1 to petition the Secretary for a review of any deter2 mination of the extent of the health status and re3 source deficiency of such Indian Tribe or Tribal Or4 ganization. 

5 ‘‘(e) ELIGIBILITY FOR FUNDS.—Tribal Health Pro6 grams shall be eligible for funds appropriated under the 

7 authority of this section on an equal basis with programs 

8 that are administered directly by the Service. 

9 ‘‘(f) REPORT.—By no later than the date that is 3 

10 years after the date of enactment of the Indian Health 

11 Care Improvement Act Amendments of 2009, the Sec12 retary shall submit to Congress the current health status 

13 and resource deficiency report of the Service for each 

14 Service Unit, including newly recognized or acknowledged 

15 Indian Tribes. Such report shall set out— 

16 ‘‘(1) the methodology then in use by the Service 

17 for determining Tribal health status and resource 

18 deficiencies, as well as the most recent application of 

19 that methodology; 

20 ‘‘(2) the extent of the health status and re21 source deficiency of each Indian Tribe served by the 

22 Service or a Tribal Health Program; 

23 ‘‘(3) the amount of funds necessary to eliminate 

24 the health status and resource deficiencies of all In-
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1 dian Tribes served by the Service or a Tribal Health 

2 Program; and 

3 ‘‘(4) an estimate of— 

4 ‘‘(A) the amount of health service funds 

5 appropriated under the authority of this Act, or 

6 any other Act, including the amount of any 

7 funds transferred to the Service for the pre8 ceding fiscal year which is allocated to each 

9 Service Unit, Indian Tribe, or Tribal Organiza10 tion; 

11 ‘‘(B) the number of Indians eligible for 

12 health services in each Service Unit or Indian 

13 Tribe or Tribal Organization; and 

14 ‘‘(C) the number of Indians using the 

15 Service resources made available to each Service 

16 Unit, Indian Tribe or Tribal Organization, and, 

17 to the extent available, information on the wait18 ing lists and number of Indians turned away for 

19 services due to lack of resources. 

20 ‘‘(g) INCLUSION IN BASE BUDGET.—Funds appro21 priated under this section for any fiscal year shall be in22 cluded in the base budget of the Service for the purpose 

23 of determining appropriations under this section in subse24 quent fiscal years. 
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1 ‘‘(h) CLARIFICATION.—Nothing in this section is in2 tended to diminish the primary responsibility of the Serv3 ice to eliminate existing backlogs in unmet health care 

4 needs, nor are the provisions of this section intended to 

5 discourage the Service from undertaking additional efforts 

6 to achieve equity among Indian Tribes and Tribal Organi7 zations. 

8 ‘‘(i) FUNDING DESIGNATION.—Any funds appro9 priated under the authority of this section shall be des10 ignated as the ‘Indian Health Care Improvement Fund’. 

11 ‘‘SEC. 202. HEALTH PROMOTION AND DISEASE PREVENTION 

12 SERVICES. 

13 ‘‘(a) FINDINGS.—Congress finds that health pro14 motion and disease prevention activities— 

15 ‘‘(1) improve the health and well-being of Indi16 ans; and 

17 ‘‘(2) reduce the expenses for health care of In18 dians. 

19 ‘‘(b) PROVISION OF SERVICES.—The Secretary, act20 ing through the Service, shall provide health promotion 

21 and disease prevention services to Indians to achieve the 

22 health status objectives set forth in section 3(2). 

23 ‘‘(c) EVALUATION.—The Secretary, after obtaining 

24 input from the affected Tribal Health Programs, shall 

25 submit to the President for inclusion in the report which 
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1 is required to be submitted to Congress under section 801 

2 an evaluation of— 

3 ‘‘(1) the health promotion and disease preven4 tion needs of Indians; 

5 ‘‘(2) the health promotion and disease preven6 tion activities which would best meet such needs; 

7 ‘‘(3) the internal capacity of the Service and 

8 Tribal Health Programs to meet such needs; and 

9 ‘‘(4) the resources which would be required to 

10 enable the Service and Tribal Health Programs to 

11 undertake the health promotion and disease preven12 tion activities necessary to meet such needs. 

13 ‘‘SEC. 203. DIABETES PREVENTION, TREATMENT, AND CON14 TROL. 

15 ‘‘(a) DETERMINATIONS REGARDING DIABETES.— 

16 The Secretary, acting through the Service, and in con17 sultation with Indian Tribes and Tribal Organizations, 

18 shall determine— 

19 ‘‘(1) by Indian Tribe and by Service Unit, the 

20 incidence of, and the types of complications resulting 

21 from, diabetes among Indians; and 

22 ‘‘(2) based on the determinations made pursu23 ant to paragraph (1), the measures (including pa24 tient education and effective ongoing monitoring of 

25 disease indicators) each Service Unit should take to 
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1 reduce the incidence of, and prevent, treat, and con2 trol the complications resulting from, diabetes 

3 among Indian Tribes within that Service Unit. 

4 ‘‘(b) DIABETES SCREENING.—To the extent medi5 cally indicated and with informed consent, the Secretary 

6 shall screen each Indian who receives services from the 

7 Service for diabetes and for conditions which indicate a 

8 high risk that the individual will become diabetic and es9 tablish a cost-effective approach to ensure ongoing moni10 toring of disease indicators. Such screening and moni11 toring may be conducted by a Tribal Health Program and 

12 may be conducted through appropriate Internet-based 

13 health care management programs. 

14 ‘‘(c) DIABETES PROJECTS.—The Secretary shall con15 tinue to maintain each model diabetes project in existence 

16 on the date of enactment of the Indian Health Care Im17 provement Act Amendments of 2009. 

18 ‘‘(d) DIALYSIS PROGRAMS.—The Secretary is author19 ized to provide, through the Service, Indian Tribes, and 

20 Tribal Organizations, dialysis programs, including the 

21 purchase of dialysis equipment and the provision of nec22 essary staffing. 

23 ‘‘(e) OTHER DUTIES OF THE SECRETARY.— 

24 ‘‘(1) IN GENERAL.—The Secretary shall, to the 

25 extent funding is available— 
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1 ‘‘(A) in each Area Office, consult with In2 dian Tribes and Tribal Organizations regarding 

3 programs for the prevention, treatment, and 

4 control of diabetes; 

5 ‘‘(B) establish in each Area Office a reg6 istry of patients with diabetes to track the inci7 dence of diabetes and the complications from 

8 diabetes in that area; and 

9 ‘‘(C) ensure that data collected in each 

10 Area Office regarding diabetes and related com11 plications among Indians are disseminated to 

12 all other Area Offices, subject to applicable pa13 tient privacy laws. 

14 ‘‘(2) DIABETES CONTROL OFFICERS.— 

15 ‘‘(A) IN GENERAL.—The Secretary may es16 tablish and maintain in each Area Office a posi17 tion of diabetes control officer to coordinate and 

18 manage any activity of that Area Office relating 

19 to the prevention, treatment, or control of dia20 betes to assist the Secretary in carrying out a 

21 program under this section or section 330C of 

22 the Public Health Service Act (42 U.S.C. 254c– 

23 3). 

24 ‘‘(B) CERTAIN ACTIVITIES.—Any activity 

25 carried out by a diabetes control officer under 
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1 subparagraph (A) that is the subject of a con2 tract or compact under the Indian Self-Deter3 mination and Education Assistance Act (25 

4 U.S.C. 450 et seq.), and any funds made avail5 able to carry out such an activity, shall not be 

6 divisible for purposes of that Act. 

7 ‘‘SEC. 204. SHARED SERVICES FOR LONG-TERM CARE. 

8 ‘‘(a) LONG-TERM CARE.—Notwithstanding any other 

9 provision of law, the Secretary, acting through the Service, 

10 is authorized to provide directly, or enter into contracts 

11 or compacts under the Indian Self-Determination and 

12 Education Assistance Act (25 U.S.C. 450 et seq.) with 

13 Indian Tribes or Tribal Organizations for, the delivery of 

14 long-term care (including health care services associated 

15 with long-term care) provided in a facility to Indians. Such 

16 agreements shall provide for the sharing of staff or other 

17 services between the Service or a Tribal Health Program 

18 and a long-term care or related facility owned and oper19 ated (directly or through a contract or compact under the 

20 Indian Self-Determination and Education Assistance Act 

21 (25 U.S.C. 450 et seq.)) by such Indian Tribe or Tribal 

22 Organization. 

23 ‘‘(b) CONTENTS OF AGREEMENTS.—An agreement 

24 entered into pursuant to subsection (a)— 
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1 ‘‘(1) may, at the request of the Indian Tribe or 

2 Tribal Organization, delegate to such Indian Tribe 

3 or Tribal Organization such powers of supervision 

4 and control over Service employees as the Secretary 

5 deems necessary to carry out the purposes of this 

6 section; 

7 ‘‘(2) shall provide that expenses (including sala8 ries) relating to services that are shared between the 

9 Service and the Tribal Health Program be allocated 

10 proportionately between the Service and the Indian 

11 Tribe or Tribal Organization; and 

12 ‘‘(3) may authorize such Indian Tribe or Tribal 

13 Organization to construct, renovate, or expand a 

14 long-term care or other similar facility (including the 

15 construction of a facility attached to a Service facil16 ity). 

17 ‘‘(c) MINIMUM REQUIREMENT.—Any nursing facility 

18 provided for under this section shall meet the require19 ments for nursing facilities under section 1919 of the So20 cial Security Act. 

21 ‘‘(d) OTHER ASSISTANCE.—The Secretary shall pro22 vide such technical and other assistance as may be nec23 essary to enable applicants to comply with the provisions 

24 of this section. 
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1 ‘‘(e) USE OF EXISTING OR UNDERUSED FACILI2 TIES.—The Secretary shall encourage the use of existing 

3 facilities that are underused or allow the use of swing beds 

4 for long-term or similar care. 

5 ‘‘SEC. 205. HEALTH SERVICES RESEARCH. 

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

7 the Service, shall make funding available for research to 

8 further the performance of the health service responsibil9 ities of Indian Health Programs. 

10 ‘‘(b) COORDINATION OF RESOURCES AND ACTIVI11 TIES.—The Secretary shall also, to the maximum extent 

12 practicable, coordinate departmental research resources 

13 and activities to address relevant Indian Health Program 

14 research needs. 

15 ‘‘(c) AVAILABILITY.—Tribal Health Programs shall 

16 be given an equal opportunity to compete for, and receive, 

17 research funds under this section. 

18 ‘‘(d) USE OF FUNDS.—This funding may be used for 

19 both clinical and nonclinical research. 

20 ‘‘(e) EVALUATION AND DISSEMINATION.—The Sec21 retary shall periodically— 

22 ‘‘(1) evaluate the impact of research conducted 

23 under this section; and 
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1 ‘‘(2) disseminate to Tribal Health Programs in2 formation regarding that research as the Secretary 

3 determines to be appropriate. 

4 ‘‘SEC. 206. MAMMOGRAPHY AND OTHER CANCER SCREEN5 ING. 

6 ‘‘The Secretary, acting through the Service, shall pro7 vide for screening as follows: 

8 ‘‘(1) Screening mammography (as defined in 

9 section 1861(jj) of the Social Security Act) for In10 dian women at a frequency appropriate to such 

11 women under accepted and appropriate national 

12 standards, and under such terms and conditions as 

13 are consistent with standards established by the Sec14 retary to ensure the safety and accuracy of screen15 ing mammography under part B of title XVIII of 

16 such Act. 

17 ‘‘(2) Other cancer screening that receives an A 

18 or B rating as recommended by the United States 

19 Preventive Services Task Force established under 

20 section 915(a)(1) of the Public Health Service Act 

21 (42 U.S.C. 299b–4(a)(1)). The Secretary shall en22 sure that screening provided for under this para23 graph complies with the recommendations of the 

24 Task Force with respect to— 

25 ‘‘(A) frequency; 
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1 ‘‘(B) the population to be served; 

2 ‘‘(C) the procedure or technology to be 

3 used; 

4 ‘‘(D) evidence of effectiveness; and 

5 ‘‘(E) other matters that the Secretary de6 termines appropriate. 

7 ‘‘SEC. 207. PATIENT TRAVEL COSTS. 

8 ‘‘(a) DEFINITION OF QUALIFIED ESCORT.—In this 

9 section, the term ‘qualified escort’ means— 

10 ‘‘(1) an adult escort (including a parent, guard11 ian, or other family member) who is required be12 cause of the physical or mental condition, or age, of 

13 the applicable patient; 

14 ‘‘(2) a health professional for the purpose of 

15 providing necessary medical care during travel by 

16 the applicable patient; or 

17 ‘‘(3) other escorts, as the Secretary or applica18 ble Indian Health Program determines to be appro19 priate. 

20 ‘‘(b) PROVISION OF FUNDS.—The Secretary, acting 

21 through the Service, is authorized to provide funds for the 

22 following patient travel costs, including qualified escorts, 

23 associated with receiving health care services provided (ei24 ther through direct or contract care or through a contract 

25 or compact under the Indian Self-Determination and Edu-
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1 cation Assistance Act (25 U.S.C. 450 et seq.)) under this 

2 Act— 

3 ‘‘(1) emergency air transportation and non4 emergency air transportation where ground trans5 portation is infeasible; 

6 ‘‘(2) transportation by private vehicle (where no 

7 other means of transportation is available), specially 

8 equipped vehicle, and ambulance; and 

9 ‘‘(3) transportation by such other means as 

10 may be available and required when air or motor ve11 hicle transportation is not available. 

12 ‘‘SEC. 208. EPIDEMIOLOGY CENTERS. 

13 ‘‘(a) ESTABLISHMENT OF CENTERS.—The Secretary 

14 shall establish an epidemiology center in each Service Area 

15 to carry out the functions described in subsection (b). Any 

16 new center established after the date of enactment of the 

17 Indian Health Care Improvement Act Amendments of 

18 2008 may be operated under a grant authorized by sub19 section (d), but funding under such a grant shall not be 

20 divisible. 

21 ‘‘(b) FUNCTIONS OF CENTERS.—In consultation with 

22 and upon the request of Indian Tribes, Tribal Organiza23 tions, and Urban Indian communities, each Service Area 

24 epidemiology center established under this section shall, 

25 with respect to such Service Area— 
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1 ‘‘(1) collect data relating to, and monitor 

2 progress made toward meeting, each of the health 

3 status objectives of the Service, the Indian Tribes, 

4 Tribal Organizations, and Urban Indian commu5 nities in the Service Area; 

6 ‘‘(2) evaluate existing delivery systems, data 

7 systems, and other systems that impact the improve8 ment of Indian health; 

9 ‘‘(3) assist Indian Tribes, Tribal Organizations, 

10 and Urban Indian Organizations in identifying their 

11 highest priority health status objectives and the 

12 services needed to achieve such objectives, based on 

13 epidemiological data; 

14 ‘‘(4) make recommendations for the targeting 

15 of services needed by the populations served; 

16 ‘‘(5) make recommendations to improve health 

17 care delivery systems for Indians and Urban Indi18 ans; 

19 ‘‘(6) provide requested technical assistance to 

20 Indian Tribes, Tribal Organizations, and Urban In21 dian Organizations in the development of local 

22 health service priorities and incidence and prevalence 

23 rates of disease and other illness in the community; 

24 and 
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1 ‘‘(7) provide disease surveillance and assist In2 dian Tribes, Tribal Organizations, and Urban Indian 

3 communities to promote public health. 

4 ‘‘(c) TECHNICAL ASSISTANCE.—The Director of the 

5 Centers for Disease Control and Prevention shall provide 

6 technical assistance to the centers in carrying out the re7 quirements of this section. 

8 ‘‘(d) GRANTS FOR STUDIES.— 

9 ‘‘(1) IN GENERAL.—The Secretary may make 

10 grants to Indian Tribes, Tribal Organizations, In11 dian organizations, and eligible intertribal consortia 

12 to conduct epidemiological studies of Indian commu13 nities. 

14 ‘‘(2) ELIGIBLE INTERTRIBAL CONSORTIA.—An 

15 intertribal consortium or Indian organization is eligi16 ble to receive a grant under this subsection if— 

17 ‘‘(A) the intertribal consortium is incor18 porated for the primary purpose of improving 

19 Indian health; and 

20 ‘‘(B) the intertribal consortium is rep21 resentative of the Indian Tribes or urban In22 dian communities in which the intertribal con23 sortium is located. 

24 ‘‘(3) APPLICATIONS.—An application for a 

25 grant under this subsection shall be submitted in 
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1 such manner and at such time as the Secretary shall 

2 prescribe. 

3 ‘‘(4) REQUIREMENTS.—An applicant for a 

4 grant under this subsection shall— 

5 ‘‘(A) demonstrate the technical, adminis6 trative, and financial expertise necessary to 

7 carry out the functions described in paragraph 

8 (5); 

9 ‘‘(B) consult and cooperate with providers 

10 of related health and social services in order to 

11 avoid duplication of existing services; and 

12 ‘‘(C) demonstrate cooperation from Indian 

13 Tribes or Urban Indian Organizations in the 

14 area to be served. 

15 ‘‘(5) USE OF FUNDS.—A grant awarded under 

16 paragraph (1) may be used— 

17 ‘‘(A) to carry out the functions described 

18 in subsection (b); 

19 ‘‘(B) to provide information to and consult 

20 with tribal leaders, urban Indian community 

21 leaders, and related health staff on health care 

22 and health service management issues; and 

23 ‘‘(C) in collaboration with Indian Tribes, 

24 Tribal Organizations, and urban Indian com25 munities, to provide the Service with informa-
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1 tion regarding ways to improve the health sta2 tus of Indians. 

3 ‘‘(e) ACCESS TO INFORMATION.— 

4 ‘‘(1) An epidemiology center operated by a 

5 grantee pursuant to a grant awarded under sub6 section (d) shall be treated as a public health au7 thority for purposes of the Health Insurance Port8 ability and Accountability Act of 1996, as such enti9 ties are defined in part 164.501 of title 45, Code of 

10 Federal Regulations. 

11 ‘‘(2) The Secretary shall grant to such epidemi12 ology center access to use of the data, data sets, 

13 monitoring systems, delivery systems, and other pro14 tected health information in the possession of the 

15 Secretary. 

16 ‘‘(3) The activities of such an epidemiology cen17 ter shall be for the purposes of research and for pre18 venting and controlling disease, injury, or disability 

19 for purposes of the Health Insurance Portability and 

20 Accountability Act of 1996 (Public Law 104–191; 

21 110 Stat. 2033), as such activities are described in 

22 part 164.512 of title 45, Code of Federal Regula23 tions (or a successor regulation). 

24 ‘‘(f) FUNDS NOT DIVISIBLE.—An epidemiology cen25 ter established under this section shall be subject to the 
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1 provisions of the Indian Self-Determination and Edu2 cation Assistance Act (25 U.S.C. 450 et seq.), but the 

3 funds for such center shall not be divisible. 

4 ‘‘SEC. 209. COMPREHENSIVE SCHOOL HEALTH EDUCATION 

5 PROGRAMS. 

6 ‘‘(a) FUNDING FOR DEVELOPMENT OF PROGRAMS.— 

7 In addition to carrying out any other program for health 

8 promotion or disease prevention, the Secretary, acting 

9 through the Service, is authorized to award grants to In10 dian Tribes and Tribal Organizations to develop com11 prehensive school health education programs for children 

12 from pre-school through grade 12 in schools for the benefit 

13 of Indian children. 

14 ‘‘(b) USE OF GRANT FUNDS.—A grant awarded 

15 under this section may be used for purposes which may 

16 include, but are not limited to, the following: 

17 ‘‘(1) Developing health education materials both 

18 for regular school programs and afterschool pro19 grams. 

20 ‘‘(2) Training teachers in comprehensive school 

21 health education materials. 

22 ‘‘(3) Integrating school-based, community23 based, and other public and private health promotion 

24 efforts. 
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1 ‘‘(4) Encouraging healthy, tobacco-free school 

2 environments. 

3 ‘‘(5) Coordinating school-based health programs 

4 with existing services and programs available in the 

5 community. 

6 ‘‘(6) Developing school programs on nutrition 

7 education, personal health, oral health, and fitness. 

8 ‘‘(7) Developing behavioral health wellness pro9 grams. 

10 ‘‘(8) Developing chronic disease prevention pro11 grams. 

12 ‘‘(9) Developing substance abuse prevention 

13 programs. 

14 ‘‘(10) Developing injury prevention and safety 

15 education programs. 

16 ‘‘(11) Developing activities for the prevention 

17 and control of communicable diseases. 

18 ‘‘(12) Developing community and environmental 

19 health education programs that include traditional 

20 health care practitioners. 

21 ‘‘(13) Violence prevention. 

22 ‘‘(14) Such other health issues as are appro23 priate. 

24 ‘‘(c) TECHNICAL ASSISTANCE.—Upon request, the 

25 Secretary, acting through the Service, shall provide tech-
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1 nical assistance to Indian Tribes and Tribal Organizations 

2 in the development of comprehensive health education 

3 plans and the dissemination of comprehensive health edu4 cation materials and information on existing health pro5 grams and resources. 

6 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP7 PLICATIONS.—The Secretary, acting through the Service, 

8 and in consultation with Indian Tribes and Tribal Organi9 zations, shall establish criteria for the review and approval 

10 of applications for grants awarded under this section. 

11 ‘‘(e) DEVELOPMENT OF PROGRAM FOR BIA-FUNDED

12 SCHOOLS.— 

13 ‘‘(1) IN GENERAL.—The Secretary of the Inte14 rior, acting through the Bureau of Indian Affairs 

15 and in cooperation with the Secretary, acting 

16 through the Service, shall develop a comprehensive 

17 school health education program for children from 

18 preschool through grade 12 in schools for which sup19 port is provided by the Bureau of Indian Affairs. 

20 ‘‘(2) REQUIREMENTS FOR PROGRAMS.—Such 

21 programs shall include— 

22 ‘‘(A) school programs on nutrition edu23 cation, personal health, oral health, and fitness; 

24 ‘‘(B) behavioral health wellness programs; 

25 ‘‘(C) chronic disease prevention programs; 
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1 ‘‘(D) substance abuse prevention pro2 grams; 

3 ‘‘(E) injury prevention and safety edu4 cation programs; and 

5 ‘‘(F) activities for the prevention and con6 trol of communicable diseases. 

7 ‘‘(3) DUTIES OF THE SECRETARY.—The Sec8 retary of the Interior shall— 

9 ‘‘(A) provide training to teachers in com10 prehensive school health education materials; 

11 ‘‘(B) ensure the integration and coordina12 tion of school-based programs with existing 

13 services and health programs available in the 

14 community; and 

15 ‘‘(C) encourage healthy, tobacco-free school 

16 environments. 

17 ‘‘SEC. 210. INDIAN YOUTH PROGRAM. 

18 ‘‘(a) PROGRAM AUTHORIZED.—The Secretary, acting 

19 through the Service, is authorized to establish and admin20 ister a program to provide grants to Indian Tribes, Tribal 

21 Organizations, and urban Indian organizations for innova22 tive mental and physical disease prevention and health 

23 promotion and treatment programs for Indian and urban 

24 Indian preadolescent and adolescent youths. 

25 ‘‘(b) USE OF FUNDS.— 
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1 ‘‘(1) ALLOWABLE USES.—Funds made available 

2 under this section may be used to— 

3 ‘‘(A) develop prevention and treatment 

4 programs for Indian youth which promote men5 tal and physical health and incorporate cultural 

6 values, community and family involvement, and 

7 traditional health care practitioners; and 

8 ‘‘(B) develop and provide community train9 ing and education. 

10 ‘‘(2) PROHIBITED USE.—Funds made available 

11 under this section may not be used to provide serv12 ices described in section 707(c). 

13 ‘‘(c) DUTIES OF THE SECRETARY.—The Secretary 

14 shall— 

15 ‘‘(1) disseminate to Indian Tribes, Tribal Orga16 nizations, and urban Indian organizations informa17 tion regarding models for the delivery of comprehen18 sive health care services to Indian and urban Indian 

19 adolescents; 

20 ‘‘(2) encourage the implementation of such 

21 models; and 

22 ‘‘(3) at the request of an Indian Tribe, Tribal 

23 Organization, or urban Indian organization, provide 

24 technical assistance in the implementation of such 

25 models. 
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1 ‘‘(d) CRITERIA FOR REVIEW AND APPROVAL OF AP2 PLICATIONS.—The Secretary, in consultation with Indian 

3 Tribes, Tribal Organizations, and urban Indian organiza4 tions, shall establish criteria for the review and approval 

5 of applications or proposals under this section. 

6 ‘‘SEC. 211. PREVENTION, CONTROL, AND ELIMINATION OF 

7 COMMUNICABLE AND INFECTIOUS DISEASES. 

8 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

9 through the Service, and after consultation with the Cen10 ters for Disease Control and Prevention, may make grants 

11 available to Indian Tribes, Tribal Organizations, and 

12 urban Indian organizations for the following: 

13 ‘‘(1) Projects for the prevention, control, and 

14 elimination of communicable and infectious diseases, 

15 including tuberculosis, hepatitis, HIV, respiratory 

16 syncytial virus, hanta virus, sexually transmitted dis17 eases, and H. Pylori. 

18 ‘‘(2) Public information and education pro19 grams for the prevention, control, and elimination of 

20 communicable and infectious diseases. 

21 ‘‘(3) Education, training, and clinical skills im22 provement activities in the prevention, control, and 

23 elimination of communicable and infectious diseases 

24 for health professionals, including allied health pro25 fessionals. 
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1 ‘‘(4) Demonstration projects for the screening, 

2 treatment, and prevention of hepatitis C virus 

3 (HCV). 

4 ‘‘(b) APPLICATION REQUIRED.—The Secretary may 

5 provide funding under subsection (a) only if an application 

6 or proposal for funding is submitted to the Secretary. 

7 ‘‘(c) COORDINATION WITH HEALTH AGENCIES.—In8 dian Tribes, Tribal Organizations, and urban Indian orga9 nizations receiving funding under this section are encour10 aged to coordinate their activities with the Centers for 

11 Disease Control and Prevention and State and local health 

12 agencies. 

13 ‘‘(d) TECHNICAL ASSISTANCE; REPORT.—In carrying 

14 out this section, the Secretary— 

15 ‘‘(1) may, at the request of an Indian Tribe, 

16 Tribal Organization, or urban Indian organization, 

17 provide technical assistance; and 

18 ‘‘(2) shall prepare and submit a report to Con19 gress biennially on the use of funds under this sec20 tion and on the progress made toward the preven21 tion, control, and elimination of communicable and 

22 infectious diseases among Indians and Urban Indi23 ans. 
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1 ‘‘SEC. 212. OTHER AUTHORITY FOR PROVISION OF SERV2 ICES. 

3 ‘‘(a) FUNDING AUTHORIZED.—The Secretary may 

4 provide funding under this Act to meet the objectives set 

5 forth in section 3 of this Act through health care-related 

6 services and programs of the Service, Indian Tribes, and 

7 Tribal Organizations not otherwise described in this Act 

8 for the following services: 

9 ‘‘(1) Hospice care. 

10 ‘‘(2) Assisted living services. 

11 ‘‘(3) Long-term care services. 

12 ‘‘(4) Home- and community-based services. 

13 ‘‘(b) ELIGIBILITY.—The following individuals shall be 

14 eligible to receive long-term care under this section: 

15 ‘‘(1) Individuals who are unable to perform a 

16 certain number of activities of daily living without 

17 assistance. 

18 ‘‘(2) Individuals with a mental impairment, 

19 such as dementia, Alzheimer’s disease, or another 

20 disabling mental illness, who may be able to perform 

21 activities of daily living under supervision. 

22 ‘‘(3) Such other individuals as an applicable In23 dian Health Program determines to be appropriate. 

24 ‘‘(c) DEFINITIONS.—For the purposes of this section, 

25 the following definitions shall apply: 
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1 ‘‘(1) The term ‘assisted living services’ means 

2 any service provided by an assisted living facility (as 

3 defined in section 232(b) of the National Housing 

4 Act (12 U.S.C. 1715w(b))), except that such an as5 sisted living facility— 

6 ‘‘(A) shall not be required to obtain a li7 cense; but 

8 ‘‘(B) shall meet all applicable standards 

9 for licensure. 

10 ‘‘(2) The term ‘home- and community-based 

11 services’ means 1 or more of the services specified 

12 in paragraphs (1) through (9) of section 1929(a) of 

13 the Social Security Act (42 U.S.C. 1396t(a)) 

14 (whether provided by the Service or by an Indian 

15 Tribe or Tribal Organization pursuant to the Indian 

16 Self-Determination and Education Assistance Act 

17 (25 U.S.C. 450 et seq.)) that are or will be provided 

18 in accordance with applicable standards. 

19 ‘‘(3) The term ‘hospice care’ means the items 

20 and services specified in subparagraphs (A) through 

21 (H) of section 1861(dd)(1) of the Social Security 

22 Act (42 U.S.C. 1395x(dd)(1)), and such other serv23 ices which an Indian Tribe or Tribal Organization 

24 determines are necessary and appropriate to provide 

25 in furtherance of this care. 
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1 ‘‘(4) The term ‘long-term care services’ has the 

2 meaning given the term ‘qualified long-term care 

3 services’ in section 7702B(c) of the Internal Rev4 enue Code of 1986. 

5 ‘‘(d) AUTHORIZATION OF CONVENIENT CARE SERV6 ICES.—The Secretary, acting through the Service, Indian 

7 Tribes, and Tribal Organizations, may also provide fund8 ing under this Act to meet the objectives set forth in sec9 tion 3 of this Act for convenient care services programs 

10 pursuant to section 306(c)(2)(A). 

11 ‘‘SEC. 213. INDIAN WOMEN’S HEALTH CARE. 

12 ‘‘The Secretary, acting through the Service and In13 dian Tribes, Tribal Organizations, and Urban Indian Or14 ganizations, shall monitor and improve the quality of 

15 health care for Indian women of all ages through the plan16 ning and delivery of programs administered by the Service, 

17 in order to improve and enhance the treatment models of 

18 care for Indian women. 

19 ‘‘SEC. 214. ENVIRONMENTAL AND NUCLEAR HEALTH HAZ20 ARDS. 

21 ‘‘(a) STUDIES AND MONITORING.—The Secretary 

22 and the Service shall conduct, in conjunction with other 

23 appropriate Federal agencies and in consultation with con24 cerned Indian Tribes and Tribal Organizations, studies 

25 and ongoing monitoring programs to determine trends in 
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1 the health hazards to Indian miners and to Indians on 

2 or near reservations and Indian communities as a result 

3 of environmental hazards which may result in chronic or 

4 life threatening health problems, such as nuclear resource 

5 development, petroleum contamination, and contamination 

6 of water source and of the food chain. Such studies shall 

7 include— 

8 ‘‘(1) an evaluation of the nature and extent of 

9 health problems caused by environmental hazards 

10 currently exhibited among Indians and the causes of 

11 such health problems; 

12 ‘‘(2) an analysis of the potential effect of ongo13 ing and future environmental resource development 

14 on or near reservations and Indian communities, in15 cluding the cumulative effect over time on health; 

16 ‘‘(3) an evaluation of the types and nature of 

17 activities, practices, and conditions causing or affect18 ing such health problems, including uranium mining 

19 and milling, uranium mine tailing deposits, nuclear 

20 power plant operation and construction, and nuclear 

21 waste disposal; oil and gas production or transpor22 tation on or near reservations or Indian commu23 nities; and other development that could affect the 

24 health of Indians and their water supply and food 

25 chain; 
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1 ‘‘(4) a summary of any findings and rec2 ommendations provided in Federal and State stud3 ies, reports, investigations, and inspections during 

4 the 5 years prior to the date of enactment of the In5 dian Health Care Improvement Act Amendments of 

6 2009 that directly or indirectly relate to the activi7 ties, practices, and conditions affecting the health or 

8 safety of such Indians; and 

9 ‘‘(5) the efforts that have been made by Federal 

10 and State agencies and resource and economic devel11 opment companies to effectively carry out an edu12 cation program for such Indians regarding the 

13 health and safety hazards of such development. 

14 ‘‘(b) HEALTH CARE PLANS.—Upon completion of 

15 such studies, the Secretary and the Service shall take into 

16 account the results of such studies and develop health care 

17 plans to address the health problems studied under sub18 section (a). The plans shall include— 

19 ‘‘(1) methods for diagnosing and treating Indi20 ans currently exhibiting such health problems; 

21 ‘‘(2) preventive care and testing for Indians 

22 who may be exposed to such health hazards, includ23 ing the monitoring of the health of individuals who 

24 have or may have been exposed to excessive amounts 

25 of radiation or affected by other activities that have 
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1 had or could have a serious impact upon the health 

2 of such individuals; and 

3 ‘‘(3) a program of education for Indians who, 

4 by reason of their work or geographic proximity to 

5 such nuclear or other development activities, may ex6 perience health problems. 

7 ‘‘(c) SUBMISSION OF REPORT AND PLAN TO CON8 GRESS.—The Secretary and the Service shall submit to 

9 Congress the study prepared under subsection (a) no later 

10 than 18 months after the date of enactment of the Indian 

11 Health Care Improvement Act Amendments of 2009. The 

12 health care plan prepared under subsection (b) shall be 

13 submitted in a report no later than 1 year after the study 

14 prepared under subsection (a) is submitted to Congress. 

15 Such report shall include recommended activities for the 

16 implementation of the plan, as well as an evaluation of 

17 any activities previously undertaken by the Service to ad18 dress such health problems. 

19 ‘‘(d) INTERGOVERNMENTAL TASK FORCE.— 

20 ‘‘(1) ESTABLISHMENT; MEMBERS.—There is es21 tablished an Intergovernmental Task Force to be 

22 composed of the following individuals (or their des23 ignees): 

24 ‘‘(A) The Secretary of Energy. 
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1 ‘‘(B) The Secretary of the Environmental 

2 Protection Agency. 

3 ‘‘(C) The Director of the Bureau of Mines. 

4 ‘‘(D) The Assistant Secretary for Occupa5 tional Safety and Health. 

6 ‘‘(E) The Secretary of the Interior. 

7 ‘‘(F) The Secretary of Health and Human 

8 Services. 

9 ‘‘(G) The Director of the Indian Health 

10 Service. 

11 ‘‘(2) DUTIES.—The Task Force shall— 

12 ‘‘(A) identify existing and potential oper13 ations related to nuclear resource development 

14 or other environmental hazards that affect or 

15 may affect the health of Indians on or near a 

16 reservation or in an Indian community; and 

17 ‘‘(B) enter into activities to correct exist18 ing health hazards and ensure that current and 

19 future health problems resulting from nuclear 

20 resource or other development activities are 

21 minimized or reduced. 

22 ‘‘(3) CHAIRMAN; MEETINGS.—The Secretary of 

23 Health and Human Services shall be the Chairman 

24 of the Task Force. The Task Force shall meet at 

25 least twice each year. 
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1 ‘‘(e) HEALTH SERVICES TO CERTAIN EMPLOYEES.— 

2 In the case of any Indian who— 

3 ‘‘(1) as a result of employment in or near a 

4 uranium mine or mill or near any other environ5 mental hazard, suffers from a work-related illness or 

6 condition; 

7 ‘‘(2) is eligible to receive diagnosis and treat8 ment services from an Indian Health Program; and 

9 ‘‘(3) by reason of such Indian’s employment, is 

10 entitled to medical care at the expense of such mine 

11 or mill operator or entity responsible for the environ12 mental hazard, the Indian Health Program shall, at 

13 the request of such Indian, render appropriate med14 ical care to such Indian for such illness or condition 

15 and may be reimbursed for any medical care so ren16 dered to which such Indian is entitled at the expense 

17 of such operator or entity from such operator or en18 tity. Nothing in this subsection shall affect the 

19 rights of such Indian to recover damages other than 

20 such amounts paid to the Indian Health Program 

21 from the employer for providing medical care for 

22 such illness or condition. 
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1 ‘‘SEC. 215. ARIZONA AS A CONTRACT HEALTH SERVICE DE2 LIVERY AREA. 

3 ‘‘(a) IN GENERAL.—For fiscal years beginning with 

4 the fiscal year ending September 30, 1983, and ending 

5 with the fiscal year ending September 30, 2025, the State 

6 of Arizona shall be designated as a contract health service 

7 delivery area by the Service for the purpose of providing 

8 contract health care services to members of federally rec9 ognized Indian Tribes of Arizona. 

10 ‘‘(b) MAINTENANCE OF SERVICES.—The Service 

11 shall not curtail any health care services provided to Indi12 ans residing on reservations in the State of Arizona if such 

13 curtailment is due to the provision of contract services in 

14 such State pursuant to the designation of such State as 

15 a contract health service delivery area pursuant to sub16 section (a). 

17 ‘‘SEC. 216. NORTH DAKOTA AND SOUTH DAKOTA AS CON18 TRACT HEALTH SERVICE DELIVERY AREA. 

19 ‘‘(a) IN GENERAL.—Beginning in fiscal year 2003, 

20 the States of North Dakota and South Dakota shall be 

21 designated as a contract health service delivery area by 

22 the Service for the purpose of providing contract health 

23 care services to members of federally recognized Indian 

24 Tribes of North Dakota and South Dakota. 

25 ‘‘(b) LIMITATION.—The Service shall not curtail any 

26 health care services provided to Indians residing on any 
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1 reservation, or in any county that has a common boundary 

2 with any reservation, in the State of North Dakota or 

3 South Dakota if such curtailment is due to the provision 

4 of contract services in such States pursuant to the des5 ignation of such States as a contract health service deliv6 ery area pursuant to subsection (a). 

7 ‘‘SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PRO8 GRAM. 

9 ‘‘(a) FUNDING AUTHORIZED.—The Secretary is au10 thorized to fund a program using an intertribal consor11 tium as a contract care intermediary to improve the acces12 sibility of health services to California Indians. 

13 ‘‘(b) REIMBURSEMENT CONTRACT.—The Secretary 

14 shall enter into an agreement with the intertribal consor15 tium to reimburse the intertribal consortium for costs (in16 cluding reasonable administrative costs) incurred pursu17 ant to this section, in providing medical treatment under 

18 contract to California Indians described in section 805(a) 

19 throughout the California contract health services delivery 

20 area described in section 219 with respect to high cost 

21 contract care cases. 

22 ‘‘(c) ADMINISTRATIVE EXPENSES.—Not more than 5 

23 percent of the amounts provided to the intertribal consor24 tium under this section for any fiscal year may be for re-
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1 imbursement for administrative expenses incurred by the 

2 intertribal consortium during such fiscal year. 

3 ‘‘(d) LIMITATION ON PAYMENT.—No payment may 

4 be made for treatment provided hereunder to the extent 

5 payment may be made for such treatment under the In6 dian Catastrophic Health Emergency Fund described in 

7 section 202 or from amounts appropriated or otherwise 

8 made available to the California contract health service de9 livery area for a fiscal year. 

10 ‘‘(e) ADVISORY BOARD.—There is established an ad11 visory board which shall advise the intertribal consortium 

12 in carrying out this section. The advisory board shall be 

13 composed of representatives, selected by the intertribal 

14 consortium, from not less than 8 Tribal Health Programs 

15 serving California Indians covered under this section at 

least 1 16 ⁄2 of whom are not affiliated with the intertribal con17 sortium. 

18 ‘‘SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE 

19 DELIVERY AREA. 

20 ‘‘The State of California, excluding the counties of 

21 Alameda, Contra Costa, Los Angeles, Marin, Orange, Sac22 ramento, San Francisco, San Mateo, Santa Clara, Kern, 

23 Merced, Monterey, Napa, San Benito, San Joaquin, San 

24 Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ven25 tura, shall be designated as a contract health service deliv-
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1 ery area by the Service for the purpose of providing con2 tract health services to California Indians. However, any 

3 of the counties listed herein may only be included in the 

4 contract health services delivery area if funding is specifi5 cally provided by the Service for such services in those 

6 counties. 

7 ‘‘SEC. 219. CONTRACT HEALTH SERVICES FOR THE TREN8 TON SERVICE AREA. 

9 ‘‘(a) AUTHORIZATION FOR SERVICES.—The Sec10 retary, acting through the Service, is directed to provide 

11 contract health services to members of the Turtle Moun12 tain Band of Chippewa Indians that reside in the Trenton 

13 Service Area of Divide, McKenzie, and Williams counties 

14 in the State of North Dakota and the adjoining counties 

15 of Richland, Roosevelt, and Sheridan in the State of Mon16 tana. 

17 ‘‘(b) NO EXPANSION OF ELIGIBILITY.—Nothing in 

18 this section may be construed as expanding the eligibility 

19 of members of the Turtle Mountain Band of Chippewa In20 dians for health services provided by the Service beyond 

21 the scope of eligibility for such health services that applied 

22 on May 1, 1986. 
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1 ‘‘SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND 

2 TRIBAL ORGANIZATIONS. 

3 ‘‘The Service shall provide funds for health care pro4 grams, functions, services, activities, information tech5 nology, and facilities operated by Tribal Health Programs 

6 on the same basis as such funds are provided to programs, 

7 functions, services, activities, information technology, and 

8 facilities operated directly by the Service. 

9 ‘‘SEC. 221. LICENSING. 

10 ‘‘Licensed health care professionals employed by a 

11 Tribal Health Program shall, if licensed in any State, be 

12 exempt from the licensing requirements of the State in 

13 which the Tribal Health Program performs the services 

14 described in its contract or compact under the Indian Self15 Determination and Education Assistance Act (25 U.S.C. 

16 450 et seq.) while performing such services. 

17 ‘‘SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY 

18 CONTRACT HEALTH SERVICES. 

19 ‘‘With respect to an elderly Indian or an Indian with 

20 a disability receiving emergency medical care or services 

21 from a non-Service provider or in a non-Service facility 

22 under the authority of this Act, the time limitation (as 

23 a condition of payment) for notifying the Service of such 

24 treatment or admission shall be 30 days. 
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1 ‘‘SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS. 

2 ‘‘(a) DEADLINE FOR RESPONSE.—The Service shall 

3 respond to a notification of a claim by a provider of a 

4 contract care service with either an individual purchase 

5 order or a denial of the claim within 5 working days after 

6 the receipt of such notification. 

7 ‘‘(b) EFFECT OF UNTIMELY RESPONSE.—If the 

8 Service fails to respond to a notification of a claim in ac9 cordance with subsection (a), the Service shall accept as 

10 valid the claim submitted by the provider of a contract 

11 care service. 

12 ‘‘(c) DEADLINE FOR PAYMENT OF VALID CLAIM.— 

13 The Service shall pay a valid contract care service claim 

14 within 30 days after the completion of the claim. 

15 ‘‘SEC. 224. LIABILITY FOR PAYMENT. 

16 ‘‘(a) NO PATIENT LIABILITY.—A patient who re17 ceives contract health care services that are authorized by 

18 the Service shall not be liable for the payment of any 

19 charges or costs associated with the provision of such serv20 ices. 

21 ‘‘(b) NOTIFICATION.—The Secretary shall notify a 

22 contract care provider and any patient who receives con23 tract health care services authorized by the Service that 

24 such patient is not liable for the payment of any charges 

25 or costs associated with the provision of such services not 
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1 later than 5 business days after receipt of a notification 

2 of a claim by a provider of contract care services. 

3 ‘‘(c) NO RECOURSE.—Following receipt of the notice 

4 provided under subsection (b), or, if a claim has been 

5 deemed accepted under section 224(b), the provider shall 

6 have no further recourse against the patient who received 

7 the services. 

8 ‘‘SEC. 225. OFFICE OF INDIAN MEN’S HEALTH. 

9 ‘‘(a) ESTABLISHMENT.—The Secretary may establish 

10 within the Service an office to be known as the ‘Office 

11 of Indian Men’s Health’ (referred to in this section as the 

12 ‘Office’). 

13 ‘‘(b) DIRECTOR.— 

14 ‘‘(1) IN GENERAL.—The Office shall be headed 

15 by a director, to be appointed by the Secretary. 

16 ‘‘(2) DUTIES.—The director shall coordinate 

17 and promote the status of the health of Indian men 

18 in the United States. 

19 ‘‘(c) REPORT.—Not later than 2 years after the date 

20 of enactment of the Indian Health Care Improvement Act 

21 Amendments of 2009, the Secretary, acting through the 

22 director of the Office, shall submit to Congress a report 

23 describing— 

24 ‘‘(1) any activity carried out by the director as 

25 of the date on which the report is prepared; and 
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1 ‘‘(2) any finding of the director with respect to 

2 the health of Indian men. 

3 ‘‘SEC. 226. CATASTROPHIC HEALTH EMERGENCY FUND. 

4 ‘‘(a) ESTABLISHMENT.—There is established an In5 dian Catastrophic Health Emergency Fund (hereafter in 

6 this section referred to as the ‘CHEF’) consisting of— 

7 ‘‘(1) the amounts deposited under subsection 

8 (f); and 

9 ‘‘(2) the amounts appropriated to CHEF under 

10 this section. 

11 ‘‘(b) ADMINISTRATION.—CHEF shall be adminis12 tered by the Secretary, acting through the headquarters 

13 of the Service, solely for the purpose of meeting the ex14 traordinary medical costs associated with the treatment of 

15 victims of disasters or catastrophic illnesses who are with16 in the responsibility of the Service. 

17 ‘‘(c) CONDITIONS ON USE OF FUND.—No part of 

18 CHEF or its administration shall be subject to contract 

19 or grant under any law, including the Indian Self-Deter20 mination and Education Assistance Act (25 U.S.C. 450 

21 et seq.), nor shall CHEF funds be allocated, apportioned, 

22 or delegated on an Area Office, Service Unit, or other 

23 similar basis. 
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1 ‘‘(d) REGULATIONS.—The Secretary shall promul2 gate regulations consistent with the provisions of this sec3 tion to— 

4 ‘‘(1) establish a definition of disasters and cata5 strophic illnesses for which the cost of the treatment 

6 provided under contract would qualify for payment 

7 from CHEF; 

8 ‘‘(2) provide that a Service Unit shall not be el9 igible for reimbursement for the cost of treatment 

10 from CHEF until its cost of treating any victim of 

11 such catastrophic illness or disaster has reached a 

12 certain threshold cost which the Secretary shall es13 tablish at— 

14 ‘‘(A) the 2000 level of $19,000; and 

15 ‘‘(B) for any subsequent year, not less 

16 than the threshold cost of the previous year in17 creased by the percentage increase in the med18 ical care expenditure category of the consumer 

19 price index for all urban consumers (United 

20 States city average) for the 12-month period 

21 ending with December of the previous year; 

22 ‘‘(3) establish a procedure for the reimburse23 ment of the portion of the costs that exceeds such 

24 threshold cost incurred by— 

25 ‘‘(A) Service Units; or 
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1 ‘‘(B) whenever otherwise authorized by the 

2 Service, non-Service facilities or providers; 

3 ‘‘(4) establish a procedure for payment from 

4 CHEF in cases in which the exigencies of the med5 ical circumstances warrant treatment prior to the 

6 authorization of such treatment by the Service; and 

7 ‘‘(5) establish a procedure that will ensure that 

8 no payment shall be made from CHEF to any pro9 vider of treatment to the extent that such provider 

10 is eligible to receive payment for the treatment from 

11 any other Federal, State, local, or private source of 

12 reimbursement for which the patient is eligible. 

13 ‘‘(e) NO OFFSET OR LIMITATION.—Amounts appro14 priated to CHEF under this section shall not be used to 

15 offset or limit appropriations made to the Service under 

16 the authority of the Act of November 2, 1921 (25 U.S.C. 

17 13) (commonly known as the ‘Snyder Act’), or any other 

18 law. 

19 ‘‘(f) DEPOSIT OF REIMBURSEMENT FUNDS.—There 

20 shall be deposited into CHEF all reimbursements to which 

21 the Service is entitled from any Federal, State, local, or 

22 private source (including third party insurance) by reason 

23 of treatment rendered to any victim of a disaster or cata24 strophic illness the cost of which was paid from CHEF. 
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1 ‘‘SEC. 227. AUTHORIZATION OF APPROPRIATIONS. 

2 ‘‘There are authorized to be appropriated such sums 

3 as may be necessary to carry out this title. 

4 ‘‘TITLE III—FACILITIES 

5 ‘‘SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVA6 TION OF FACILITIES; REPORTS. 

7 ‘‘(a) PREREQUISITES FOR EXPENDITURE OF

8 FUNDS.—Prior to the expenditure of, or the making of 

9 any binding commitment to expend, any funds appro10 priated for the planning, design, construction, or renova11 tion of facilities pursuant to the Act of November 2, 1921 

12 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

13 the Secretary, acting through the Service, shall— 

14 ‘‘(1) consult with any Indian Tribe that would 

15 be significantly affected by such expenditure for the 

16 purpose of determining and, whenever practicable, 

17 honoring tribal preferences concerning size, location, 

18 type, and other characteristics of any facility on 

19 which such expenditure is to be made; and 

20 ‘‘(2) ensure, whenever practicable and applica21 ble, that such facility meets the construction stand22 ards of any accrediting body recognized by the Sec23 retary for the purposes of the Medicare, Medicaid, 

24 and SCHIP programs under titles XVIII, XIX, and 

25 XXI of the Social Security Act by not later than 1 
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1 year after the date on which the construction or ren2 ovation of such facility is completed. 

3 ‘‘(b) CLOSURES.— 

4 ‘‘(1) EVALUATION REQUIRED.—Notwith5 standing any other provision of law, no facility oper6 ated by the Service may be closed if the Secretary 

7 has not submitted to Congress, not less than 1 year 

8 and not more than 2 years before the date of the 

9 proposed closure, an evaluation, completed not more 

10 than 2 years before such submission, of the impact 

11 of the proposed closure that specifies, in addition to 

12 other considerations— 

13 ‘‘(A) the accessibility of alternative health 

14 care resources for the population served by such 

15 facility; 

16 ‘‘(B) the cost-effectiveness of such closure; 

17 ‘‘(C) the quality of health care to be pro18 vided to the population served by such facility 

19 after such closure; 

20 ‘‘(D) the availability of contract health 

21 care funds to maintain existing levels of service; 

22 ‘‘(E) the views of the Indian Tribes served 

23 by such facility concerning such closure; 

24 ‘‘(F) the level of use of such facility by all 

25 eligible Indians; and 
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1 ‘‘(G) the distance between such facility and 

2 the nearest operating Service hospital. 

3 ‘‘(2) EXCEPTION FOR CERTAIN TEMPORARY

4 CLOSURES.—Paragraph (1) shall not apply to any 

5 temporary closure of a facility or any portion of a 

6 facility if such closure is necessary for medical, envi7 ronmental, or construction safety reasons. 

8 ‘‘(c) HEALTH CARE FACILITY PRIORITY SYSTEM.— 

9 ‘‘(1) IN GENERAL.— 

10 ‘‘(A) PRIORITY SYSTEM.—The Secretary, 

11 acting through the Service, shall maintain a 

12 health care facility priority system, which— 

13 ‘‘(i) shall be developed in consultation 

14 with Indian Tribes and Tribal Organiza15 tions; 

16 ‘‘(ii) shall give Indian Tribes’ needs 

17 the highest priority; 

18 ‘‘(iii)(I) may include the lists required 

19 in paragraph (2)(B)(ii); and 

20 ‘‘(II) shall include the methodology re21 quired in paragraph (2)(B)(v); and 

22 ‘‘(III) may include such other facili23 ties, and such renovation or expansion 

24 needs of any health care facility, as the 
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1 Service, Indian Tribes, and Tribal Organi2 zations may identify; and 

3 ‘‘(iv) shall provide an opportunity for 

4 the nomination of planning, design, and 

5 construction projects by the Service, In6 dian Tribes, and Tribal Organizations for 

7 consideration under the priority system at 

8 least once every 3 years, or more fre9 quently as the Secretary determines to be 

10 appropriate. 

11 ‘‘(B) NEEDS OF FACILITIES UNDER

12 ISDEAA AGREEMENTS.—The Secretary shall en13 sure that the planning, design, construction, 

14 renovation, and expansion needs of Service and 

15 non-Service facilities operated under contracts 

16 or compacts in accordance with the Indian Self17 Determination and Education Assistance Act 

18 (25 U.S.C. 450 et seq.) are fully and equitably 

19 integrated into the health care facility priority 

20 system. 

21 ‘‘(C) CRITERIA FOR EVALUATING

22 NEEDS.—For purposes of this subsection, the 

23 Secretary, in evaluating the needs of facilities 

24 operated under a contract or compact under the 

25 Indian Self-Determination and Education As-
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1 sistance Act (25 U.S.C. 450 et seq.), shall use 

2 the criteria used by the Secretary in evaluating 

3 the needs of facilities operated directly by the 

4 Service. 

5 ‘‘(D) PRIORITY OF CERTAIN PROJECTS

6 PROTECTED.—The priority of any project estab7 lished under the construction priority system in 

8 effect on the date of enactment of the Indian 

9 Health Care Improvement Act Amendments of 

10 2009 shall not be affected by any change in the 

11 construction priority system taking place after 

12 that date if the project— 

13 ‘‘(i) was identified in the fiscal year 

14 2008 Service budget justification as— 

15 ‘‘(I) 1 of the 10 top-priority inpa16 tient projects; 

17 ‘‘(II) 1 of the 10 top-priority out18 patient projects; 

19 ‘‘(III) 1 of the 10 top-priority 

20 staff quarters developments; or 

21 ‘‘(IV) 1 of the 10 top-priority 

22 Youth Regional Treatment Centers; 

23 ‘‘(ii) had completed both Phase I and 

24 Phase II of the construction priority sys-
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1 tem in effect on the date of enactment of 

2 such Act; or 

3 ‘‘(iii) is not included in clause (i) or 

4 (ii) and is selected, as determined by the 

5 Secretary— 

6 ‘‘(I) on the initiative of the Sec7 retary; or 

8 ‘‘(II) pursuant to a request of an 

9 Indian Tribe or Tribal Organization. 

10 ‘‘(2) REPORT; CONTENTS.— 

11 ‘‘(A) INITIAL COMPREHENSIVE REPORT.— 

12 ‘‘(i) DEFINITIONS.—In this subpara13 graph: 

14 ‘‘(I) FACILITIES APPROPRIATION

15 ADVISORY BOARD.—The term ‘Facili16 ties Appropriation Advisory Board’ 

17 means the advisory board, comprised 

18 of 12 members representing Indian 

19 tribes and 2 members representing 

20 the Service, established at the discre21 tion of the Assistant Secretary— 

22 ‘‘(aa) to provide advice and 

23 recommendations for policies and 

24 procedures of the programs fund-
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1 ed pursuant to facilities appro2 priations; and 

3 ‘‘(bb) to address other facili4 ties issues. 

5 ‘‘(II) FACILITIES NEEDS ASSESS6 MENT WORKGROUP.—The term ‘Fa7 cilities Needs Assessment Workgroup’ 

8 means the workgroup established at 

9 the discretion of the Assistant Sec10 retary— 

11 ‘‘(aa) to review the health 

12 care facilities construction pri13 ority system; and 

14 ‘‘(bb) to make recommenda15 tions to the Facilities Appropria16 tion Advisory Board for revising 

17 the priority system. 

18 ‘‘(ii) INITIAL REPORT.— 

19 ‘‘(I) IN GENERAL.—Not later 

20 than 1 year after the date of enact21 ment of the Indian Health Care Im22 provement Act Amendments of 2009, 

23 the Secretary shall submit to the 

24 Committee on Indian Affairs of the 

25 Senate and the Committee on Natural 
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1 Resources of the House of Represent2 atives a report that describes the com3 prehensive, national, ranked list of all 

4 health care facilities needs for the 

5 Service, Indian Tribes, and Tribal Or6 ganizations (including inpatient health 

7 care facilities, outpatient health care 

8 facilities, specialized health care facili9 ties (such as for long-term care and 

10 alcohol and drug abuse treatment), 

11 wellness centers, staff quarters and 

12 hostels associated with health care fa13 cilities, and the renovation and expan14 sion needs, if any, of such facilities) 

15 developed by the Service, Indian 

16 Tribes, and Tribal Organizations for 

17 the Facilities Needs Assessment 

18 Workgroup and the Facilities Appro19 priation Advisory Board. 

20 ‘‘(II) INCLUSIONS.—The initial 

21 report shall include— 

22 ‘‘(aa) the methodology and 

23 criteria used by the Service in de24 termining the needs and estab-
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1 lishing the ranking of the facili2 ties needs; and 

3 ‘‘(bb) such other information 

4 as the Secretary determines to be 

5 appropriate. 

6 ‘‘(iii) UPDATES OF REPORT.—Begin7 ning in calendar year 2011, the Secretary 

8 shall— 

9 ‘‘(I) update the report under 

10 clause (ii) not less frequently that 

11 once every 5 years; and 

12 ‘‘(II) include the updated report 

13 in the appropriate annual report 

14 under subparagraph (B) for submis15 sion to Congress under section 801. 

16 ‘‘(B) ANNUAL REPORTS.—The Secretary 

17 shall submit to the President, for inclusion in 

18 the report required to be transmitted to Con19 gress under section 801, a report which sets 

20 forth the following: 

21 ‘‘(i) A description of the health care 

22 facility priority system of the Service es23 tablished under paragraph (1). 

24 ‘‘(ii) Health care facilities lists, which 

25 may include— 
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1 ‘‘(I) the 10 top-priority inpatient 

2 health care facilities; 

3 ‘‘(II) the 10 top-priority out4 patient health care facilities; 

5 ‘‘(III) the 10 top-priority special6 ized health care facilities (such as 

7 long-term care and alcohol and drug 

8 abuse treatment); 

9 ‘‘(IV) the 10 top-priority staff 

10 quarters developments associated with 

11 health care facilities; and 

12 ‘‘(V) the 10 top-priority hostels 

13 associated with health care facilities. 

14 ‘‘(iii) The justification for such order 

15 of priority. 

16 ‘‘(iv) The projected cost of such 

17 projects. 

18 ‘‘(v) The methodology adopted by the 

19 Service in establishing priorities under its 

20 health care facility priority system. 

21 ‘‘(3) REQUIREMENTS FOR PREPARATION OF RE22 PORTS.—In preparing the report required under 

23 paragraph (2), the Secretary shall— 

24 ‘‘(A) consult with and obtain information 

25 on all health care facilities needs from Indian 
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1 Tribes, Tribal Organizations, and urban Indian 

2 organizations; and 

3 ‘‘(B) review the total unmet needs of all 

4 Indian Tribes, Tribal Organizations, and urban 

5 Indian organizations for health care facilities 

6 (including hostels and staff quarters), including 

7 needs for renovation and expansion of existing 

8 facilities. 

9 ‘‘(d) REVIEW OF METHODOLOGY USED FOR HEALTH

10 FACILITIES CONSTRUCTION PRIORITY SYSTEM.— 

11 ‘‘(1) IN GENERAL.—Not later than 1 year after 

12 the establishment of the priority system under sub13 section (c)(1)(A), the Comptroller General of the 

14 United States shall prepare and finalize a report re15 viewing the methodologies applied, and the processes 

16 followed, by the Service in making each assessment 

17 of needs for the list under subsection (c)(2)(A)(ii) 

18 and developing the priority system under subsection 

19 (c)(1), including a review of— 

20 ‘‘(A) the recommendations of the Facilities 

21 Appropriation Advisory Board and the Facili22 ties Needs Assessment Workgroup (as those 

23 terms are defined in subsection (c)(2)(A)(i)); 

24 and 
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1 ‘‘(B) the relevant criteria used in ranking 

2 or prioritizing facilities other than hospitals or 

3 clinics. 

4 ‘‘(2) SUBMISSION TO CONGRESS.—The Comp5 troller General of the United States shall submit the 

6 report under paragraph (1) to— 

7 ‘‘(A) the Committees on Indian Affairs and 

8 Appropriations of the Senate; 

9 ‘‘(B) the Committees on Natural Re10 sources and Appropriations of the House of 

11 Representatives; and 

12 ‘‘(C) the Secretary. 

13 ‘‘(e) FUNDING CONDITION.—All funds appropriated 

14 under the Act of November 2, 1921 (25 U.S.C. 13) (com15 monly known as the ‘Snyder Act’), for the planning, de16 sign, construction, or renovation of health facilities for the 

17 benefit of 1 or more Indian Tribes shall be subject to the 

18 provisions of the Indian Self-Determination and Edu19 cation Assistance Act (25 U.S.C. 450 et seq.). 

20 ‘‘(f) DEVELOPMENT OF INNOVATIVE APPROACHES.— 

21 The Secretary shall consult and cooperate with Indian 

22 Tribes, Tribal Organizations, and urban Indian organiza23 tions in developing innovative approaches to address all 

24 or part of the total unmet need for construction of health 
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1 facilities, including those provided for in other sections of 

2 this title and other approaches. 

3 ‘‘SEC. 302. SANITATION FACILITIES. 

4 ‘‘(a) FINDINGS.—Congress finds the following: 

5 ‘‘(1) The provision of sanitation facilities is pri6 marily a health consideration and function. 

7 ‘‘(2) Indian people suffer an inordinately high 

8 incidence of disease, injury, and illness directly at9 tributable to the absence or inadequacy of sanitation 

10 facilities. 

11 ‘‘(3) The long-term cost to the United States of 

12 treating and curing such disease, injury, and illness 

13 is substantially greater than the short-term cost of 

14 providing sanitation facilities and other preventive 

15 health measures. 

16 ‘‘(4) Many Indian homes and Indian commu17 nities still lack sanitation facilities. 

18 ‘‘(5) It is in the interest of the United States, 

19 and it is the policy of the United States, that all In20 dian communities and Indian homes, new and exist21 ing, be provided with sanitation facilities. 

22 ‘‘(b) FACILITIES AND SERVICES.—In furtherance of 

23 the findings made in subsection (a), Congress reaffirms 

24 the primary responsibility and authority of the Service to 

25 provide the necessary sanitation facilities and services as 
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1 provided in section 7 of the Act of August 5, 1954 (42 

2 U.S.C. 2004a). Under such authority, the Secretary, act3 ing through the Service, is authorized to provide the fol4 lowing: 

5 ‘‘(1) Financial and technical assistance to In6 dian Tribes, Tribal Organizations, and Indian com7 munities in the establishment, training, and equip8 ping of utility organizations to operate and maintain 

9 sanitation facilities, including the provision of exist10 ing plans, standard details, and specifications avail11 able in the Department, to be used at the option of 

12 the Indian Tribe, Tribal Organization, or Indian 

13 community. 

14 ‘‘(2) Ongoing technical assistance and training 

15 to Indian Tribes, Tribal Organizations, and Indian 

16 communities in the management of utility organiza17 tions which operate and maintain sanitation facili18 ties. 

19 ‘‘(3) Priority funding for operation and mainte20 nance assistance for, and emergency repairs to, sani21 tation facilities operated by an Indian Tribe, Tribal 

22 Organization or Indian community when necessary 

23 to avoid an imminent health threat or to protect the 

24 investment in sanitation facilities and the investment 
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1 in the health benefits gained through the provision 

2 of sanitation facilities. 

3 ‘‘(c) FUNDING.—Notwithstanding any other provi4 sion of law— 

5 ‘‘(1) the Secretary of Housing and Urban De6 velopment is authorized to transfer funds appro7 priated under the Native American Housing Assist8 ance and Self-Determination Act of 1996 (25 U.S.C. 

9 4101 et seq.) to the Secretary of Health and Human 

10 Services; 

11 ‘‘(2) the Secretary of Health and Human Serv12 ices is authorized to accept and use such funds for 

13 the purpose of providing sanitation facilities and 

14 services for Indians under section 7 of the Act of 

15 August 5, 1954 (42 U.S.C. 2004a); 

16 ‘‘(3) unless specifically authorized when funds 

17 are appropriated, the Secretary shall not use funds 

18 appropriated under section 7 of the Act of August 

19 5, 1954 (42 U.S.C. 2004a), to provide sanitation fa20 cilities to new homes constructed using funds pro21 vided by the Department of Housing and Urban De22 velopment; 

23 ‘‘(4) the Secretary of Health and Human Serv24 ices is authorized to accept from any source, includ25 ing Federal and State agencies, funds for the pur-
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1 pose of providing sanitation facilities and services 

2 and place these funds into contracts or compacts 

3 under the Indian Self-Determination and Education 

4 Assistance Act (25 U.S.C. 450 et seq.); 

5 ‘‘(5) except as otherwise prohibited by this sec6 tion, the Secretary may use funds appropriated 

7 under the authority of section 7 of the Act of Au8 gust 5, 1954 (42 U.S.C. 2004a), to fund up to 100 

9 percent of the amount of an Indian Tribe’s loan ob10 tained under any Federal program for new projects 

11 to construct eligible sanitation facilities to serve In12 dian homes; 

13 ‘‘(6) except as otherwise prohibited by this sec14 tion, the Secretary may use funds appropriated 

15 under the authority of section 7 of the Act of Au16 gust 5, 1954 (42 U.S.C. 2004a), to meet matching 

17 or cost participation requirements under other Fed18 eral and non-Federal programs for new projects to 

19 construct eligible sanitation facilities; 

20 ‘‘(7) all Federal agencies are authorized to 

21 transfer to the Secretary funds identified, granted, 

22 loaned, or appropriated whereby the Department’s 

23 applicable policies, rules, and regulations shall apply 

24 in the implementation of such projects; 
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1 ‘‘(8) the Secretary of Health and Human Serv2 ices shall enter into interagency agreements with 

3 Federal and State agencies for the purpose of pro4 viding financial assistance for sanitation facilities 

5 and services under this Act; 

6 ‘‘(9) the Secretary of Health and Human Serv7 ices shall, by regulation, establish standards applica8 ble to the planning, design, and construction of sani9 tation facilities funded under this Act; and 

10 ‘‘(10) the Secretary of Health and Human 

11 Services is authorized to accept payments for goods 

12 and services furnished by the Service from appro13 priate public authorities, nonprofit organizations or 

14 agencies, or Indian Tribes, as contributions by that 

15 authority, organization, agency, or tribe to agree16 ments made under section 7 of the Act of August 5, 

17 1954 (42 U.S.C. 2004a), and such payments shall 

18 be credited to the same or subsequent appropriation 

19 account as funds appropriated under the authority 

20 of section 7 of the Act of August 5, 1954 (42 U.S.C. 

21 2004a). 

22 ‘‘(d) CERTAIN CAPABILITIES NOT PREREQUISITE.— 

23 The financial and technical capability of an Indian Tribe, 

24 Tribal Organization, or Indian community to safely oper25 ate, manage, and maintain a sanitation facility shall not 
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1 be a prerequisite to the provision or construction of sanita2 tion facilities by the Secretary. 

3 ‘‘(e) FINANCIAL ASSISTANCE.—The Secretary is au4 thorized to provide financial assistance to Indian Tribes, 

5 Tribal Organizations, and Indian communities in an 

6 amount equal to the Federal share of the costs of oper7 ating, managing, and maintaining the facilities provided 

8 under the plan described in subsection (h)(1)(F). 

9 ‘‘(f) OPERATION, MANAGEMENT, AND MAINTENANCE

10 OF FACILITIES.—The Indian Tribe has the primary re11 sponsibility to establish, collect, and use reasonable user 

12 fees, or otherwise set aside funding, for the purpose of 

13 operating, managing, and maintaining sanitation facilities. 

14 If a sanitation facility serving a community that is oper15 ated by an Indian Tribe or Tribal Organization is threat16 ened with imminent failure and such operator lacks capac17 ity to maintain the integrity or the health benefits of the 

18 sanitation facility, then the Secretary is authorized to as19 sist the Indian Tribe, Tribal Organization, or Indian com20 munity in the resolution of the problem on a short-term 

21 basis through cooperation with the emergency coordinator 

22 or by providing operation, management, and maintenance 

23 service. 

24 ‘‘(g) ISDEAA PROGRAM FUNDED ON EQUAL

25 BASIS.—Tribal Health Programs shall be eligible (on an 
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1 equal basis with programs that are administered directly 

2 by the Service) for— 

3 ‘‘(1) any funds appropriated pursuant to this 

4 section; and 

5 ‘‘(2) any funds appropriated for the purpose of 

6 providing sanitation facilities. 

7 ‘‘(h) REPORT.— 

8 ‘‘(1) REQUIRED; CONTENTS.—The Secretary, in 

9 consultation with the Secretary of Housing and 

10 Urban Development, Indian Tribes, Tribal Organiza11 tions, and tribally designated housing entities (as de12 fined in section 4 of the Native American Housing 

13 Assistance and Self-Determination Act of 1996 (25 

14 U.S.C. 4103)) shall submit to the President, for in15 clusion in the report required to be transmitted to 

16 Congress under section 801, a report which sets 

17 forth— 

18 ‘‘(A) the current Indian sanitation facility 

19 priority system of the Service; 

20 ‘‘(B) the methodology for determining 

21 sanitation deficiencies and needs; 

22 ‘‘(C) the criteria on which the deficiencies 

23 and needs will be evaluated; 

24 ‘‘(D) the level of initial and final sanitation 

25 deficiency for each type of sanitation facility for 
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1 each project of each Indian Tribe or Indian 

2 community; 

3 ‘‘(E) the amount and most effective use of 

4 funds, derived from whatever source, necessary 

5 to accommodate the sanitation facilities needs 

6 of new homes assisted with funds under the 

7 Native American Housing Assistance and Self8 Determination Act (25 U.S.C. 4101 et seq.), 

9 and to reduce the identified sanitation defi10 ciency levels of all Indian Tribes and Indian 

11 communities to level I sanitation deficiency as 

12 defined in paragraph (3)(A); and 

13 ‘‘(F) a 10-year plan to provide sanitation 

14 facilities to serve existing Indian homes and In15 dian communities and new and renovated In16 dian homes. 

17 ‘‘(2) UNIFORM METHODOLOGY.—The method18 ology used by the Secretary in determining, pre19 paring cost estimates for, and reporting sanitation 

20 deficiencies for purposes of paragraph (1) shall be 

21 applied uniformly to all Indian Tribes and Indian 

22 communities. 

23 ‘‘(3) SANITATION DEFICIENCY LEVELS.—For 

24 purposes of this subsection, the sanitation deficiency 

25 levels for an individual, Indian Tribe, or Indian com-
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1 munity sanitation facility to serve Indian homes are 

2 determined as follows: 

3 ‘‘(A) A level I deficiency exists if a sanita4 tion facility serving an individual, Indian Tribe, 

5 or Indian community— 

6 ‘‘(i) complies with all applicable water 

7 supply, pollution control, and solid waste 

8 disposal laws; and 

9 ‘‘(ii) deficiencies relate to routine re10 placement, repair, or maintenance needs. 

11 ‘‘(B) A level II deficiency exists if a sanita12 tion facility serving an individual, Indian Tribe, 

13 or Indian community substantially or recently 

14 complied with all applicable water supply, pollu15 tion control, and solid waste laws and any defi16 ciencies relate to— 

17 ‘‘(i) small or minor capital improve18 ments needed to bring the facility back 

19 into compliance; 

20 ‘‘(ii) capital improvements that are 

21 necessary to enlarge or improve the facili22 ties in order to meet the current needs for 

23 domestic sanitation facilities; or 

24 ‘‘(iii) the lack of equipment or train25 ing by an Indian Tribe, Tribal Organiza-
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•HR 3962 EH

1 tion, or an Indian community to properly 

2 operate and maintain the sanitation facili3 ties. 

4 ‘‘(C) A level III deficiency exists if a sani5 tation facility serving an individual, Indian 

6 Tribe or Indian community meets 1 or more of 

7 the following conditions— 

8 ‘‘(i) water or sewer service in the 

9 home is provided by a haul system with 

10 holding tanks and interior plumbing; 

11 ‘‘(ii) major significant interruptions to 

12 water supply or sewage disposal occur fre13 quently, requiring major capital improve14 ments to correct the deficiencies; or 

15 ‘‘(iii) there is no access to or no ap16 proved or permitted solid waste facility 

17 available. 

18 ‘‘(D) A level IV deficiency exists— 

19 ‘‘(i) if a sanitation facility for an indi20 vidual home, an Indian Tribe, or an Indian 

21 community exists but— 

22 ‘‘(I) lacks— 

23 ‘‘(aa) a safe water supply 

24 system; or 
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•HR 3962 EH

1 ‘‘(bb) a waste disposal sys2 tem; 

3 ‘‘(II) contains no piped water or 

4 sewer facilities; or 

5 ‘‘(III) has become inoperable due 

6 to a major component failure; or 

7 ‘‘(ii) if only a washeteria or central fa8 cility exists in the community. 

9 ‘‘(E) A level V deficiency exists in the ab10 sence of a sanitation facility, where individual 

11 homes do not have access to safe drinking 

12 water or adequate wastewater (including sew13 age) disposal. 

14 ‘‘(i) DEFINITIONS.—For purposes of this section, the 

15 following terms apply: 

16 ‘‘(1) INDIAN COMMUNITY.—The term ‘Indian 

17 community’ means a geographic area, a significant 

18 proportion of whose inhabitants are Indians and 

19 which is served by or capable of being served by a 

20 facility described in this section. 

21 ‘‘(2) SANITATION FACILITIES.—The terms 

22 ‘sanitation facility’ and ‘sanitation facilities’ mean 

23 safe and adequate water supply systems, sanitary 

24 sewage disposal systems, and sanitary solid waste 
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•HR 3962 EH

1 systems (and all related equipment and support in2 frastructure). 

3 ‘‘SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS. 

4 ‘‘(a) BUY INDIAN ACT.—The Secretary, acting 

5 through the Service, may use the negotiating authority of 

6 section 23 of the Act of June 25, 1910 (25 U.S.C. 47, 

7 commonly known as the ‘Buy Indian Act’), to give pref8 erence to any Indian or any enterprise, partnership, cor9 poration, or other type of business organization owned and 

10 controlled by an Indian or Indians including former or 

11 currently federally recognized Indian Tribes in the State 

12 of New York (hereinafter referred to as an ‘Indian firm’) 

13 in the construction and renovation of Service facilities pur14 suant to section 301 and in the construction of sanitation 

15 facilities pursuant to section 302. Such preference may be 

16 accorded by the Secretary unless the Secretary finds, pur17 suant to regulations, that the project or function to be 

18 contracted for will not be satisfactory or such project or 

19 function cannot be properly completed or maintained 

20 under the proposed contract. The Secretary, in arriving 

21 at such a finding, shall consider whether the Indian or 

22 Indian firm will be deficient with respect to— 

23 ‘‘(1) ownership and control by Indians; 

24 ‘‘(2) equipment; 

25 ‘‘(3) bookkeeping and accounting procedures; 
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•HR 3962 EH

1 ‘‘(4) substantive knowledge of the project or 

2 function to be contracted for; 

3 ‘‘(5) adequately trained personnel; or 

4 ‘‘(6) other necessary components of contract 

5 performance. 

6 ‘‘(b) PAY RATES.—For the purposes of implementing 

7 the provisions of this title, the Secretary shall assure that 

8 the rates of pay for personnel engaged in the construction 

9 or renovation of facilities constructed or renovated in 

10 whole or in part by funds made available pursuant to this 

11 title are not less than the prevailing local wage rates for 

12 similar work as determined in accordance with the Act of 

13 March 3, 1931 (40 U.S.C. 276a–276a–5, known as the 

14 Davis-Bacon Act). 

15 ‘‘(c) LABOR STANDARDS.—For the purposes of im16 plementing the provisions of this title, contracts for the 

17 construction or renovation of health care facilities, staff 

18 quarters, and sanitation facilities, and related support in19 frastructure, funded in whole or in part with funds made 

20 available pursuant to this title, shall contain a provision 

21 requiring compliance with subchapter IV of chapter 31 of 

22 title 40, United States Code (commonly known as the 

23 ‘Davis-Bacon Act’). 
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1 ‘‘SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR 

2 RENOVATION. 

3 ‘‘(a) IN GENERAL.—Notwithstanding any other pro4 vision of law, if the requirements of subsection (c) are met, 

5 the Secretary, acting through the Service, is authorized 

6 to accept any major expansion, renovation, or moderniza7 tion by any Indian Tribe or Tribal Organization of any 

8 Service facility or of any other Indian health facility oper9 ated pursuant to a contract or compact under the Indian 

10 Self-Determination and Education Assistance Act (25 

11 U.S.C. 450 et seq.), including— 

12 ‘‘(1) any plans or designs for such expansion, 

13 renovation, or modernization; and 

14 ‘‘(2) any expansion, renovation, or moderniza15 tion for which funds appropriated under any Federal 

16 law were lawfully expended. 

17 ‘‘(b) PRIORITY LIST.— 

18 ‘‘(1) IN GENERAL.—The Secretary shall main19 tain a separate priority list to address the needs for 

20 increased operating expenses, personnel, or equip21 ment for such facilities. The methodology for estab22 lishing priorities shall be developed through regula23 tions. The list of priority facilities will be revised an24 nually in consultation with Indian Tribes and Tribal 

25 Organizations. 
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•HR 3962 EH

1 ‘‘(2) REPORT.—The Secretary shall submit to 

2 the President, for inclusion in the report required to 

3 be transmitted to Congress under section 801, the 

4 priority list maintained pursuant to paragraph (1). 

5 ‘‘(c) REQUIREMENTS.—The requirements of this sub6 section are met with respect to any expansion, renovation, 

7 or modernization if— 

8 ‘‘(1) the Indian Tribe or Tribal Organization— 

9 ‘‘(A) provides notice to the Secretary of its 

10 intent to expand, renovate, or modernize; and 

11 ‘‘(B) applies to the Secretary to be placed 

12 on a separate priority list to address the needs 

13 of such new facilities for increased operating ex14 penses, personnel, or equipment; and 

15 ‘‘(2) the expansion, renovation, or moderniza16 tion— 

17 ‘‘(A) is approved by the appropriate area 

18 director of the Service for Federal facilities; and 

19 ‘‘(B) is administered by the Indian Tribe 

20 or Tribal Organization in accordance with any 

21 applicable regulations prescribed by the Sec22 retary with respect to construction or renova23 tion of Service facilities. 

24 ‘‘(d) ADDITIONAL REQUIREMENT FOR EXPANSION.— 

25 In addition to the requirements under subsection (c), for 
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•HR 3962 EH

1 any expansion, the Indian Tribe or Tribal Organization 

2 shall provide to the Secretary additional information pur3 suant to regulations, including additional staffing, equip4 ment, and other costs associated with the expansion. 

5 ‘‘(e) CLOSURE OR CONVERSION OF FACILITIES.—If 

6 any Service facility which has been expanded, renovated, 

7 or modernized by an Indian Tribe or Tribal Organization 

8 under this section ceases to be used as a Service facility 

9 during the 20-year period beginning on the date such ex10 pansion, renovation, or modernization is completed, such 

11 Indian Tribe or Tribal Organization shall be entitled to 

12 recover from the United States an amount which bears 

13 the same ratio to the value of such facility at the time 

14 of such cessation as the value of such expansion, renova15 tion, or modernization (less the total amount of any funds 

16 provided specifically for such facility under any Federal 

17 program that were expended for such expansion, renova18 tion, or modernization) bore to the value of such facility 

19 at the time of the completion of such expansion, renova20 tion, or modernization. 

21 ‘‘SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, 

22 AND MODERNIZATION OF SMALL AMBULA23 TORY CARE FACILITIES. 

24 ‘‘(a) GRANTS.— 
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•HR 3962 EH

1 ‘‘(1) IN GENERAL.—The Secretary, acting 

2 through the Service, shall make grants to Indian 

3 Tribes and Tribal Organizations for the construc4 tion, expansion, or modernization of facilities for the 

5 provision of ambulatory care services to eligible Indi6 ans (and noneligible persons pursuant to subsections 

7 (b)(2) and (c)(1)(C)). A grant made under this sec8 tion may cover up to 100 percent of the costs of 

9 such construction, expansion, or modernization. For 

10 the purposes of this section, the term ‘construction’ 

11 includes the replacement of an existing facility. 

12 ‘‘(2) GRANT AGREEMENT REQUIRED.—A grant 

13 under paragraph (1) may only be made available to 

14 a Tribal Health Program operating an Indian health 

15 facility (other than a facility owned or constructed 

16 by the Service, including a facility originally owned 

17 or constructed by the Service and transferred to an 

18 Indian Tribe or Tribal Organization). 

19 ‘‘(b) USE OF GRANT FUNDS.— 

20 ‘‘(1) ALLOWABLE USES.—A grant awarded 

21 under this section may be used for the construction, 

22 expansion, or modernization (including the planning 

23 and design of such construction, expansion, or mod24 ernization) of an ambulatory care facility— 

25 ‘‘(A) located apart from a hospital; 
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•HR 3962 EH

1 ‘‘(B) not funded under section 301 or sec2 tion 306; and 

3 ‘‘(C) which, upon completion of such con4 struction or modernization will— 

5 ‘‘(i) have a total capacity appropriate 

6 to its projected service population; 

7 ‘‘(ii) provide annually no fewer than 

8 150 patient visits by eligible Indians and 

9 other users who are eligible for services in 

10 such facility in accordance with section 

11 806(c)(2); and 

12 ‘‘(iii) provide ambulatory care in a 

13 Service Area (specified in the contract or 

14 compact under the Indian Self-Determina15 tion and Education Assistance Act (25 

16 U.S.C. 450 et seq.)) with a population of 

17 no fewer than 1,500 eligible Indians and 

18 other users who are eligible for services in 

19 such facility in accordance with section 

20 806(c)(2). 

21 ‘‘(2) ADDITIONAL ALLOWABLE USE.—The Sec22 retary may also reserve a portion of the funding pro23 vided under this section and use those reserved 

24 funds to reduce an outstanding debt incurred by In25 dian Tribes or Tribal Organizations for the con-
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•HR 3962 EH

1 struction, expansion, or modernization of an ambula2 tory care facility that meets the requirements under 

3 paragraph (1). The provisions of this section shall 

4 apply, except that such applications for funding 

5 under this paragraph shall be considered separately 

6 from applications for funding under paragraph (1). 

7 ‘‘(3) USE ONLY FOR CERTAIN PORTION OF

8 COSTS.—A grant provided under this section may be 

9 used only for the cost of that portion of a construc10 tion, expansion, or modernization project that bene11 fits the Service population identified above in sub12 section (b)(1)(C) (ii) and (iii). The requirements of 

13 clauses (ii) and (iii) of paragraph (1)(C) shall not 

14 apply to an Indian Tribe or Tribal Organization ap15 plying for a grant under this section for a health 

16 care facility located or to be constructed on an is17 land or when such facility is not located on a road 

18 system providing direct access to an inpatient hos19 pital where care is available to the Service popu20 lation. 

21 ‘‘(c) GRANTS.— 

22 ‘‘(1) APPLICATION.—No grant may be made 

23 under this section unless an application or proposal 

24 for the grant has been approved by the Secretary in 

25 accordance with applicable regulations and has set 
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•HR 3962 EH

1 forth reasonable assurance by the applicant that, at 

2 all times after the construction, expansion, or mod3 ernization of a facility carried out using a grant re4 ceived under this section— 

5 ‘‘(A) adequate financial support will be 

6 available for the provision of services at such 

7 facility; 

8 ‘‘(B) such facility will be available to eligi9 ble Indians without regard to ability to pay or 

10 source of payment; and 

11 ‘‘(C) such facility will, as feasible without 

12 diminishing the quality or quantity of services 

13 provided to eligible Indians, serve noneligible 

14 persons on a cost basis. 

15 ‘‘(2) PRIORITY.—In awarding grants under this 

16 section, the Secretary shall give priority to Indian 

17 Tribes and Tribal Organizations that demonstrate— 

18 ‘‘(A) a need for increased ambulatory care 

19 services; and 

20 ‘‘(B) insufficient capacity to deliver such 

21 services. 

22 ‘‘(3) PEER REVIEW PANELS.—The Secretary 

23 may provide for the establishment of peer review 

24 panels, as necessary, to review and evaluate applica25 tions and proposals and to advise the Secretary re-
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•HR 3962 EH

1 garding such applications using the criteria devel2 oped pursuant to subsection (a)(1). 

3 ‘‘(d) REVERSION OF FACILITIES.—If any facility (or 

4 portion thereof) with respect to which funds have been 

5 paid under this section, ceases, at any time after comple6 tion of the construction, expansion, or modernization car7 ried out with such funds, to be used for the purposes of 

8 providing health care services to eligible Indians, all of the 

9 right, title, and interest in and to such facility (or portion 

10 thereof) shall transfer to the United States unless other11 wise negotiated by the Service and the Indian Tribe or 

12 Tribal Organization. 

13 ‘‘(e) FUNDING NONRECURRING.—Funding provided 

14 under this section shall be nonrecurring and shall not be 

15 available for inclusion in any individual Indian Tribe’s 

16 tribal share for an award under the Indian Self-Deter17 mination and Education Assistance Act (25 U.S.C. 450 

18 et seq.) or for reallocation or redesign thereunder. 

19 ‘‘SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRA20 TION PROJECT. 

21 ‘‘(a) HEALTH CARE DEMONSTRATION PROJECTS.— 

22 The Secretary, acting through the Service, is authorized 

23 to make grants to, and enter into construction contracts 

24 or construction project agreements with, Indian Tribes or 

25 Tribal Organizations under the Indian Self-Determination 
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•HR 3962 EH

1 and Education Assistance Act (25 U.S.C. 450 et seq.) for 

2 the purpose of carrying out a health care delivery dem3 onstration project to test alternative means of delivering 

4 health care and services to Indians through facilities. 

5 ‘‘(b) USE OF FUNDS.—The Secretary, in approving 

6 projects pursuant to this section, may authorize such con7 tracts for the construction and renovation of hospitals, 

8 health centers, health stations, and other facilities to de9 liver health care services and is authorized to— 

10 ‘‘(1) waive any leasing prohibition; 

11 ‘‘(2) permit carryover of funds appropriated for 

12 the provision of health care services; 

13 ‘‘(3) permit the use of other available funds; 

14 ‘‘(4) permit the use of funds or property do15 nated from any source for project purposes; 

16 ‘‘(5) provide for the reversion of donated real or 

17 personal property to the donor; and 

18 ‘‘(6) permit the use of Service funds to match 

19 other funds, including Federal funds. 

20 ‘‘(c) REGULATIONS.—The Secretary shall develop 

21 and promulgate regulations, not later than 1 year after 

22 the date of enactment of the Indian Health Care Improve23 ment Act Amendments of 2009, for the review and ap24 proval of applications submitted under this section. 
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•HR 3962 EH

1 ‘‘(d) CRITERIA.—The Secretary may approve projects 

2 that meet the following criteria: 

3 ‘‘(1) There is a need for a new facility or pro4 gram or the reorientation of an existing facility or 

5 program. 

6 ‘‘(2) A significant number of Indians, including 

7 those with low health status, will be served by the 

8 project. 

9 ‘‘(3) The project has the potential to deliver 

10 services in an efficient and effective manner. 

11 ‘‘(4) The project is economically viable. 

12 ‘‘(5) The Indian Tribe or Tribal Organization 

13 has the administrative and financial capability to ad14 minister the project. 

15 ‘‘(6) The project is integrated with providers of 

16 related health and social services and is coordinated 

17 with, and avoids duplication of, existing services. 

18 ‘‘(e) PEER REVIEW PANELS.—The Secretary may 

19 provide for the establishment of peer review panels, as nec20 essary, to review and evaluate applications using the cri21 teria developed pursuant to subsection (d). 

22 ‘‘(f) PRIORITY.—The Secretary shall give priority to 

23 applications for demonstration projects in each of the fol24 lowing Service Units to the extent that such applications 
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•HR 3962 EH

1 are timely filed and meet the criteria specified in sub2 section (d): 

3 ‘‘(1) Cass Lake, Minnesota. 

4 ‘‘(2) Mescalero, New Mexico. 

5 ‘‘(3) Owyhee, Nevada. 

6 ‘‘(4) Schurz, Nevada. 

7 ‘‘(5) Ft. Yuma, California. 

8 ‘‘(g) TECHNICAL ASSISTANCE.—The Secretary shall 

9 provide such technical and other assistance as may be nec10 essary to enable applicants to comply with the provisions 

11 of this section. 

12 ‘‘(h) SERVICE TO INELIGIBLE PERSONS.—Subject to 

13 section 806, the authority to provide services to persons 

14 otherwise ineligible for the health care benefits of the 

15 Service and the authority to extend hospital privileges in 

16 Service facilities to non-Service health practitioners as 

17 provided in section 806 may be included, subject to the 

18 terms of such section, in any demonstration project ap19 proved pursuant to this section. 

20 ‘‘(i) EQUITABLE TREATMENT.—For purposes of sub21 section (d)(1), the Secretary shall, in evaluating facilities 

22 operated under any contract or compact under the Indian 

23 Self-Determination and Education Assistance Act (25 

24 U.S.C. 450 et seq.), use the same criteria that the Sec-
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•HR 3962 EH

1 retary uses in evaluating facilities operated directly by the 

2 Service. 

3 ‘‘(j) EQUITABLE INTEGRATION OF FACILITIES.—The 

4 Secretary shall ensure that the planning, design, construc5 tion, renovation, and expansion needs of Service and non6 Service facilities which are the subject of a contract or 

7 compact under the Indian Self-Determination and Edu8 cation Assistance Act (25 U.S.C. 450 et seq.) for health 

9 services are fully and equitably integrated into the imple10 mentation of the health care delivery demonstration 

11 projects under this section. 

12 ‘‘SEC. 307. LAND TRANSFER. 

13 ‘‘Notwithstanding any other provision of law, the Bu14 reau of Indian Affairs and all other agencies and depart15 ments of the United States are authorized to transfer, at 

16 no cost, land and improvements to the Service for the pro17 vision of health care services. The Secretary is authorized 

18 to accept such land and improvements for such purposes. 

19 ‘‘SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS. 

20 ‘‘The Secretary, acting through the Service, may 

21 enter into leases, contracts, and other agreements with In22 dian Tribes and Tribal Organizations which hold (1) title 

23 to, (2) a leasehold interest in, or (3) a beneficial interest 

24 in (when title is held by the United States in trust for 

25 the benefit of an Indian Tribe) facilities used or to be used 
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•HR 3962 EH

1 for the administration and delivery of health services by 

2 an Indian Health Program. Such leases, contracts, or 

3 agreements may include provisions for construction or ren4 ovation and provide for compensation to the Indian Tribe 

5 or Tribal Organization of rental and other costs consistent 

6 with section 105(l) of the Indian Self-Determination and 

7 Education Assistance Act (25 U.S.C. 450j(l)) and regula8 tions thereunder. 

9 ‘‘SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND 

10 LOAN REPAYMENT. 

11 ‘‘(a) IN GENERAL.—The Secretary, in consultation 

12 with the Secretary of the Treasury, Indian Tribes, and 

13 Tribal Organizations, shall carry out a study to determine 

14 the feasibility of establishing a loan fund to provide to In15 dian Tribes and Tribal Organizations direct loans or guar16 antees for loans for the construction of health care facili17 ties, including— 

18 ‘‘(1) inpatient facilities; 

19 ‘‘(2) outpatient facilities; 

20 ‘‘(3) staff quarters; 

21 ‘‘(4) hostels; and 

22 ‘‘(5) specialized care facilities, such as behav23 ioral health and elder care facilities. 

24 ‘‘(b) DETERMINATIONS.—In carrying out the study 

25 under subsection (a), the Secretary shall determine— 
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•HR 3962 EH

1 ‘‘(1) the maximum principal amount of a loan 

2 or loan guarantee that should be offered to a recipi3 ent from the loan fund; 

4 ‘‘(2) the percentage of eligible costs, not to ex5 ceed 100 percent, that may be covered by a loan or 

6 loan guarantee from the loan fund (including costs 

7 relating to planning, design, financing, site land de8 velopment, construction, rehabilitation, renovation, 

9 conversion, improvements, medical equipment and 

10 furnishings, and other facility-related costs and cap11 ital purchase (but excluding staffing)); 

12 ‘‘(3) the cumulative total of the principal of di13 rect loans and loan guarantees, respectively, that 

14 may be outstanding at any 1 time; 

15 ‘‘(4) the maximum term of a loan or loan guar16 antee that may be made for a facility from the loan 

17 fund; 

18 ‘‘(5) the maximum percentage of funds from 

19 the loan fund that should be allocated for payment 

20 of costs associated with planning and applying for a 

21 loan or loan guarantee; 

22 ‘‘(6) whether acceptance by the Secretary of an 

23 assignment of the revenue of an Indian Tribe or 

24 Tribal Organization as security for any direct loan 
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1 or loan guarantee from the loan fund would be ap2 propriate; 

3 ‘‘(7) whether, in the planning and design of 

4 health facilities under this section, users eligible 

5 under section 806(c) may be included in any projec6 tion of patient population; 

7 ‘‘(8) whether funds of the Service provided 

8 through loans or loan guarantees from the loan fund 

9 should be eligible for use in matching other Federal 

10 funds under other programs; 

11 ‘‘(9) the appropriateness of, and best methods 

12 for, coordinating the loan fund with the health care 

13 priority system of the Service under section 301; and 

14 ‘‘(10) any legislative or regulatory changes re15 quired to implement recommendations of the Sec16 retary based on results of the study. 

17 ‘‘(c) REPORT.—Not later than September 30, 2010, 

18 the Secretary shall submit to the Committee on Indian Af19 fairs of the Senate and the Committee on Natural Re20 sources and the Committee on Energy and Commerce of 

21 the House of Representatives a report that describes— 

22 ‘‘(1) the manner of consultation made as re23 quired by subsection (a); and 
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1 ‘‘(2) the results of the study, including any rec2 ommendations of the Secretary based on results of 

3 the study. 

4 ‘‘SEC. 310. TRIBAL LEASING. 

5 ‘‘A Tribal Health Program may lease permanent 

6 structures for the purpose of providing health care services 

7 without obtaining advance approval in appropriation Acts. 

8 ‘‘SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES 

9 JOINT VENTURE PROGRAM. 

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

11 the Service, shall make arrangements with Indian Tribes 

12 and Tribal Organizations to establish joint venture dem13 onstration projects under which an Indian Tribe or Tribal 

14 Organization shall expend tribal, private, or other avail15 able funds, for the acquisition or construction of a health 

16 facility for a minimum of 10 years, under a no-cost lease, 

17 in exchange for agreement by the Service to provide the 

18 equipment, supplies, and staffing for the operation and 

19 maintenance of such a health facility. An Indian Tribe or 

20 Tribal Organization may use tribal funds, private sector, 

21 or other available resources, including loan guarantees, to 

22 fulfill its commitment under a joint venture entered into 

23 under this subsection. An Indian Tribe or Tribal Organi24 zation shall be eligible to establish a joint venture project 

25 if, when it submits a letter of intent, it— 
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1 ‘‘(1) has begun but not completed the process 

2 of acquisition or construction of a health facility to 

3 be used in the joint venture project; 

4 ‘‘(2) has not begun the process of acquisition or 

5 construction of a health facility for use in the joint 

6 venture project; or 

7 ‘‘(3) in its application for a joint venture agree8 ment, agrees— 

9 ‘‘(A) to construct a facility for the joint 

10 venture which complies with the size and space 

11 criteria established by the Service; or 

12 ‘‘(B) if the facility it proposes for the joint 

13 venture is already in existence or under con14 struction, that only the portion of such facility 

15 which complies with the size and space criteria 

16 of the Service will be eligible for the joint ven17 ture agreement. 

18 ‘‘(b) REQUIREMENTS.—The Secretary shall make 

19 such an arrangement with an Indian Tribe or Tribal Orga20 nization only if— 

21 ‘‘(1) the Secretary first determines that the In22 dian Tribe or Tribal Organization has the adminis23 trative and financial capabilities necessary to com24 plete the timely acquisition or construction of the 

25 relevant health facility; and 
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1 ‘‘(2) the Indian Tribe or Tribal Organization 

2 meets the need criteria determined using the criteria 

3 developed under the health care facility priority sys4 tem under section 301, unless the Secretary deter5 mines, pursuant to regulations, that other criteria 

6 will result in a more cost-effective and efficient 

7 method of facilitating and completing construction of 

8 health care facilities. 

9 ‘‘(c) CONTINUED OPERATION.—The Secretary shall 

10 negotiate an agreement with the Indian Tribe or Tribal 

11 Organization regarding the continued operation of the fa12 cility at the end of the initial 10 year no-cost lease period. 

13 ‘‘(d) BREACH OF AGREEMENT.—An Indian Tribe or 

14 Tribal Organization that has entered into a written agree15 ment with the Secretary under this section, and that 

16 breaches or terminates without cause such agreement, 

17 shall be liable to the United States for the amount that 

18 has been paid to the Indian Tribe or Tribal Organization, 

19 or paid to a third party on the Indian Tribe’s or Tribal 

20 Organization’s behalf, under the agreement. The Sec21 retary has the right to recover tangible property (including 

22 supplies) and equipment, less depreciation, and any funds 

23 expended for operations and maintenance under this sec24 tion. The preceding sentence does not apply to any funds 
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1 expended for the delivery of health care services, per2 sonnel, or staffing. 

3 ‘‘(e) RECOVERY FOR NONUSE.—An Indian Tribe or 

4 Tribal Organization that has entered into a written agree5 ment with the Secretary under this subsection shall be en6 titled to recover from the United States an amount that 

7 is proportional to the value of such facility if, at any time 

8 within the 10-year term of the agreement, the Service 

9 ceases to use the facility or otherwise breaches the agree10 ment. 

11 ‘‘(f) DEFINITION.—For the purposes of this section, 

12 the term ‘health facility’ or ‘health facilities’ includes 

13 quarters needed to provide housing for staff of the rel14 evant Tribal Health Program. 

15 ‘‘SEC. 312. LOCATION OF FACILITIES. 

16 ‘‘(a) IN GENERAL.—In all matters involving the reor17 ganization or development of Service facilities or in the 

18 establishment of related employment projects to address 

19 unemployment conditions in economically depressed areas, 

20 the Bureau of Indian Affairs and the Service shall give 

21 priority to locating such facilities and projects on Indian 

22 lands, or lands in Alaska owned by any Alaska Native vil23 lage, or village or regional corporation under the Alaska 

24 Native Claims Settlement Act (43 U.S.C. 1601 et seq.), 

25 or any land allotted to any Alaska Native, if requested 
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1 by the Indian owner and the Indian Tribe with jurisdiction 

2 over such lands or other lands owned or leased by the In3 dian Tribe or Tribal Organization. Top priority shall be 

4 given to Indian land owned by 1 or more Indian Tribes. 

5 ‘‘(b) DEFINITION.—For purposes of this section, the 

6 term ‘Indian lands’ means— 

7 ‘‘(1) all lands within the exterior boundaries of 

8 any reservation; and 

9 ‘‘(2) any lands title to which is held in trust by 

10 the United States for the benefit of any Indian 

11 Tribe or individual Indian or held by any Indian 

12 Tribe or individual Indian subject to restriction by 

13 the United States against alienation. 

14 ‘‘SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH 

15 CARE FACILITIES. 

16 ‘‘(a) REPORT.—The Secretary shall submit to the 

17 President, for inclusion in the report required to be trans18 mitted to Congress under section 801, a report which iden19 tifies the backlog of maintenance and repair work required 

20 at both Service and tribal health care facilities, including 

21 new health care facilities expected to be in operation in 

22 the next fiscal year. The report shall also identify the need 

23 for renovation and expansion of existing facilities to sup24 port the growth of health care programs. 
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1 ‘‘(b) MAINTENANCE OF NEWLY CONSTRUCTED

2 SPACE.—The Secretary, acting through the Service, is au3 thorized to expend maintenance and improvement funds 

4 to support maintenance of newly constructed space only 

5 if such space falls within the approved supportable space 

6 allocation for the Indian Tribe or Tribal Organization. 

7 Supportable space allocation shall be defined through the 

8 health care facility priority system under section 301(c). 

9 ‘‘(c) REPLACEMENT FACILITIES.—In addition to 

10 using maintenance and improvement funds for renovation, 

11 modernization, and expansion of facilities, an Indian Tribe 

12 or Tribal Organization may use maintenance and improve13 ment funds for construction of a replacement facility if 

14 the costs of renovation of such facility would exceed a 

15 maximum renovation cost threshold. The Secretary shall 

16 consult with Indian Tribes and Tribal Organizations in de17 termining the maximum renovation cost threshold. 

18 ‘‘SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED 

19 QUARTERS. 

20 ‘‘(a) RENTAL RATES.— 

21 ‘‘(1) ESTABLISHMENT.—Notwithstanding any 

22 other provision of law, a Tribal Health Program 

23 which operates a hospital or other health facility and 

24 the federally owned quarters associated therewith 

25 pursuant to a contract or compact under the Indian 
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1 Self-Determination and Education Assistance Act 

2 (25 U.S.C. 450 et seq.) shall have the authority to 

3 establish the rental rates charged to the occupants 

4 of such quarters by providing notice to the Secretary 

5 of its election to exercise such authority. 

6 ‘‘(2) OBJECTIVES.—In establishing rental rates 

7 pursuant to authority of this subsection, a Tribal 

8 Health Program shall endeavor to achieve the fol9 lowing objectives: 

10 ‘‘(A) To base such rental rates on the rea11 sonable value of the quarters to the occupants 

12 thereof. 

13 ‘‘(B) To generate sufficient funds to pru14 dently provide for the operation and mainte15 nance of the quarters, and subject to the discre16 tion of the Tribal Health Program, to supply 

17 reserve funds for capital repairs and replace18 ment of the quarters. 

19 ‘‘(3) EQUITABLE FUNDING.—Any quarters 

20 whose rental rates are established by a Tribal 

21 Health Program pursuant to this subsection shall 

22 remain eligible for quarters improvement and repair 

23 funds to the same extent as all federally owned 

24 quarters used to house personnel in Services-sup25 ported programs. 
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1 ‘‘(4) NOTICE OF RATE CHANGE.—A Tribal 

2 Health Program which exercises the authority pro3 vided under this subsection shall provide occupants 

4 with no less than 60 days notice of any change in 

5 rental rates. 

6 ‘‘(b) DIRECT COLLECTION OF RENT.— 

7 ‘‘(1) IN GENERAL.—Notwithstanding any other 

8 provision of law, and subject to paragraph (2), a 

9 Tribal Health Program shall have the authority to 

10 collect rents directly from Federal employees who oc11 cupy such quarters in accordance with the following: 

12 ‘‘(A) The Tribal Health Program shall no13 tify the Secretary and the subject Federal em14 ployees of its election to exercise its authority 

15 to collect rents directly from such Federal em16 ployees. 

17 ‘‘(B) Upon receipt of a notice described in 

18 subparagraph (A), the Federal employees shall 

19 pay rents for occupancy of such quarters di20 rectly to the Tribal Health Program and the 

21 Secretary shall have no further authority to col22 lect rents from such employees through payroll 

23 deduction or otherwise. 

24 ‘‘(C) Such rent payments shall be retained 

25 by the Tribal Health Program and shall not be 
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1 made payable to or otherwise be deposited with 

2 the United States. 

3 ‘‘(D) Such rent payments shall be depos4 ited into a separate account which shall be used 

5 by the Tribal Health Program for the mainte6 nance (including capital repairs and replace7 ment) and operation of the quarters and facili8 ties as the Tribal Health Program shall deter9 mine. 

10 ‘‘(2) RETROCESSION OF AUTHORITY.—If a 

11 Tribal Health Program which has made an election 

12 under paragraph (1) requests retrocession of its au13 thority to directly collect rents from Federal employ14 ees occupying federally owned quarters, such ret15 rocession shall become effective on the earlier of— 

16 ‘‘(A) the first day of the month that begins 

17 no less than 180 days after the Tribal Health 

18 Program notifies the Secretary of its desire to 

19 retrocede; or 

20 ‘‘(B) such other date as may be mutually 

21 agreed by the Secretary and the Tribal Health 

22 Program. 

23 ‘‘(c) RATES IN ALASKA.—To the extent that a Tribal 

24 Health Program, pursuant to authority granted in sub25 section (a), establishes rental rates for federally owned 
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1 quarters provided to a Federal employee in Alaska, such 

2 rents may be based on the cost of comparable private rent3 al housing in the nearest established community with a 

4 year-round population of 1,500 or more individuals. 

5 ‘‘SEC. 315. APPLICABILITY OF BUY AMERICAN ACT RE6 QUIREMENT. 

7 ‘‘(a) APPLICABILITY.—The Secretary shall ensure 

8 that the requirements of the Buy American Act apply to 

9 all procurements made with funds provided pursuant to 

10 section 317. Indian Tribes and Tribal Organizations shall 

11 be exempt from these requirements. 

12 ‘‘(b) EFFECT OF VIOLATION.—If it has been finally 

13 determined by a court or Federal agency that any person 

14 intentionally affixed a label bearing a ‘Made in America’ 

15 inscription or any inscription with the same meaning, to 

16 any product sold in or shipped to the United States that 

17 is not made in the United States, such person shall be 

18 ineligible to receive any contract or subcontract made with 

19 funds provided pursuant to section 317, pursuant to the 

20 debarment, suspension, and ineligibility procedures de21 scribed in sections 9.400 through 9.409 of title 48, Code 

22 of Federal Regulations. 

23 ‘‘(c) DEFINITIONS.—For purposes of this section, the 

24 term ‘Buy American Act’ means title III of the Act enti25 tled ‘An Act making appropriations for the Treasury and 
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1 Post Office Departments for the fiscal year ending June 

2 30, 1934, and for other purposes’, approved March 3, 

3 1933 (41 U.S.C. 10a et seq.). 

4 ‘‘SEC. 316. OTHER FUNDING FOR FACILITIES. 

5 ‘‘(a) AUTHORITY TO ACCEPT FUNDS.—The Sec6 retary is authorized to accept from any source, including 

7 Federal and State agencies, funds that are available for 

8 the construction of health care facilities and use such 

9 funds to plan, design, and construct health care facilities 

10 for Indians and to place such funds into a contract or com11 pact under the Indian Self-Determination and Education 

12 Assistance Act (25 U.S.C. 450 et seq.). Receipt of such 

13 funds shall have no effect on the priorities established pur14 suant to section 301. 

15 ‘‘(b) INTERAGENCY AGREEMENTS.—The Secretary is 

16 authorized to enter into interagency agreements with 

17 other Federal agencies or State agencies and other entities 

18 and to accept funds from such Federal or State agencies 

19 or other sources to provide for the planning, design, and 

20 construction of health care facilities to be administered by 

21 Indian Health Programs in order to carry out the pur22 poses of this Act and the purposes for which the funds 

23 were appropriated or for which the funds were otherwise 

24 provided. 
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1 ‘‘(c) TRANSFERRED FUNDS.—Any Federal agency to 

2 which funds for the construction of health care facilities 

3 are appropriated is authorized to transfer such funds to 

4 the Secretary for the construction of health care facilities 

5 to carry out the purposes of this Act as well as the pur6 poses for which such funds are appropriated to such other 

7 Federal agency. 

8 ‘‘(d) ESTABLISHMENT OF STANDARDS.—The Sec9 retary, through the Service, shall establish standards by 

10 regulation for the planning, design, and construction of 

11 health care facilities serving Indians under this Act. 

12 ‘‘SEC. 317. AUTHORIZATION OF APPROPRIATIONS. 

13 ‘‘There are authorized to be appropriated such sums 

14 as may be necessary to carry out this title. 

15 ‘‘TITLE IV—ACCESS TO HEALTH 

16 SERVICES 

17 ‘‘SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SE18 CURITY ACT HEALTH BENEFITS PROGRAMS. 

19 ‘‘(a) DISREGARD OF MEDICARE, MEDICAID, AND

20 SCHIP PAYMENTS IN DETERMINING APPROPRIATIONS.— 

21 Any payments received by an Indian Health Program or 

22 by an urban Indian organization under title XVIII, XIX, 

23 or XXI of the Social Security Act for services provided 

24 to Indians eligible for benefits under such respective titles 
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1 shall not be considered in determining appropriations for 

2 the provision of health care and services to Indians. 

3 ‘‘(b) NONPREFERENTIAL TREATMENT.—Nothing in 

4 this Act authorizes the Secretary to provide services to an 

5 Indian with coverage under title XVIII, XIX, or XXI of 

6 the Social Security Act in preference to an Indian without 

7 such coverage. 

8 ‘‘(c) USE OF FUNDS.— 

9 ‘‘(1) SPECIAL FUND.— 

10 ‘‘(A) 100 PERCENT PASS-THROUGH OF

11 PAYMENTS DUE TO FACILITIES.—Notwith12 standing any other provision of law, but subject 

13 to paragraph (2), payments to which a facility 

14 of the Service is entitled by reason of a provi15 sion of title XVIII or XIX of the Social Secu16 rity Act shall be placed in a special fund to be 

17 held by the Secretary. In making payments 

18 from such fund, the Secretary shall ensure that 

19 each Service Unit of the Service receives 100 

20 percent of the amount to which the facilities of 

21 the Service, for which such Service Unit makes 

22 collections, are entitled by reason of a provision 

23 of either such title. 

24 ‘‘(B) USE OF FUNDS.—Amounts received 

25 by a facility of the Service under subparagraph 
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1 (A) by reason of a provision of title XVIII or 

2 XIX of the Social Security Act shall first be 

3 used (to such extent or in such amounts as are 

4 provided in appropriation Acts) for the purpose 

5 of making any improvements in the programs 

6 of the Service operated by or through such fa7 cility which may be necessary to achieve or 

8 maintain compliance with the applicable condi9 tions and requirements of such respective title. 

10 Any amounts so received that are in excess of 

11 the amount necessary to achieve or maintain 

12 such conditions and requirements shall, subject 

13 to consultation with the Indian Tribes being 

14 served by the Service Unit, be used for increas15 ing the facility’s capacity to provide, or improv16 ing the quality or accessibility of, services. 

17 ‘‘(2) DIRECT PAYMENT OPTION.—Paragraph 

18 (1) shall not apply to a Tribal Health Program upon 

19 the election of such Program under subsection (d) to 

20 receive payments directly. No payment may be made 

21 out of the special fund described in such paragraph 

22 with respect to reimbursement made for services 

23 provided by such Program during the period of such 

24 election. 

25 ‘‘(d) DIRECT BILLING.— 
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1 ‘‘(1) IN GENERAL.—Subject to complying with 

2 the requirements of paragraph (2), a Tribal Health 

3 Program may elect to directly bill for, and receive 

4 payment for, health care items and services provided 

5 by such Program for which payment is made under 

6 title XVIII, XIX, or XXI of the Social Security Act. 

7 ‘‘(2) DIRECT REIMBURSEMENT.— 

8 ‘‘(A) USE OF FUNDS.—Each Tribal Health 

9 Program making the election described in para10 graph (1) with respect to a program under title 

11 XVIII, XIX, or XXI of the Social Security Act 

12 shall be reimbursed directly by that program 

13 for items and services furnished without regard 

14 to subsection (c)(1), but all amounts so reim15 bursed shall be used by the Tribal Health Pro16 gram for the same purposes with respect to 

17 such Program for which payment under sub18 paragraph (A) of subsection (c)(1) to a facility 

19 of the Service may be used pursuant to sub20 paragraph (B) of such subsection with respect 

21 to the Service. 

22 ‘‘(B) AUDITS.—The amounts paid to a 

23 Tribal Health Program making the election de24 scribed in paragraph (1) with respect to a pro25 gram under title XVIII, XIX, or XXI of the So-
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1 cial Security Act shall be subject to all auditing 

2 requirements applicable to the program under 

3 such title, as well as all auditing requirements 

4 applicable to programs administered by an In5 dian Health Program. Nothing in the preceding 

6 sentence shall be construed as limiting the ap7 plication of auditing requirements applicable to 

8 amounts paid under title XVIII, XIX, or XXI 

9 of the Social Security Act. 

10 ‘‘(C) IDENTIFICATION OF SOURCE OF PAY11 MENTS.—Any Tribal Health Program that re12 ceives reimbursements or payments under title 

13 XVIII, XIX, or XXI of the Social Security Act 

14 shall provide to the Service a list of each pro15 vider enrollment number (or other identifier) 

16 under which such Program receives such reim17 bursements or payments. 

18 ‘‘(3) EXAMINATION AND IMPLEMENTATION OF

19 CHANGES.— 

20 ‘‘(A) IN GENERAL.—The Secretary, acting 

21 through the Service and with the assistance of 

22 the Administrator of the Centers for Medicare 

23 & Medicaid Services, shall examine on an ongo24 ing basis and implement any administrative 

25 changes that may be necessary to facilitate di-
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1 rect billing and reimbursement under the pro2 gram established under this subsection, includ3 ing any agreements with States that may be 

4 necessary to provide for direct billing under a 

5 program under title XIX or XXI of the Social 

6 Security Act. 

7 ‘‘(B) COORDINATION OF INFORMATION.— 

8 The Service shall provide the Administrator of 

9 the Centers for Medicare & Medicaid Services 

10 with copies of the lists submitted to the Service 

11 under paragraph (2)(C), enrollment data re12 garding patients served by the Service (and by 

13 Tribal Health Programs, to the extent such 

14 data is available to the Service), and such other 

15 information as the Administrator may require 

16 for purposes of administering title XVIII, XIX, 

17 or XXI of the Social Security Act. 

18 ‘‘(4) WITHDRAWAL FROM PROGRAM.—A Tribal 

19 Health Program that bills directly under the pro20 gram established under this subsection may with21 draw from participation in the same manner and 

22 under the same conditions that an Indian Tribe or 

23 Tribal Organization may retrocede a contracted pro24 gram to the Secretary under the authority of the In25 dian Self-Determination and Education Assistance 
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1 Act (25 U.S.C. 450 et seq.). All cost accounting and 

2 billing authority under the program established 

3 under this subsection shall be returned to the Sec4 retary upon the Secretary’s acceptance of the with5 drawal of participation in this program. 

6 ‘‘(5) TERMINATION FOR FAILURE TO COMPLY

7 WITH REQUIREMENTS.—The Secretary may termi8 nate the participation of a Tribal Health Program or 

9 in the direct billing program established under this 

10 subsection if the Secretary determines that the Pro11 gram has failed to comply with the requirements of 

12 paragraph (2). The Secretary shall provide a Tribal 

13 Health Program with notice of a determination that 

14 the Program has failed to comply with any such re15 quirement and a reasonable opportunity to correct 

16 such noncompliance prior to terminating the Pro17 gram’s participation in the direct billing program es18 tablished under this subsection. 

19 ‘‘(e) RELATED PROVISIONS UNDER THE SOCIAL SE20 CURITY ACT.—For provisions related to subsections (c) 

21 and (d), see sections 1880, 1911, and 2107(e)(1)(D) of 

22 the Social Security Act. 
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1 ‘‘SEC. 402. GRANTS TO AND CONTRACTS WITH THE SERV2 ICE, INDIAN TRIBES, TRIBAL ORGANIZA3 TIONS, AND URBAN INDIAN ORGANIZATIONS 

4 TO FACILITATE OUTREACH, ENROLLMENT, 

5 AND COVERAGE OF INDIANS UNDER SOCIAL 

6 SECURITY ACT HEALTH BENEFIT PROGRAMS. 

7 ‘‘(a) INDIAN TRIBES AND TRIBAL ORGANIZA8 TIONS.—The Secretary, acting through the Service, shall 

9 make grants to or enter into contracts with Indian Tribes 

10 and Tribal Organizations to assist such Tribes and Tribal 

11 Organizations in establishing and administering programs 

12 on or near reservations, trust lands, and Alaska Native 

13 Villages, including programs to provide outreach and en14 rollment through video, electronic delivery methods, or 

15 telecommunication devices that allow real-time or time-de16 layed communication between individual Indians and the 

17 benefit program, to assist individual Indians— 

18 ‘‘(1) to enroll for benefits under a program es19 tablished under title XVIII, XIX, or XXI of the So20 cial Security Act; and 

21 ‘‘(2) with respect to such programs for which 

22 the charging of premiums and cost sharing is not 

23 prohibited under such programs, to pay premiums or 

24 cost sharing for coverage for such benefits, which 

25 may be based on financial need (as determined by 

26 the Indian Tribe or Tribes or Tribal Organizations 
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1 being served based on a schedule of income levels de2 veloped or implemented by such Tribe, Tribes, or 

3 Tribal Organizations). 

4 ‘‘(b) CONDITIONS.—The Secretary, acting through 

5 the Service, shall place conditions as deemed necessary to 

6 effect the purpose of this section in any grant or contract 

7 which the Secretary makes with any Indian Tribe or Trib8 al Organization pursuant to this section. Such conditions 

9 shall include requirements that the Indian Tribe or Tribal 

10 Organization successfully undertake— 

11 ‘‘(1) to determine the population of Indians eli12 gible for the benefits described in subsection (a); 

13 ‘‘(2) to educate Indians with respect to the ben14 efits available under the respective programs; 

15 ‘‘(3) to provide transportation for such indi16 vidual Indians to the appropriate offices for enroll17 ment or applications for such benefits; and 

18 ‘‘(4) to develop and implement methods of im19 proving the participation of Indians in receiving ben20 efits under such programs. 

21 ‘‘(c) APPLICATION TO URBAN INDIAN ORGANIZA22 TIONS.— 

23 ‘‘(1) IN GENERAL.—The provisions of sub24 section (a) shall apply with respect to grants and 

25 other funding to urban Indian organizations with re-
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1 spect to populations served by such organizations in 

2 the same manner they apply to grants and contracts 

3 with Indian Tribes and Tribal Organizations with 

4 respect to programs on or near reservations. 

5 ‘‘(2) REQUIREMENTS.—The Secretary shall in6 clude in the grants or contracts made or provided 

7 under paragraph (1) requirements that are— 

8 ‘‘(A) consistent with the requirements im9 posed by the Secretary under subsection (b); 

10 ‘‘(B) appropriate to urban Indian organi11 zations and urban Indians; and 

12 ‘‘(C) necessary to effect the purposes of 

13 this section. 

14 ‘‘(d) FACILITATING COOPERATION IN ENROLLMENT

15 AND RETENTION.—The Secretary, acting through the 

16 Centers for Medicare & Medicaid Services, shall consult 

17 with States, the Service, Indian Tribes, Tribal Organiza18 tions, and urban Indian organizations to develop and dis19 seminate best practices with respect to facilitating agree20 ments between the States and Indian Tribes, Tribal Orga21 nizations, and urban Indian organizations relating to en22 rollment and retention of Indians in programs established 

23 under titles XVIII, XIX, and XXI of the Social Security 

24 Act. 
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1 ‘‘(e) AGREEMENTS TO IMPROVE ENROLLMENT OF

2 INDIANS UNDER SOCIAL SECURITY ACT HEALTH BENE3 FITS PROGRAMS.—For provisions relating to agreements 

4 between the Secretary and the Service, Indian Tribes, 

5 Tribal Organizations, and urban Indian organizations for 

6 the collection, preparation, and submission of applications 

7 by Indians for assistance under the Medicaid and chil8 dren’s health insurance programs established under titles 

9 XIX and XXI of the Social Security Act, and benefits 

10 under the Medicare program established under title XVIII 

11 of such Act, see subsections (a) and (b) of section 1139 

12 of the Social Security Act. 

13 ‘‘(f) DEFINITIONS.—In this section: 

14 ‘‘(1) PREMIUM.—The term ‘premium’ includes 

15 any enrollment fee or similar charge. 

16 ‘‘(2) COST SHARING.—The term ‘cost sharing’ 

17 includes any deduction, deductible, copayment, coin18 surance, or similar charge. 

19 ‘‘(3) BENEFITS.—The term ‘benefits’ means, 

20 with respect to— 

21 ‘‘(A) title XVIII of the Social Security Act, 

22 benefits under such title; 

23 ‘‘(B) title XIX of such Act, medical assist24 ance under such title; and 
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1 ‘‘(C) title XXI of such Act, assistance 

2 under such title. 

3 ‘‘SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PAR4 TIES OF COSTS OF HEALTH SERVICES. 

5 ‘‘(a) RIGHT OF RECOVERY.—Except as provided in 

6 subsection (f), the United States, an Indian Tribe, or 

7 Tribal Organization shall have the right to recover from 

8 an insurance company, health maintenance organization, 

9 employee benefit plan, third-party tortfeasor, or any other 

10 responsible or liable third party (including a political sub11 division or local governmental entity of a State) the rea12 sonable charges incurred by the Secretary, an Indian 

13 Tribe, or Tribal Organization, or, if higher, the highest 

14 amount the third party would pay for care and services 

15 furnished by providers other than governmental entities, 

16 in providing health services through the Service, an Indian 

17 Tribe, or Tribal Organization to any individual to the 

18 same extent that such individual, or any nongovernmental 

19 provider of such services, would be eligible to receive dam20 ages, reimbursement, or indemnification for such charges 

21 if— 

22 ‘‘(1) such services had been provided by a non23 governmental provider; and 
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1 ‘‘(2) such individual had been required to pay 

2 such charges or expenses and did pay such charges 

3 or expenses. 

4 ‘‘(b) LIMITATIONS ON RECOVERIES FROM STATES.— 

5 Subsection (a) shall provide a right of recovery against 

6 any State, only if the injury, illness, or disability for which 

7 health services were provided is covered under— 

8 ‘‘(1) workers’ compensation laws; or 

9 ‘‘(2) a no-fault automobile accident insurance 

10 plan or program. 

11 ‘‘(c) NONAPPLICATION OF OTHER LAWS.—No law of 

12 any State, or of any political subdivision of a State and 

13 no provision of any contract, insurance or health mainte14 nance organization policy, employee benefit plan, self-in15 surance plan, managed care plan, or other health care plan 

16 or program entered into or renewed after the date of the 

17 enactment of the Indian Health Care Amendments of 

18 1988, shall prevent or hinder the right of recovery of the 

19 United States, an Indian Tribe, or Tribal Organization 

20 under subsection (a). 

21 ‘‘(d) NO EFFECT ON PRIVATE RIGHTS OF ACTION.— 

22 No action taken by the United States, an Indian Tribe, 

23 or Tribal Organization to enforce the right of recovery 

24 provided under this section shall operate to deny to the 
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1 injured person the recovery for that portion of the person’s 

2 damage not covered hereunder. 

3 ‘‘(e) ENFORCEMENT.— 

4 ‘‘(1) IN GENERAL.—The United States, an In5 dian Tribe, or Tribal Organization may enforce the 

6 right of recovery provided under subsection (a) by— 

7 ‘‘(A) intervening or joining in any civil ac8 tion or proceeding brought— 

9 ‘‘(i) by the individual for whom health 

10 services were provided by the Secretary, an 

11 Indian Tribe, or Tribal Organization; or 

12 ‘‘(ii) by any representative or heirs of 

13 such individual, or 

14 ‘‘(B) instituting a civil action, including a 

15 civil action for injunctive relief and other relief 

16 and including, with respect to a political sub17 division or local governmental entity of a State, 

18 such an action against an official thereof. 

19 ‘‘(2) NOTICE.—All reasonable efforts shall be 

20 made to provide notice of action instituted under 

21 paragraph (1)(B) to the individual to whom health 

22 services were provided, either before or during the 

23 pendency of such action. 

24 ‘‘(3) RECOVERY FROM TORTFEASORS.— 
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1 ‘‘(A) IN GENERAL.—In any case in which 

2 an Indian Tribe or Tribal Organization that is 

3 authorized or required under a compact or con4 tract issued pursuant to the Indian Self-Deter5 mination and Education Assistance Act (25 

6 U.S.C. 450 et seq.) to furnish or pay for health 

7 services to a person who is injured or suffers a 

8 disease on or after the date of enactment of the 

9 Indian Health Care Improvement Act Amend10 ments of 2009 under circumstances that estab11 lish grounds for a claim of liability against the 

12 tortfeasor with respect to the injury or disease, 

13 the Indian Tribe or Tribal Organization shall 

14 have a right to recover from the tortfeasor (or 

15 an insurer of the tortfeasor) the reasonable 

16 value of the health services so furnished, paid 

17 for, or to be paid for, in accordance with the 

18 Federal Medical Care Recovery Act (42 U.S.C. 

19 2651 et seq.), to the same extent and under the 

20 same circumstances as the United States may 

21 recover under that Act. 

22 ‘‘(B) TREATMENT.—The right of an In23 dian Tribe or Tribal Organization to recover 

24 under subparagraph (A) shall be independent of 

25 the rights of the injured or diseased person 
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1 served by the Indian Tribe or Tribal Organiza2 tion. 

3 ‘‘(f) LIMITATION.—Absent specific written authoriza4 tion by the governing body of an Indian Tribe for the pe5 riod of such authorization (which may not be for a period 

6 of more than 1 year and which may be revoked at any 

7 time upon written notice by the governing body to the 

8 Service), the United States shall not have a right of recov9 ery under this section if the injury, illness, or disability 

10 for which health services were provided is covered under 

11 a self-insurance plan funded by an Indian Tribe, Tribal 

12 Organization, or urban Indian organization. Where such 

13 authorization is provided, the Service may receive and ex14 pend such amounts for the provision of additional health 

15 services consistent with such authorization. 

16 ‘‘(g) COSTS AND ATTORNEYS’ FEES.—In any action 

17 brought to enforce the provisions of this section, a pre18 vailing plaintiff shall be awarded its reasonable attorneys’ 

19 fees and costs of litigation. 

20 ‘‘(h) NONAPPLICATION OF CLAIMS FILING REQUIRE21 MENTS.—An insurance company, health maintenance or22 ganization, self-insurance plan, managed care plan, or 

23 other health care plan or program (under the Social Secu24 rity Act or otherwise) may not deny a claim for benefits 

25 submitted by the Service or by an Indian Tribe or Tribal 
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1 Organization based on the format in which the claim is 

2 submitted if such format complies with the format re3 quired for submission of claims under title XVIII of the 

4 Social Security Act or recognized under section 1175 of 

5 such Act. 

6 ‘‘(i) APPLICATION TO URBAN INDIAN ORGANIZA7 TIONS.—The previous provisions of this section shall apply 

8 to urban Indian organizations with respect to populations 

9 served by such Organizations in the same manner they 

10 apply to Indian Tribes and Tribal Organizations with re11 spect to populations served by such Indian Tribes and 

12 Tribal Organizations. 

13 ‘‘(j) STATUTE OF LIMITATIONS.—The provisions of 

14 section 2415 of title 28, United States Code, shall apply 

15 to all actions commenced under this section, and the ref16 erences therein to the United States are deemed to include 

17 Indian Tribes, Tribal Organizations, and urban Indian or18 ganizations. 

19 ‘‘(k) SAVINGS.—Nothing in this section shall be con20 strued to limit any right of recovery available to the 

21 United States, an Indian Tribe, or Tribal Organization 

22 under the provisions of any applicable, Federal, State, or 

23 Tribal law, including medical lien laws. 
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1 ‘‘SEC. 404. CREDITING OF REIMBURSEMENTS. 

2 ‘‘(a) RETENTION OF AMOUNTS FOR USE BY PRO3 GRAM.—Except as provided in section 202(f) (relating to 

4 the Catastrophic Health Emergency Fund) and section 

5 806 (relating to health services for ineligible persons), all 

6 reimbursements received or recovered, including under 

7 section 806, by reason of the provision of health services 

8 by the Service, by an Indian Tribe or Tribal Organization, 

9 or by an urban Indian organization, shall be credited to 

10 the Service, such Indian Tribe or Tribal Organization, or 

11 such urban Indian organization, respectively, and may be 

12 used as provided in section 401. In the case of such a 

13 service provided by or through a Service Unit, such 

14 amounts shall be credited to such unit and used for such 

15 purposes. 

16 ‘‘(b) NO OFFSET OF AMOUNTS.—The Service may 

17 not offset or limit any amount obligated to any Service 

18 Unit or entity receiving funding from the Service because 

19 of the receipt of reimbursements under subsection (a). 

20 ‘‘SEC. 405. PURCHASING HEALTH CARE COVERAGE. 

21 ‘‘(a) PURCHASING COVERAGE.— 

22 ‘‘(1) IN GENERAL.—Insofar as amounts are 

23 made available under law (including a provision of 

24 the Social Security Act, the Indian Self-Determina25 tion and Education Assistance Act (25 U.S.C. 450 

26 et seq.), or other law, other than under section 402) 
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1 to Indian Tribes, Tribal Organizations, and urban 

2 Indian organizations for health benefits for Service 

3 beneficiaries, Indian Tribes, Tribal Organizations, 

4 and urban Indian organizations may use such 

5 amounts to purchase health benefits coverage that 

6 qualifies as creditable coverage under section 

7 2701(c)(1) of the Public Health Service Act for such 

8 beneficiaries, including, subject to paragraph (2), 

9 through— 

10 ‘‘(A) a tribally owned and operated health 

11 care plan; 

12 ‘‘(B) a State or locally authorized or li13 censed health care plan; 

14 ‘‘(C) a health insurance provider or man15 aged care organization; or 

16 ‘‘(D) a self-insured plan. 

17 ‘‘(2) EXCEPTION.—The coverage provided 

18 under paragraph (1) may not include coverage con19 sisting of— 

20 ‘‘(A) benefits provided under a health flexi21 ble spending arrangement (as defined in section 

22 106(c)(2) of the Internal Revenue Code of 

23 1986); or 

24 ‘‘(B) a high deductible health plan (as de25 fined in section 223(c)(2) of such Code), with-
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1 out regard to whether the plan is purchased in 

2 conjunction with a health savings account (as 

3 defined under section 223(d) of such Code). 

4 ‘‘(3) PERMITTING PURCHASE OF COVERAGE

5 BASED ON FINANCIAL NEED.—The purchase of cov6 erage by an Indian Tribe, Tribal Organization, or 

7 urban Indian organization under this subsection may 

8 be based on the financial needs of beneficiaries (as 

9 determined by the Indian Tribe or Tribes being 

10 served based on a schedule of income levels devel11 oped or implemented by such Indian Tribe or 

12 Tribes). 

13 ‘‘(b) EXPENSES FOR SELF-INSURED PLAN.—In the 

14 case of a self-insured plan under subsection (a)(4), the 

15 amounts may be used for expenses of operating the plan, 

16 including administration and insurance to limit the finan17 cial risks to the entity offering the plan. 

18 ‘‘(c) CONSTRUCTION.—Nothing in this section shall 

19 be construed as affecting the use of any amounts not re20 ferred to in subsection (a). 

21 ‘‘SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGEN22 CIES. 

23 ‘‘(a) AUTHORITY.— 

24 ‘‘(1) IN GENERAL.—The Secretary may enter 

25 into (or expand) arrangements for the sharing of 
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1 medical facilities and services between the Service, 

2 Indian Tribes, and Tribal Organizations and the De3 partment of Veterans Affairs and the Department of 

4 Defense. 

5 ‘‘(2) CONSULTATION BY SECRETARY RE6 QUIRED.—The Secretary may not finalize any ar7 rangement between the Service and a Department 

8 described in paragraph (1) without first consulting 

9 with the Indian Tribes which will be significantly af10 fected by the arrangement. 

11 ‘‘(b) LIMITATIONS.—The Secretary shall not take 

12 any action under this section or under subchapter IV of 

13 chapter 81 of title 38, United States Code, which would 

14 impair— 

15 ‘‘(1) the priority access of any Indian to health 

16 care services provided through the Service and the 

17 eligibility of any Indian to receive health services 

18 through the Service; 

19 ‘‘(2) the quality of health care services provided 

20 to any Indian through the Service; 

21 ‘‘(3) the priority access of any veteran to health 

22 care services provided by the Department of Vet23 erans Affairs; 
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1 ‘‘(4) the quality of health care services provided 

2 by the Department of Veterans Affairs or the De3 partment of Defense; or 

4 ‘‘(5) the eligibility of any Indian who is a vet5 eran to receive health services through the Depart6 ment of Veterans Affairs. 

7 ‘‘(c) REIMBURSEMENT.—The Service, Indian Tribe, 

8 or Tribal Organization shall be reimbursed by the Depart9 ment of Veterans Affairs or the Department of Defense 

10 (as the case may be) where services are provided through 

11 the Service, an Indian Tribe, or a Tribal Organization to 

12 beneficiaries eligible for services from either such Depart13 ment, notwithstanding any other provision of law. 

14 ‘‘(d) CONSTRUCTION.—Nothing in this section may 

15 be construed as creating any right of a non-Indian veteran 

16 to obtain health services from the Service. 

17 ‘‘SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES. 

18 ‘‘(a) FINDINGS; PURPOSE.— 

19 ‘‘(1) FINDINGS.—Congress finds that— 

20 ‘‘(A) collaborations between the Secretary 

21 and the Secretary of Veterans Affairs regarding 

22 the treatment of Indian veterans at facilities of 

23 the Service should be encouraged to the max24 imum extent practicable; and 
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1 ‘‘(B) increased enrollment for services of 

2 the Department of Veterans Affairs by veterans 

3 who are members of Indian tribes should be en4 couraged to the maximum extent practicable. 

5 ‘‘(2) PURPOSE.—The purpose of this section is 

6 to reaffirm the goals stated in the document entitled 

7 ‘Memorandum of Understanding Between the VA/ 

8 Veterans Health Administration And HHS/Indian 

9 Health Service’ and dated February 25, 2003 (relat10 ing to cooperation and resource sharing between the 

11 Veterans Health Administration and Service). 

12 ‘‘(b) DEFINITIONS.—In this section: 

13 ‘‘(1) ELIGIBLE INDIAN VETERAN.—The term 

14 ‘eligible Indian veteran’ means an Indian or Alaska 

15 Native veteran who receives any medical service that 

16 is— 

17 ‘‘(A) authorized under the laws adminis18 tered by the Secretary of Veterans Affairs; and 

19 ‘‘(B) administered at a facility of the Serv20 ice (including a facility operated by an Indian 

21 tribe or tribal organization through a contract 

22 or compact with the Service under the Indian 

23 Self-Determination and Education Assistance 

24 Act (25 U.S.C. 450 et seq.)) pursuant to a local 

25 memorandum of understanding. 
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1 ‘‘(2) LOCAL MEMORANDUM OF UNDER2 STANDING.—The term ‘local memorandum of under3 standing’ means a memorandum of understanding 

4 between the Secretary (or a designee, including the 

5 director of any Area Office of the Service) and the 

6 Secretary of Veterans Affairs (or a designee) to im7 plement the document entitled ‘Memorandum of Un8 derstanding Between the VA/Veterans Health Ad9 ministration And HHS/Indian Health Service’ and 

10 dated February 25, 2003 (relating to cooperation 

11 and resource sharing between the Veterans Health 

12 Administration and Indian Health Service). 

13 ‘‘(c) ELIGIBLE INDIAN VETERANS’ EXPENSES.— 

14 ‘‘(1) IN GENERAL.—Notwithstanding any other 

15 provision of law, the Secretary shall provide for vet16 eran-related expenses incurred by eligible Indian vet17 erans as described in subsection (b)(1)(B). 

18 ‘‘(2) METHOD OF PAYMENT.—The Secretary 

19 shall establish such guidelines as the Secretary de20 termines to be appropriate regarding the method of 

21 payments to the Secretary of Veterans Affairs under 

22 paragraph (1). 

23 ‘‘(d) TRIBAL APPROVAL OF MEMORANDA.—In nego24 tiating a local memorandum of understanding with the 

25 Secretary of Veterans Affairs regarding the provision of 
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1 services to eligible Indian veterans, the Secretary shall 

2 consult with each Indian tribe that would be affected by 

3 the local memorandum of understanding. 

4 ‘‘(e) FUNDING.— 

5 ‘‘(1) TREATMENT.—Expenses incurred by the 

6 Secretary in carrying out subsection (c)(1) shall not 

7 be considered to be Contract Health Service ex8 penses. 

9 ‘‘(2) USE OF FUNDS.—Of funds made available 

10 to the Secretary in appropriations Acts for the Serv11 ice (excluding funds made available for facilities, 

12 Contract Health Services, or contract support costs), 

13 the Secretary shall use such sums as are necessary 

14 to carry out this section. 

15 ‘‘SEC. 408. PAYOR OF LAST RESORT. 

16 ‘‘Indian Health Programs and health care programs 

17 operated by Urban Indian Organizations shall be the 

18 payor of last resort for services provided to persons eligible 

19 for services from Indian Health Programs and Urban In20 dian Organizations, notwithstanding any Federal, State, 

21 or local law to the contrary. 

22 ‘‘SEC. 409. CONSULTATION. 

23 ‘‘For provisions related to consultation with rep24 resentatives of Indian Health Programs and urban Indian 

25 organizations with respect to the health care programs es-
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1 tablished under titles XVIII, XIX, and XXI of the Social 

2 Security Act, see section 1139(d) of the Social Security 

3 Act (42 U.S.C. 1320b–9(d)). 

4 ‘‘SEC. 410. STATE CHILDREN’S HEALTH INSURANCE PRO5 GRAM (SCHIP). 

6 ‘‘For provisions relating to— 

7 ‘‘(1) outreach to families of Indian children 

8 likely to be eligible for child health assistance under 

9 the State children’s health insurance program estab10 lished under title XXI of the Social Security Act, see 

11 sections 2105(c)(2)(C) and 1139(a) of such Act (42 

12 U.S.C. 1397ee(c)(2), 1320b–9); and 

13 ‘‘(2) ensuring that child health assistance is 

14 provided under such program to targeted low-income 

15 children who are Indians and that payments are 

16 made under such program to Indian Health Pro17 grams and urban Indian organizations operating in 

18 the State that provide such assistance, see sections 

19 2102(b)(3)(D) and 2105(c)(6)(B) of such Act (42 

20 U.S.C. 1397bb(b)(3)(D), 1397ee(c)(6)(B)). 
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1 ‘‘SEC. 411. PREMIUM AND COST SHARING PROTECTIONS 

2 AND ELIGIBILITY DETERMINATIONS UNDER 

3 MEDICAID AND SCHIP AND PROTECTION OF 

4 CERTAIN INDIAN PROPERTY FROM MEDICAID 

5 ESTATE RECOVERY. 

6 ‘‘For provisions relating to— 

7 ‘‘(1) premiums or cost sharing protections for 

8 Indians furnished items or services directly by In9 dian Health Programs or through referral under the 

10 contract health service under the Medicaid program 

11 established under title XIX of the Social Security 

12 Act, see sections 1916(j) and 1916A(a)(1) of the So13 cial Security Act (42 U.S.C. 1396o(j), 1396o– 

14 1(a)(1)); 

15 ‘‘(2) rules regarding the treatment of certain 

16 property for purposes of determining eligibility 

17 under such programs, see sections 1902(e)(13) and 

18 2107(e)(1)(B) of such Act (42 U.S.C. 1396a(e)(13), 

19 1397gg(e)(1)(B)); and 

20 ‘‘(3) the protection of certain property from es21 tate recovery provisions under the Medicaid pro22 gram, see section 1917(b)(3)(B) of such Act (42 

23 U.S.C. 1396p(b)(3)(B)). 
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1 ‘‘SEC. 412. TREATMENT UNDER MEDICAID AND SCHIP MAN2 AGED CARE. 

3 ‘‘For provisions relating to the treatment of Indians 

4 enrolled in a managed care entity under the Medicaid pro5 gram under title XIX of the Social Security Act and In6 dian Health Programs and urban Indian organizations 

7 that are providers of items or services to such Indian en8 rollees, see sections 1932(h) and 2107(e)(1)(H) of the So9 cial Security Act (42 U.S.C. 1396u–2(h), 

10 1397gg(e)(1)(H)). 

11 ‘‘SEC. 413. NAVAJO NATION MEDICAID AGENCY FEASI12 BILITY STUDY. 

13 ‘‘(a) STUDY.—The Secretary shall conduct a study 

14 to determine the feasibility of treating the Navajo Nation 

15 as a State for the purposes of title XIX of the Social Secu16 rity Act, to provide services to Indians living within the 

17 boundaries of the Navajo Nation through an entity estab18 lished having the same authority and performing the same 

19 functions as single-State Medicaid agencies responsible for 

20 the administration of the State plan under title XIX of 

21 the Social Security Act. 

22 ‘‘(b) CONSIDERATIONS.—In conducting the study, 

23 the Secretary shall consider the feasibility of— 

24 ‘‘(1) assigning and paying all expenditures for 

25 the provision of services and related administration 

26 funds, under title XIX of the Social Security Act, to 
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1 Indians living within the boundaries of the Navajo 

2 Nation that are currently paid to or would otherwise 

3 be paid to the State of Arizona, New Mexico, or 

4 Utah; 

5 ‘‘(2) providing assistance to the Navajo Nation 

6 in the development and implementation of such enti7 ty for the administration, eligibility, payment, and 

8 delivery of medical assistance under title XIX of the 

9 Social Security Act; 

10 ‘‘(3) providing an appropriate level of matching 

11 funds for Federal medical assistance with respect to 

12 amounts such entity expends for medical assistance 

13 for services and related administrative costs; and 

14 ‘‘(4) authorizing the Secretary, at the option of 

15 the Navajo Nation, to treat the Navajo Nation as a 

16 State for the purposes of title XIX of the Social Se17 curity Act (relating to the State children’s health in18 surance program) under terms equivalent to those 

19 described in paragraphs (2) through (4). 

20 ‘‘(c) REPORT.—Not later than 3 years after the date 

21 of enactment of the Indian Health Care Improvement Act 

22 Amendments of 2009, the Secretary shall submit to the 

23 Committee on Indian Affairs and Committee on Finance 

24 of the Senate and the Committee on Natural Resources 
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1 and Committee on Energy and Commerce of the House 

2 of Representatives a report that includes— 

3 ‘‘(1) the results of the study under this section; 

4 ‘‘(2) a summary of any consultation that oc5 curred between the Secretary and the Navajo Na6 tion, other Indian Tribes, the States of Arizona, 

7 New Mexico, and Utah, counties which include Nav8 ajo Lands, and other interested parties, in con9 ducting this study; 

10 ‘‘(3) projected costs or savings associated with 

11 establishment of such entity, and any estimated im12 pact on services provided as described in this section 

13 in relation to probable costs or savings; and 

14 ‘‘(4) legislative actions that would be required 

15 to authorize the establishment of such entity if such 

16 entity is determined by the Secretary to be feasible. 

17 ‘‘SEC. 414. EXCEPTION FOR EXCEPTED BENEFITS. 

18 ‘‘The previous provisions of this title shall not apply 

19 to the provision of excepted benefits described in para20 graph (1)(A) or (3) of section 2791(c) of the Public 

21 Health Service Act (42 U.S.C. 300gg–91(c)). 

22 ‘‘SEC. 415. AUTHORIZATION OF APPROPRIATIONS. 

23 ‘‘There are authorized to be appropriated such sums 

24 as may be necessary to carry out this title. 
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1 ‘‘TITLE V—HEALTH SERVICES 

2 FOR URBAN INDIANS 

3 ‘‘SEC. 501. PURPOSE. 

4 ‘‘The purpose of this title is to establish and maintain 

5 programs in Urban Centers to make health services more 

6 accessible and available to Urban Indians. 

7 ‘‘SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN IN8 DIAN ORGANIZATIONS. 

9 ‘‘Under authority of the Act of November 2, 1921 

10 (25 U.S.C. 13) (commonly known as the ‘Snyder Act’), 

11 the Secretary, acting through the Service, shall enter into 

12 contracts with, or make grants to, urban Indian organiza13 tions to assist such organizations in the establishment and 

14 administration, within Urban Centers, of programs which 

15 meet the requirements set forth in this title. Subject to 

16 section 506, the Secretary, acting through the Service, 

17 shall include such conditions as the Secretary considers 

18 necessary to effect the purpose of this title in any contract 

19 into which the Secretary enters with, or in any grant the 

20 Secretary makes to, any urban Indian organization pursu21 ant to this title. 

22 ‘‘SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION 

23 OF HEALTH CARE AND REFERRAL SERVICES. 

24 ‘‘(a) REQUIREMENTS FOR GRANTS AND CON25 TRACTS.—Under authority of the Act of November 2, 
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1 1921 (25 U.S.C. 13) (commonly known as the ‘Snyder 

2 Act’), the Secretary, acting through the Service, shall 

3 enter into contracts with, and make grants to, urban In4 dian organizations for the provision of health care and re5 ferral services for Urban Indians. Any such contract or 

6 grant shall include requirements that the urban Indian or7 ganization successfully undertake to— 

8 ‘‘(1) estimate the population of Urban Indians 

9 residing in the Urban Center or centers that the or10 ganization proposes to serve who are or could be re11 cipients of health care or referral services; 

12 ‘‘(2) estimate the current health status of 

13 Urban Indians residing in such Urban Center or 

14 centers; 

15 ‘‘(3) estimate the current health care needs of 

16 Urban Indians residing in such Urban Center or 

17 centers; 

18 ‘‘(4) provide basic health education, including 

19 health promotion and disease prevention education, 

20 to Urban Indians; 

21 ‘‘(5) make recommendations to the Secretary 

22 and Federal, State, local, and other resource agen23 cies on methods of improving health service pro24 grams to meet the needs of Urban Indians; and 
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1 ‘‘(6) where necessary, provide, or enter into 

2 contracts for the provision of, health care services 

3 for Urban Indians. 

4 ‘‘(b) CRITERIA.—The Secretary, acting through the 

5 Service, shall, by regulation, prescribe the criteria for se6 lecting urban Indian organizations to enter into contracts 

7 or receive grants under this section. Such criteria shall, 

8 among other factors, include— 

9 ‘‘(1) the extent of unmet health care needs of 

10 Urban Indians in the Urban Center or centers in11 volved; 

12 ‘‘(2) the size of the urban Indian population in 

13 the Urban Center or centers involved; 

14 ‘‘(3) the extent, if any, to which the activities 

15 set forth in subsection (a) would duplicate any 

16 project funded under this title, or under any current 

17 public health service project funded in a manner 

18 other than pursuant to this title; 

19 ‘‘(4) the capability of an urban Indian organiza20 tion to perform the activities set forth in subsection 

21 (a) and to enter into a contract with the Secretary 

22 or to meet the requirements for receiving a grant 

23 under this section; 
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1 ‘‘(5) the satisfactory performance and success2 ful completion by an urban Indian organization of 

3 other contracts with the Secretary under this title; 

4 ‘‘(6) the appropriateness and likely effectiveness 

5 of conducting the activities set forth in subsection 

6 (a) in an Urban Center or centers; and 

7 ‘‘(7) the extent of existing or likely future par8 ticipation in the activities set forth in subsection (a) 

9 by appropriate health and health-related Federal, 

10 State, local, and other agencies. 

11 ‘‘(c) ACCESS TO HEALTH PROMOTION AND DISEASE

12 PREVENTION PROGRAMS.—The Secretary, acting through 

13 the Service, shall facilitate access to or provide health pro14 motion and disease prevention services for Urban Indians 

15 through grants made to urban Indian organizations ad16 ministering contracts entered into or receiving grants 

17 under subsection (a). 

18 ‘‘(d) IMMUNIZATION SERVICES.— 

19 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

20 Secretary, acting through the Service, shall facilitate 

21 access to, or provide, immunization services for 

22 Urban Indians through grants made to urban Indian 

23 organizations administering contracts entered into or 

24 receiving grants under this section. 
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1 ‘‘(2) DEFINITION.—For purposes of this sub2 section, the term ‘immunization services’ means 

3 services to provide without charge immunizations 

4 against vaccine-preventable diseases. 

5 ‘‘(e) BEHAVIORAL HEALTH SERVICES.— 

6 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

7 Secretary, acting through the Service, shall facilitate 

8 access to, or provide, behavioral health services for 

9 Urban Indians through grants made to urban Indian 

10 organizations administering contracts entered into or 

11 receiving grants under subsection (a). 

12 ‘‘(2) ASSESSMENT REQUIRED.—Except as pro13 vided by paragraph (3)(A), a grant may not be made 

14 under this subsection to an urban Indian organiza15 tion until that organization has prepared, and the 

16 Service has approved, an assessment of the fol17 lowing: 

18 ‘‘(A) The behavioral health needs of the 

19 urban Indian population concerned. 

20 ‘‘(B) The behavioral health services and 

21 other related resources available to that popu22 lation. 

23 ‘‘(C) The barriers to obtaining those serv24 ices and resources. 
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1 ‘‘(D) The needs that are unmet by such 

2 services and resources. 

3 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

4 made under this subsection for the following: 

5 ‘‘(A) To prepare assessments required 

6 under paragraph (2). 

7 ‘‘(B) To provide outreach, educational, and 

8 referral services to Urban Indians regarding the 

9 availability of direct behavioral health services, 

10 to educate Urban Indians about behavioral 

11 health issues and services, and effect coordina12 tion with existing behavioral health providers in 

13 order to improve services to Urban Indians. 

14 ‘‘(C) To provide outpatient behavioral 

15 health services to Urban Indians, including the 

16 identification and assessment of illness, thera17 peutic treatments, case management, support 

18 groups, family treatment, and other treatment. 

19 ‘‘(D) To develop innovative behavioral 

20 health service delivery models which incorporate 

21 Indian cultural support systems and resources. 

22 ‘‘(f) PREVENTION OF CHILD ABUSE.— 

23 ‘‘(1) ACCESS OR SERVICES PROVIDED.—The 

24 Secretary, acting through the Service, shall facilitate 

25 access to or provide services for Urban Indians 
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1 through grants to urban Indian organizations ad2 ministering contracts entered into or receiving 

3 grants under subsection (a) to prevent and treat 

4 child abuse (including sexual abuse) among Urban 

5 Indians. 

6 ‘‘(2) EVALUATION REQUIRED.—Except as pro7 vided by paragraph (3)(A), a grant may not be made 

8 under this subsection to an urban Indian organiza9 tion until that organization has prepared, and the 

10 Service has approved, an assessment that documents 

11 the prevalence of child abuse in the urban Indian 

12 population concerned and specifies the services and 

13 programs (which may not duplicate existing services 

14 and programs) for which the grant is requested. 

15 ‘‘(3) PURPOSES OF GRANTS.—Grants may be 

16 made under this subsection for the following: 

17 ‘‘(A) To prepare assessments required 

18 under paragraph (2). 

19 ‘‘(B) For the development of prevention, 

20 training, and education programs for Urban In21 dians, including child education, parent edu22 cation, provider training on identification and 

23 intervention, education on reporting require24 ments, prevention campaigns, and establishing 
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1 service networks of all those involved in Indian 

2 child protection. 

3 ‘‘(C) To provide direct outpatient treat4 ment services (including individual treatment, 

5 family treatment, group therapy, and support 

6 groups) to Urban Indians who are child victims 

7 of abuse (including sexual abuse) or adult sur8 vivors of child sexual abuse, to the families of 

9 such child victims, and to urban Indian per10 petrators of child abuse (including sexual 

11 abuse). 

12 ‘‘(4) CONSIDERATIONS WHEN MAKING

13 GRANTS.—In making grants to carry out this sub14 section, the Secretary shall take into consideration— 

15 ‘‘(A) the support for the urban Indian or16 ganization demonstrated by the child protection 

17 authorities in the area, including committees or 

18 other services funded under the Indian Child 

19 Welfare Act of 1978 (25 U.S.C. 1901 et seq.), 

20 if any; 

21 ‘‘(B) the capability and expertise dem22 onstrated by the urban Indian organization to 

23 address the complex problem of child sexual 

24 abuse in the community; and 
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1 ‘‘(C) the assessment required under para2 graph (2). 

3 ‘‘(g) OTHER GRANTS.—The Secretary, acting 

4 through the Service, may enter into a contract with or 

5 make grants to an urban Indian organization that pro6 vides or arranges for the provision of health care services 

7 (through satellite facilities, provider networks, or other8 wise) to Urban Indians in more than 1 Urban Center. 

9 ‘‘SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND 

10 SOURCES OF SUPPLY. 

11 ‘‘(a) IN GENERAL.—The Secretary may permit an 

12 urban Indian organization that has entered into a contract 

13 or received a grant pursuant to this title, in carrying out 

14 such contract or grant, to use existing facilities and all 

15 equipment therein or pertaining thereto and other per16 sonal property owned by the Federal Government within 

17 the Secretary’s jurisdiction under such terms and condi18 tions as may be agreed upon for their use and mainte19 nance. 

20 ‘‘(b) DONATIONS.—Subject to subsection (d), the 

21 Secretary may donate to an urban Indian organization 

22 that has entered into a contract or received a grant pursu23 ant to this title any personal or real property determined 

24 to be excess to the needs of the Indian Health Service or 
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1 the General Services Administration for the purposes of 

2 carrying out the contract or grant. 

3 ‘‘(c) ACQUISITION OF PROPERTY.—The Secretary 

4 may acquire excess or surplus government personal or real 

5 property for donation, subject to subsection (d) to an 

6 urban Indian organization that has entered into a contract 

7 or received a grant pursuant to this title if the Secretary 

8 determines that the property is appropriate for use by the 

9 urban Indian organization for a purpose for which a con10 tract or grant is authorized under this title. 

11 ‘‘(d) PRIORITY.—In the event that the Secretary re12 ceives a request for a specific item of personal or real 

13 property described in subsections (b) or (c) from an urban 

14 Indian organization and from an Indian Tribe or Tribal 

15 Organization, the Secretary shall give priority to the re16 quest for donation to the Indian Tribe or Tribal Organiza17 tion if the Secretary receives the request from the Indian 

18 Tribe or Tribal Organization before the date the Secretary 

19 transfers title to the property or, if earlier, the date the 

20 Secretary transfers the property physically, to the urban 

21 Indian organization. 

22 ‘‘(e) EXECUTIVE AGENCY STATUS.—For purposes of 

23 section 201(a) of the Federal Property and Administrative 

24 Services Act of 1949 (40 U.S.C. 481(a)) (relating to Fed25 eral sources of supply), an urban Indian organization that 
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1 has entered into a contract or received a grant pursuant 

2 to this title may be deemed to be an executive agency when 

3 carrying out such contract or grant. 

4 ‘‘SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINA5 TION OF UNMET HEALTH CARE NEEDS. 

6 ‘‘(a) GRANTS AND CONTRACTS AUTHORIZED.— 

7 Under authority of the Act of November 2, 1921 (25 

8 U.S.C. 13) (commonly known as the ‘Snyder Act’), the 

9 Secretary, acting through the Service, may enter into con10 tracts with or make grants to urban Indian organizations 

11 situated in Urban Centers for which contracts have not 

12 been entered into or grants have not been made under sec13 tion 503. 

14 ‘‘(b) PURPOSE.—The purpose of a contract or grant 

15 made under this section shall be the determination of the 

16 matters described in subsection (c)(1) in order to assist 

17 the Secretary in assessing the health status and health 

18 care needs of Urban Indians in the Urban Center involved 

19 and determining whether the Secretary should enter into 

20 a contract or make a grant under section 503 with respect 

21 to the urban Indian organization which the Secretary has 

22 entered into a contract with, or made a grant to, under 

23 this section. 
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1 ‘‘(c) GRANT AND CONTRACT REQUIREMENTS.—Any 

2 contract entered into, or grant made, by the Secretary 

3 under this section shall include requirements that— 

4 ‘‘(1) the urban Indian organization successfully 

5 undertakes to— 

6 ‘‘(A) document the health care status and 

7 unmet health care needs of urban Indians in 

8 the Urban Center involved; and 

9 ‘‘(B) with respect to urban Indians in the 

10 Urban Center involved, determine the matters 

11 described in paragraphs (2), (3), (4), and (7) of 

12 section 503(b); and 

13 ‘‘(2) the urban Indian organization complete 

14 performance of the contract, or carry out the re15 quirements of the grant, within 1 year after the date 

16 on which the Secretary and such organization enter 

17 into such contract, or within 1 year after such orga18 nization receives such grant, whichever is applicable. 

19 ‘‘(d) NO RENEWALS.—The Secretary may not renew 

20 any contract entered into or grant made under this sec21 tion. 

22 ‘‘SEC. 506. EVALUATIONS; RENEWALS. 

23 ‘‘(a) PROCEDURES FOR EVALUATIONS.—The Sec24 retary, acting through the Service, shall develop proce25 dures to evaluate compliance with grant requirements and 
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1 compliance with and performance of contracts entered into 

2 by urban Indian organizations under this title. Such pro3 cedures shall include provisions for carrying out the re4 quirements of this section. 

5 ‘‘(b) EVALUATIONS.—The Secretary, acting through 

6 the Service, shall evaluate the compliance of each Urban 

7 Indian Organization which has entered into a contract or 

8 received a grant under section 503 with the terms of such 

9 contract or grant. For purposes of this evaluation, the 

10 Secretary shall— 

11 ‘‘(1) acting through the Service, conduct an an12 nual onsite evaluation of the organization; or 

13 ‘‘(2) accept in lieu of such onsite evaluation evi14 dence of the organization’s provisional or full accred15 itation by a private independent entity recognized by 

16 the Secretary for purposes of conducting quality re17 views of providers participating in the Medicare pro18 gram under title XVIII of the Social Security Act. 

19 ‘‘(c) NONCOMPLIANCE; UNSATISFACTORY PERFORM20 ANCE.—If, as a result of the evaluations conducted under 

21 this section, the Secretary determines that an urban In22 dian organization has not complied with the requirements 

23 of a grant or complied with or satisfactorily performed a 

24 contract under section 503, the Secretary shall, prior to 

25 renewing such contract or grant, attempt to resolve with 
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1 the organization the areas of noncompliance or unsatisfac2 tory performance and modify the contract or grant to pre3 vent future occurrences of noncompliance or unsatisfac4 tory performance. If the Secretary determines that the 

5 noncompliance or unsatisfactory performance cannot be 

6 resolved and prevented in the future, the Secretary shall 

7 not renew the contract or grant with the organization and 

8 is authorized to enter into a contract or make a grant 

9 under section 503 with another urban Indian organization 

10 which is situated in the same Urban Center as the urban 

11 Indian organization whose contract or grant is not re12 newed under this section. 

13 ‘‘(d) CONSIDERATIONS FOR RENEWALS.—In deter14 mining whether to renew a contract or grant with an 

15 urban Indian organization under section 503 which has 

16 completed performance of a contract or grant under sec17 tion 504, the Secretary shall review the records of the 

18 urban Indian organization, the reports submitted under 

19 section 507, and shall consider the results of the onsite 

20 evaluations or accreditations under subsection (b). 

21 ‘‘SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS. 

22 ‘‘(a) PROCUREMENT.—Contracts with urban Indian 

23 organizations entered into pursuant to this title shall be 

24 in accordance with all Federal contracting laws and regu25 lations relating to procurement except that in the discre-
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1 tion of the Secretary, such contracts may be negotiated 

2 without advertising and need not conform to the provisions 

3 of sections 1304 and 3131 through 3133 of title 40, 

4 United States Code. 

5 ‘‘(b) PAYMENTS UNDER CONTRACTS OR GRANTS.— 

6 ‘‘(1) IN GENERAL.—Payments under any con7 tracts or grants pursuant to this title, notwith8 standing any term or condition of such contract or 

9 grant— 

10 ‘‘(A) may be made in a single advance pay11 ment by the Secretary to the urban Indian or12 ganization by no later than the end of the first 

13 30 days of the funding period with respect to 

14 which the payments apply, unless the Secretary 

15 determines through an evaluation under section 

16 505 that the organization is not capable of ad17 ministering such a single advance payment; and 

18 ‘‘(B) if any portion thereof is unexpended 

19 by the urban Indian organization during the 

20 funding period with respect to which the pay21 ments initially apply, shall be carried forward 

22 for expenditure with respect to allowable or re23 imbursable costs incurred by the organization 

24 during 1 or more subsequent funding periods 

25 without additional justification or documenta-
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1 tion by the organization as a condition of car2 rying forward the availability for expenditure of 

3 such funds. 

4 ‘‘(2) SEMIANNUAL AND QUARTERLY PAYMENTS

5 AND REIMBURSEMENTS.—If the Secretary deter6 mines under paragraph (1)(A) that an urban Indian 

7 organization is not capable of administering an en8 tire single advance payment, on request of the urban 

9 Indian organization, the payments may be made— 

10 ‘‘(A) in semiannual or quarterly payments 

11 by not later than 30 days after the date on 

12 which the funding period with respect to which 

13 the payments apply begins; or 

14 ‘‘(B) by way of reimbursement. 

15 ‘‘(c) REVISION OR AMENDMENT OF CONTRACTS.— 

16 Notwithstanding any provision of law to the contrary, the 

17 Secretary may, at the request and consent of an urban 

18 Indian organization, revise or amend any contract entered 

19 into by the Secretary with such organization under this 

20 title as necessary to carry out the purposes of this title. 

21 ‘‘(d) FAIR AND UNIFORM SERVICES AND ASSIST22 ANCE.—Contracts with or grants to urban Indian organi23 zations and regulations adopted pursuant to this title shall 

24 include provisions to assure the fair and uniform provision 
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1 to urban Indians of services and assistance under such 

2 contracts or grants by such organizations. 

3 ‘‘SEC. 508. REPORTS AND RECORDS. 

4 ‘‘(a) REPORTS.— 

5 ‘‘(1) IN GENERAL.—For each fiscal year during 

6 which an urban Indian organization receives or ex7 pends funds pursuant to a contract entered into or 

8 a grant received pursuant to this title, such urban 

9 Indian organization shall submit to the Secretary 

10 not more frequently than every 6 months, a report 

11 that includes the following: 

12 ‘‘(A) In the case of a contract or grant 

13 under section 503, recommendations pursuant 

14 to section 503(a)(5). 

15 ‘‘(B) Information on activities conducted 

16 by the organization pursuant to the contract or 

17 grant. 

18 ‘‘(C) An accounting of the amounts and 

19 purpose for which Federal funds were ex20 pended. 

21 ‘‘(D) A minimum set of data, using uni22 formly defined elements, as specified by the 

23 Secretary after consultation with urban Indian 

24 organizations. 

25 ‘‘(2) HEALTH STATUS AND SERVICES.— 
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1 ‘‘(A) IN GENERAL.—Not later than 18 

2 months after the date of enactment of the In3 dian Health Care Improvement Act Amend4 ments of 2009, the Secretary, acting through 

5 the Service, shall submit to Congress a report 

6 evaluating— 

7 ‘‘(i) the health status of urban Indi8 ans; 

9 ‘‘(ii) the services provided to Indians 

10 pursuant to this title; and 

11 ‘‘(iii) areas of unmet needs in the de12 livery of health services to urban Indians. 

13 ‘‘(B) CONSULTATION AND CONTRACTS.— 

14 In preparing the report under paragraph (1), 

15 the Secretary— 

16 ‘‘(i) shall consult with urban Indian 

17 organizations; and 

18 ‘‘(ii) may enter into a contract with a 

19 national organization representing urban 

20 Indian organizations to conduct any aspect 

21 of the report. 

22 ‘‘(b) AUDIT.—The reports and records of the urban 

23 Indian organization with respect to a contract or grant 

24 under this title shall be subject to audit by the Secretary 

25 and the Comptroller General of the United States. 
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1 ‘‘(c) COSTS OF AUDITS.—The Secretary shall allow 

2 as a cost of any contract or grant entered into or awarded 

3 under section 502 or 503 the cost of an annual inde4 pendent financial audit conducted by— 

5 ‘‘(1) a certified public accountant; or 

6 ‘‘(2) a certified public accounting firm qualified 

7 to conduct Federal compliance audits. 

8 ‘‘SEC. 509. LIMITATION ON CONTRACT AUTHORITY. 

9 ‘‘The authority of the Secretary to enter into con10 tracts or to award grants under this title shall be to the 

11 extent, and in an amount, provided for in appropriation 

12 Acts. 

13 ‘‘SEC. 510. FACILITIES. 

14 ‘‘(a) GRANTS.—The Secretary, acting through the 

15 Service, may make grants to contractors or grant recipi16 ents under this title for the lease, purchase, renovation, 

17 construction, or expansion of facilities, including leased fa18 cilities, in order to assist such contractors or grant recipi19 ents in complying with applicable licensure or certification 

20 requirements. 

21 ‘‘(b) LOAN FUND STUDY.—The Secretary, acting 

22 through the Service, may carry out a study to determine 

23 the feasibility of establishing a loan fund to provide to 

24 urban Indian organizations direct loans or guarantees for 

25 loans for the construction of health care facilities in a 
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1 manner consistent with section 309, including by submit2 ting a report in accordance with subsection (c) of that sec3 tion. 

4 ‘‘SEC. 511. DIVISION OF URBAN INDIAN HEALTH. 

5 ‘‘There is established within the Service a Division 

6 of Urban Indian Health, which shall be responsible for— 

7 ‘‘(1) carrying out the provisions of this title; 

8 ‘‘(2) providing central oversight of the pro9 grams and services authorized under this title; and 

10 ‘‘(3) providing technical assistance to urban In11 dian organizations. 

12 ‘‘SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE13 RELATED SERVICES. 

14 ‘‘(a) GRANTS AUTHORIZED.—The Secretary, acting 

15 through the Service, may make grants for the provision 

16 of health-related services in prevention of, treatment of, 

17 rehabilitation of, or school- and community-based edu18 cation regarding, alcohol and substance abuse in Urban 

19 Centers to those urban Indian organizations with which 

20 the Secretary has entered into a contract under this title 

21 or under section 201. 

22 ‘‘(b) GOALS.—Each grant made pursuant to sub23 section (a) shall set forth the goals to be accomplished 

24 pursuant to the grant. The goals shall be specific to each 

25 grant as agreed to between the Secretary and the grantee. 
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1 ‘‘(c) CRITERIA.—The Secretary shall establish cri2 teria for the grants made under subsection (a), including 

3 criteria relating to the following: 

4 ‘‘(1) The size of the urban Indian population. 

5 ‘‘(2) Capability of the organization to ade6 quately perform the activities required under the 

7 grant. 

8 ‘‘(3) Satisfactory performance standards for the 

9 organization in meeting the goals set forth in such 

10 grant. The standards shall be negotiated and agreed 

11 to between the Secretary and the grantee on a 

12 grant-by-grant basis. 

13 ‘‘(4) Identification of the need for services. 

14 ‘‘(d) ALLOCATION OF GRANTS.—The Secretary shall 

15 develop a methodology for allocating grants made pursu16 ant to this section based on the criteria established pursu17 ant to subsection (c). 

18 ‘‘(e) GRANTS SUBJECT TO CRITERIA.—Any grant re19 ceived by an urban Indian organization under this Act for 

20 substance abuse prevention, treatment, and rehabilitation 

21 shall be subject to the criteria set forth in subsection (c). 
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1 ‘‘SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION 

2 PROJECTS. 

3 ‘‘Notwithstanding any other provision of law, the 

4 Tulsa Clinic and Oklahoma City Clinic demonstration 

5 projects shall— 

6 ‘‘(1) be permanent programs within the Serv7 ice’s direct care program; 

8 ‘‘(2) continue to be treated as Service Units 

9 and Operating Units in the allocation of resources 

10 and coordination of care; and 

11 ‘‘(3) continue to meet the requirements and 

12 definitions of an urban Indian organization in this 

13 Act, and shall not be subject to the provisions of the 

14 Indian Self-Determination and Education Assistance 

15 Act (25 U.S.C. 450 et seq.). 

16 ‘‘SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS. 

17 ‘‘(a) GRANTS AND CONTRACTS.—The Secretary, 

18 through the Division of Urban Indian Health, shall make 

19 grants or enter into contracts with urban Indian organiza20 tions, to take effect not later than September 30, 2010, 

21 for the administration of urban Indian alcohol programs 

22 that were originally established under the National Insti23 tute on Alcoholism and Alcohol Abuse (hereafter in this 

24 section referred to as ‘NIAAA’) and transferred to the 

25 Service. 
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1 ‘‘(b) USE OF FUNDS.—Grants provided or contracts 

2 entered into under this section shall be used to provide 

3 support for the continuation of alcohol prevention and 

4 treatment services for urban Indian populations and such 

5 other objectives as are agreed upon between the Service 

6 and a recipient of a grant or contract under this section. 

7 ‘‘(c) ELIGIBILITY.—Urban Indian organizations that 

8 operate Indian alcohol programs originally funded under 

9 the NIAAA and subsequently transferred to the Service 

10 are eligible for grants or contracts under this section. 

11 ‘‘(d) REPORT.—The Secretary shall evaluate and re12 port to Congress on the activities of programs funded 

13 under this section not less than every 5 years. 

14 ‘‘SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZA15 TIONS. 

16 ‘‘(a) IN GENERAL.—The Secretary shall ensure that 

17 the Service confers or conferences, to the greatest extent 

18 practicable, with Urban Indian Organizations. 

19 ‘‘(b) DEFINITION OF CONFER; CONFERENCE.—In 

20 this section, the terms ‘confer’ and ‘conference’ mean an 

21 open and free exchange of information and opinions 

22 that— 

23 ‘‘(1) leads to mutual understanding and com24 prehension; and 
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1 ‘‘(2) emphasizes trust, respect, and shared re2 sponsibility. 

3 ‘‘SEC. 516. URBAN YOUTH TREATMENT CENTER DEM4 ONSTRATION. 

5 ‘‘(a) CONSTRUCTION AND OPERATION.— 

6 ‘‘(1) IN GENERAL.—The Secretary, acting 

7 through the Service, through grant or contract, shall 

8 fund the construction and operation of at least 1 

9 residential treatment center in each Service Area 

10 that meets the eligibility requirements set forth in 

11 subsection (b) to demonstrate the provision of alco12 hol and substance abuse treatment services to Urban 

13 Indian youth in a culturally competent residential 

14 setting. 

15 ‘‘(2) TREATMENT.—Each residential treatment 

16 center described in paragraph (1) shall be in addi17 tion to any facilities constructed under section 

18 707(b). 

19 ‘‘(b) ELIGIBILITY REQUIREMENTS.—To be eligible to 

20 obtain a facility under subsection (a)(1), a Service Area 

21 shall meet the following requirements: 

22 ‘‘(1) There is an Urban Indian Organization in 

23 the Service Area. 
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1 ‘‘(2) There reside in the Service Area Urban In2 dian youth with need for alcohol and substance 

3 abuse treatment services in a residential setting. 

4 ‘‘(3) There is a significant shortage of cul5 turally competent residential treatment services for 

6 Urban Indian youth in the Service Area. 

7 ‘‘SEC. 517. GRANTS FOR DIABETES PREVENTION, TREAT8 MENT, AND CONTROL. 

9 ‘‘(a) GRANTS AUTHORIZED.—The Secretary may 

10 make grants to those urban Indian organizations that 

11 have entered into a contract or have received a grant 

12 under this title for the provision of services for the preven13 tion and treatment of, and control of the complications 

14 resulting from, diabetes among urban Indians. 

15 ‘‘(b) GOALS.—Each grant made pursuant to sub16 section (a) shall set forth the goals to be accomplished 

17 under the grant. The goals shall be specific to each grant 

18 as agreed to between the Secretary and the grantee. 

19 ‘‘(c) ESTABLISHMENT OF CRITERIA.—The Secretary 

20 shall establish criteria for the grants made under sub21 section (a) relating to— 

22 ‘‘(1) the size and location of the urban Indian 

23 population to be served; 

24 ‘‘(2) the need for prevention of and treatment 

25 of, and control of the complications resulting from, 
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1 diabetes among the urban Indian population to be 

2 served; 

3 ‘‘(3) performance standards for the organiza4 tion in meeting the goals set forth in such grant 

5 that are negotiated and agreed to by the Secretary 

6 and the grantee; 

7 ‘‘(4) the capability of the organization to ade8 quately perform the activities required under the 

9 grant; and 

10 ‘‘(5) the willingness of the organization to col11 laborate with the registry, if any, established by the 

12 Secretary under section 203(e)(1)(B) in the Area 

13 Office of the Service in which the organization is lo14 cated. 

15 ‘‘(d) FUNDS SUBJECT TO CRITERIA.—Any funds re16 ceived by an urban Indian organization under this Act for 

17 the prevention, treatment, and control of diabetes among 

18 urban Indians shall be subject to the criteria developed 

19 by the Secretary under subsection (c). 

20 ‘‘SEC. 518. COMMUNITY HEALTH REPRESENTATIVES. 

21 ‘‘The Secretary, acting through the Service, may 

22 enter into contracts with, and make grants to, urban In23 dian organizations for the employment of Indians trained 

24 as health service providers through the Community Health 

25 Representatives Program under section 109 in the provi-
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1 sion of health care, health promotion, and disease preven2 tion services to urban Indians. 

3 ‘‘SEC. 519. EFFECTIVE DATE. 

4 ‘‘The amendments made by the Indian Health Care 

5 Improvement Act Amendments of 2009 to this title shall 

6 take effect beginning on the date of enactment of that Act, 

7 regardless of whether the Secretary has promulgated regu8 lations implementing such amendments. 

9 ‘‘SEC. 520. ELIGIBILITY FOR SERVICES. 

10 ‘‘Urban Indians shall be eligible for, and the ultimate 

11 beneficiaries of, health care or referral services provided 

12 pursuant to this title. 

13 ‘‘SEC. 521. AUTHORIZATION OF APPROPRIATIONS. 

14 ‘‘(a) IN GENERAL.—There are authorized to be ap15 propriated such sums as may be necessary to carry out 

16 this title. 

17 ‘‘(b) URBAN INDIAN ORGANIZATIONS.—The Sec18 retary, acting through the Service, is authorized to estab19 lish programs, including programs for the awarding of 

20 grants, for urban Indian organizations that are identical 

21 to any programs established pursuant to section 126 (be22 havioral health training), section 209 (school health edu23 cation), section 211 (prevention of communicable dis24 eases), section 701 (behavioral health prevention and 
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1 treatment services), and section 707(g) (multidrug abuse 

2 program). 

3 ‘‘SEC. 522. HEALTH INFORMATION TECHNOLOGY. 

4 ‘‘The Secretary, acting through the Service, may 

5 make grants to urban Indian organizations under this title 

6 for the development, adoption, and implementation of 

7 health information technology (as defined in section 

8 3000(5) of the American Recovery and Reinvestment Act), 

9 telemedicine services development, and related infrastruc10 ture. 

11 ‘‘TITLE VI—ORGANIZATIONAL 

12 IMPROVEMENTS 

13 ‘‘SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERV14 ICE AS AN AGENCY OF THE PUBLIC HEALTH 

15 SERVICE. 

16 ‘‘(a) ESTABLISHMENT.— 

17 ‘‘(1) IN GENERAL.—In order to more effectively 

18 and efficiently carry out the responsibilities, authori19 ties, and functions of the United States to provide 

20 health care services to Indians and Indian Tribes, as 

21 are or may be hereafter provided by Federal statute 

22 or treaties, there is established within the Public 

23 Health Service of the Department the Indian Health 

24 Service. 
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1 ‘‘(2) ASSISTANT SECRETARY OF INDIAN

2 HEALTH.—The Service shall be administered by an 

3 Assistant Secretary of Indian Health, who shall be 

4 appointed by the President, by and with the advice 

5 and consent of the Senate. The Assistant Secretary 

6 shall report to the Secretary. Effective with respect 

7 to an individual appointed by the President, by and 

8 with the advice and consent of the Senate, after 

9 January 1, 2010, the term of service of the Assist10 ant Secretary shall be 4 years. An Assistant Sec11 retary may serve more than 1 term. 

12 ‘‘(3) INCUMBENT.—The individual serving in 

13 the position of Director of the Service on the day be14 fore the date of enactment of the Indian Health 

15 Care Improvement Act Amendments of 2009 shall 

16 serve as Assistant Secretary. 

17 ‘‘(4) ADVOCACY AND CONSULTATION.—The po18 sition of Assistant Secretary is established to, in a 

19 manner consistent with the government-to-govern20 ment relationship between the United States and In21 dian Tribes— 

22 ‘‘(A) facilitate advocacy for the develop23 ment of appropriate Indian health policy; and 

24 ‘‘(B) promote consultation on matters re25 lating to Indian health. 
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1 ‘‘(b) AGENCY.—The Service shall be an agency within 

2 the Public Health Service of the Department, and shall 

3 not be an office, component, or unit of any other agency 

4 of the Department. 

5 ‘‘(c) DUTIES.—The Assistant Secretary shall— 

6 ‘‘(1) perform all functions that were, on the day 

7 before the date of enactment of the Indian Health 

8 Care Improvement Act Amendments of 2009, car9 ried out by or under the direction of the individual 

10 serving as Director of the Service on that day; 

11 ‘‘(2) perform all functions of the Secretary re12 lating to the maintenance and operation of hospital 

13 and health facilities for Indians and the planning 

14 for, and provision and utilization of, health services 

15 for Indians; 

16 ‘‘(3) administer all health programs under 

17 which health care is provided to Indians based upon 

18 their status as Indians which are administered by 

19 the Secretary, including programs under— 

20 ‘‘(A) this Act; 

21 ‘‘(B) the Act of November 2, 1921 (25 

22 U.S.C. 13); 

23 ‘‘(C) the Act of August 5, 1954 (42 U.S.C. 

24 2001 et seq.); 
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1 ‘‘(D) the Act of August 16, 1957 (42 

2 U.S.C. 2005 et seq.); and 

3 ‘‘(E) the Indian Self-Determination and 

4 Education Assistance Act (25 U.S.C. 450 et 

5 seq.); 

6 ‘‘(4) administer all scholarship and loan func7 tions carried out under title I; 

8 ‘‘(5) report directly to the Secretary concerning 

9 all policy- and budget-related matters affecting In10 dian health; 

11 ‘‘(6) collaborate with the Assistant Secretary 

12 for Health concerning appropriate matters of Indian 

13 health that affect the agencies of the Public Health 

14 Service; 

15 ‘‘(7) advise each Assistant Secretary of the De16 partment concerning matters of Indian health with 

17 respect to which that Assistant Secretary has au18 thority and responsibility; 

19 ‘‘(8) advise the heads of other agencies and pro20 grams of the Department concerning matters of In21 dian health with respect to which those heads have 

22 authority and responsibility; 

23 ‘‘(9) coordinate the activities of the Department 

24 concerning matters of Indian health; and 
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1 ‘‘(10) perform such other functions as the Sec2 retary may designate. 

3 ‘‘(d) AUTHORITY.— 

4 ‘‘(1) IN GENERAL.—The Secretary, acting 

5 through the Assistant Secretary, shall have the au6 thority— 

7 ‘‘(A) except to the extent provided for in 

8 paragraph (2), to appoint and compensate em9 ployees for the Service in accordance with title 

10 5, United States Code; 

11 ‘‘(B) to enter into contracts for the pro12 curement of goods and services to carry out the 

13 functions of the Service; and 

14 ‘‘(C) to manage, expend, and obligate all 

15 funds appropriated for the Service. 

16 ‘‘(2) PERSONNEL ACTIONS.—Notwithstanding 

17 any other provision of law, the provisions of section 

18 12 of the Act of June 18, 1934 (48 Stat. 986; 25 

19 U.S.C. 472), shall apply to all personnel actions 

20 taken with respect to new positions created within 

21 the Service as a result of its establishment under 

22 subsection (a). 

23 ‘‘(e) REFERENCES.—Any reference to the Director of 

24 the Indian Health Service in any other Federal law, Exec25 utive order, rule, regulation, or delegation of authority, or 
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1 in any document of or relating to the Director of the In2 dian Health Service, shall be deemed to refer to the Assist3 ant Secretary. 

4 ‘‘SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYS5 TEM. 

6 ‘‘(a) ESTABLISHMENT.— 

7 ‘‘(1) IN GENERAL.—The Secretary shall estab8 lish an automated management information system 

9 for the Service. 

10 ‘‘(2) REQUIREMENTS OF SYSTEM.—The infor11 mation system established under paragraph (1) shall 

12 include— 

13 ‘‘(A) a financial management system; 

14 ‘‘(B) a patient care information system for 

15 each area served by the Service; 

16 ‘‘(C) privacy protections consistent with 

17 the regulations promulgated under section 

18 264(c) of the Health Insurance Portability and 

19 Accountability Act of 1996 or, to the extent 

20 consistent with such regulations, other Federal 

21 rules applicable to privacy of automated man22 agement information systems of a Federal 

23 agency; 

24 ‘‘(D) a services-based cost accounting com25 ponent that provides estimates of the costs as-
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1 sociated with the provision of specific medical 

2 treatments or services in each Area office of the 

3 Service; 

4 ‘‘(E) an interface mechanism for patient 

5 billing and accounts receivable system; and 

6 ‘‘(F) a training component. 

7 ‘‘(b) PROVISION OF SYSTEMS TO TRIBES AND ORGA8 NIZATIONS.—The Secretary shall provide each Tribal 

9 Health Program automated management information sys10 tems which— 

11 ‘‘(1) meet the management information needs 

12 of such Tribal Health Program with respect to the 

13 treatment by the Tribal Health Program of patients 

14 of the Service; and 

15 ‘‘(2) meet the management information needs 

16 of the Service. 

17 ‘‘(c) ACCESS TO RECORDS.—The Service shall pro18 vide access of patients to their medical or health records 

19 which are held by, or on behalf of, the Service in accord20 ance with the regulations promulgated under section 

21 264(c) of the Health Insurance Portability and Account22 ability Act of 1996 or, to the extent consistent with such 

23 regulations, other Federal rules applicable to access to 

24 health care records. 
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1 ‘‘(d) AUTHORITY TO ENHANCE INFORMATION TECH2 NOLOGY.—The Secretary, acting through the Assistant 

3 Secretary, shall have the authority to enter into contracts, 

4 agreements, or joint ventures with other Federal agencies, 

5 States, private and nonprofit organizations, for the pur6 pose of enhancing information technology in Indian 

7 Health Programs and facilities. 

8 ‘‘SEC. 603. AUTHORIZATION OF APPROPRIATIONS. 

9 ‘‘There is authorized to be appropriated such sums 

10 as may be necessary to carry out this title. 

11 ‘‘TITLE VII—BEHAVIORAL 

12 HEALTH PROGRAMS 

13 ‘‘SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREAT14 MENT SERVICES. 

15 ‘‘(a) PURPOSES.—The purposes of this section are as 

16 follows: 

17 ‘‘(1) To authorize and direct the Secretary, act18 ing through the Service, to develop a comprehensive 

19 behavioral health prevention and treatment program 

20 which emphasizes collaboration among alcohol and 

21 substance abuse, social services, and mental health 

22 programs. 

23 ‘‘(2) To provide information, direction, and 

24 guidance relating to mental illness and dysfunction 

25 and self-destructive behavior, including child abuse 
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1 and family violence, to those Federal, tribal, State, 

2 and local agencies responsible for programs in In3 dian communities in areas of health care, education, 

4 social services, child and family welfare, alcohol and 

5 substance abuse, law enforcement, and judicial serv6 ices. 

7 ‘‘(3) To assist Indian Tribes to identify services 

8 and resources available to address mental illness and 

9 dysfunctional and self-destructive behavior. 

10 ‘‘(4) To provide authority and opportunities for 

11 Indian Tribes and Tribal Organizations to develop, 

12 implement, and coordinate with community-based 

13 programs which include identification, prevention, 

14 education, referral, and treatment services, including 

15 through multidisciplinary resource teams. 

16 ‘‘(5) To ensure that Indians, as citizens of the 

17 United States and of the States in which they re18 side, have the same access to behavioral health serv19 ices to which all citizens have access. 

20 ‘‘(6) To modify or supplement existing pro21 grams and authorities in the areas identified in 

22 paragraph (2). 

23 ‘‘(b) PLANS.— 

24 ‘‘(1) DEVELOPMENT.—The Secretary, acting 

25 through the Service, shall encourage Indian Tribes 
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1 and Tribal Organizations to develop tribal plans, 

2 and urban Indian organizations to develop local 

3 plans, and for all such groups to participate in de4 veloping areawide plans for Indian Behavioral 

5 Health Services. The plans shall include, to the ex6 tent feasible, the following components: 

7 ‘‘(A) An assessment of the scope of alcohol 

8 or other substance abuse, mental illness, and 

9 dysfunctional and self-destructive behavior, in10 cluding suicide, child abuse, and family vio11 lence, among Indians, including— 

12 ‘‘(i) the number of Indians served who 

13 are directly or indirectly affected by such 

14 illness or behavior; or 

15 ‘‘(ii) an estimate of the financial and 

16 human cost attributable to such illness or 

17 behavior. 

18 ‘‘(B) An assessment of the existing and 

19 additional resources necessary for the preven20 tion and treatment of such illness and behavior, 

21 including an assessment of the progress toward 

22 achieving the availability of the full continuum 

23 of care described in subsection (c). 

24 ‘‘(C) An estimate of the additional funding 

25 needed by the Service, Indian Tribes, Tribal 
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1 Organizations, and urban Indian organizations 

2 to meet their responsibilities under the plans. 

3 ‘‘(2) NATIONAL CLEARINGHOUSE.—The Sec4 retary, acting through the Service, shall coordinate 

5 with existing national clearinghouses and informa6 tion centers to include at the clearinghouses and 

7 centers plans and reports on the outcomes of such 

8 plans developed by Indian Tribes, Tribal Organiza9 tions, urban Indian organizations, and Service Areas 

10 relating to behavioral health. The Secretary shall en11 sure access to these plans and outcomes by any In12 dian Tribe, Tribal Organization, urban Indian orga13 nization, or the Service. 

14 ‘‘(3) TECHNICAL ASSISTANCE.—The Secretary 

15 shall provide technical assistance to Indian Tribes, 

16 Tribal Organizations, and urban Indian organiza17 tions in preparation of plans under this section and 

18 in developing standards of care that may be used 

19 and adopted locally. 

20 ‘‘(c) PROGRAMS.—The Secretary, acting through the 

21 Service, shall provide, to the extent feasible and if funding 

22 is available, programs including the following: 

23 ‘‘(1) COMPREHENSIVE CARE.—A comprehensive 

24 continuum of behavioral health care which pro25 vides— 
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1 ‘‘(A) community-based prevention, inter2 vention, outpatient, and behavioral health 

3 aftercare; 

4 ‘‘(B) detoxification (social and medical); 

5 ‘‘(C) acute hospitalization; 

6 ‘‘(D) intensive outpatient/day treatment; 

7 ‘‘(E) residential treatment; 

8 ‘‘(F) transitional living for those needing a 

9 temporary, stable living environment that is 

10 supportive of treatment and recovery goals; 

11 ‘‘(G) emergency shelter; 

12 ‘‘(H) intensive case management; and 

13 ‘‘(I) diagnostic services. 

14 ‘‘(2) CHILD CARE.—Behavioral health services 

15 for Indians from birth through age 17, including— 

16 ‘‘(A) preschool and school age fetal alcohol 

17 disorder services, including assessment and be18 havioral intervention; 

19 ‘‘(B) mental health and substance abuse 

20 services (emotional, organic, alcohol, drug, in21 halant, and tobacco); 

22 ‘‘(C) identification and treatment of co-oc23 curring disorders and comorbidity; 

24 ‘‘(D) prevention of alcohol, drug, inhalant, 

25 and tobacco use; 
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1 ‘‘(E) early intervention, treatment, and 

2 aftercare; 

3 ‘‘(F) promotion of healthy approaches to 

4 risk and safety issues; and 

5 ‘‘(G) identification and treatment of ne6 glect and physical, mental, and sexual abuse. 

7 ‘‘(3) ADULT CARE.—Behavioral health services 

8 for Indians from age 18 through 55, including— 

9 ‘‘(A) early intervention, treatment, and 

10 aftercare; 

11 ‘‘(B) mental health and substance abuse 

12 services (emotional, alcohol, drug, inhalant, and 

13 tobacco), including sex specific services; 

14 ‘‘(C) identification and treatment of co-oc15 curring disorders (dual diagnosis) and comor16 bidity; 

17 ‘‘(D) promotion of healthy approaches for 

18 risk-related behavior; 

19 ‘‘(E) treatment services for women at risk 

20 of giving birth to a child with a fetal alcohol 

21 disorder; and 

22 ‘‘(F) sex specific treatment for sexual as23 sault and domestic violence. 

24 ‘‘(4) FAMILY CARE.—Behavioral health services 

25 for families, including— 
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1 ‘‘(A) early intervention, treatment, and 

2 aftercare for affected families; 

3 ‘‘(B) treatment for sexual assault and do4 mestic violence; and 

5 ‘‘(C) promotion of healthy approaches re6 lating to parenting, domestic violence, and other 

7 abuse issues. 

8 ‘‘(5) ELDER CARE.—Behavioral health services 

9 for Indians 56 years of age and older, including— 

10 ‘‘(A) early intervention, treatment, and 

11 aftercare; 

12 ‘‘(B) mental health and substance abuse 

13 services (emotional, alcohol, drug, inhalant, and 

14 tobacco), including sex specific services; 

15 ‘‘(C) identification and treatment of co-oc16 curring disorders (dual diagnosis) and comor17 bidity; 

18 ‘‘(D) promotion of healthy approaches to 

19 managing conditions related to aging; 

20 ‘‘(E) sex specific treatment for sexual as21 sault, domestic violence, neglect, physical and 

22 mental abuse and exploitation; and 

23 ‘‘(F) identification and treatment of de24 mentias regardless of cause. 

25 ‘‘(d) COMMUNITY BEHAVIORAL HEALTH PLAN.— 
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1 ‘‘(1) ESTABLISHMENT.—The governing body of 

2 any Indian Tribe, Tribal Organization, or urban In3 dian organization may adopt a resolution for the es4 tablishment of a community behavioral health plan 

5 providing for the identification and coordination of 

6 available resources and programs to identify, pre7 vent, or treat substance abuse, mental illness, or 

8 dysfunctional and self-destructive behavior, including 

9 child abuse and family violence, among its members 

10 or its service population. This plan should include 

11 behavioral health services, social services, intensive 

12 outpatient services, and continuing aftercare. 

13 ‘‘(2) TECHNICAL ASSISTANCE.—At the request 

14 of an Indian Tribe, Tribal Organization, or urban 

15 Indian organization, the Bureau of Indian Affairs 

16 and the Service shall cooperate with and provide 

17 technical assistance to the Indian Tribe, Tribal Or18 ganization, or urban Indian organization in the de19 velopment and implementation of such plan. 

20 ‘‘(3) FUNDING.—The Secretary, acting through 

21 the Service, may make funding available to Indian 

22 Tribes and Tribal Organizations which adopt a reso23 lution pursuant to paragraph (1) to obtain technical 

24 assistance for the development of a community be-
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1 havioral health plan and to provide administrative 

2 support in the implementation of such plan. 

3 ‘‘(e) COORDINATION FOR AVAILABILITY OF SERV4 ICES.—The Secretary, acting through the Service, shall 

5 coordinate behavioral health planning, to the extent fea6 sible, with other Federal agencies and with State agencies, 

7 to encourage comprehensive behavioral health services for 

8 Indians regardless of their place of residence. 

9 ‘‘(f) MENTAL HEALTH CARE NEED ASSESSMENT.— 

10 Not later than 1 year after the date of enactment of the 

11 Indian Health Care Improvement Act Amendments of 

12 2009, the Secretary, acting through the Service, shall 

13 make an assessment of the need for inpatient mental 

14 health care among Indians and the availability and cost 

15 of inpatient mental health facilities which can meet such 

16 need. In making such assessment, the Secretary shall con17 sider the possible conversion of existing, underused Service 

18 hospital beds into psychiatric units to meet such need. 

19 ‘‘SEC. 702. MEMORANDA OF AGREEMENT WITH THE DE20 PARTMENT OF THE INTERIOR. 

21 ‘‘(a) CONTENTS.—Not later than 12 months after the 

22 date of enactment of the Indian Health Care Improvement 

23 Act Amendments of 2009, the Secretary, acting through 

24 the Service, and the Secretary of the Interior shall develop 

25 and enter into a memoranda of agreement, or review and 
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1 update any existing memoranda of agreement, as required 

2 by section 4205 of the Indian Alcohol and Substance 

3 Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 

4 2411) under which the Secretaries address the following: 

5 ‘‘(1) The scope and nature of mental illness and 

6 dysfunctional and self-destructive behavior, including 

7 child abuse and family violence, among Indians. 

8 ‘‘(2) The existing Federal, tribal, State, local, 

9 and private services, resources, and programs avail10 able to provide behavioral health services for Indi11 ans. 

12 ‘‘(3) The unmet need for additional services, re13 sources, and programs necessary to meet the needs 

14 identified pursuant to paragraph (1). 

15 ‘‘(4)(A) The right of Indians, as citizens of the 

16 United States and of the States in which they re17 side, to have access to behavioral health services to 

18 which all citizens have access. 

19 ‘‘(B) The right of Indians to participate in, and 

20 receive the benefit of, such services. 

21 ‘‘(C) The actions necessary to protect the exer22 cise of such right. 

23 ‘‘(5) The responsibilities of the Bureau of In24 dian Affairs and the Service, including mental illness 

25 identification, prevention, education, referral, and 
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1 treatment services (including services through multi2 disciplinary resource teams), at the central, area, 

3 and agency and Service Unit, Service Area, and 

4 headquarters levels to address the problems identi5 fied in paragraph (1). 

6 ‘‘(6) A strategy for the comprehensive coordina7 tion of the behavioral health services provided by the 

8 Bureau of Indian Affairs and the Service to meet 

9 the problems identified pursuant to paragraph (1), 

10 including— 

11 ‘‘(A) the coordination of alcohol and sub12 stance abuse programs of the Service, the Bu13 reau of Indian Affairs, and Indian Tribes and 

14 Tribal Organizations (developed under the In15 dian Alcohol and Substance Abuse Prevention 

16 and Treatment Act of 1986 (25 U.S.C. 2401 et 

17 seq.)) with behavioral health initiatives pursu18 ant to this Act, particularly with respect to the 

19 referral and treatment of dually diagnosed indi20 viduals requiring behavioral health and sub21 stance abuse treatment; and 

22 ‘‘(B) ensuring that the Bureau of Indian 

23 Affairs and Service programs and services (in24 cluding multidisciplinary resource teams) ad25 dressing child abuse and family violence are co-
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1 ordinated with such non-Federal programs and 

2 services. 

3 ‘‘(7) Directing appropriate officials of the Bu4 reau of Indian Affairs and the Service, particularly 

5 at the agency and Service Unit levels, to cooperate 

6 fully with tribal requests made pursuant to commu7 nity behavioral health plans adopted under section 

8 701(c) and section 4206 of the Indian Alcohol and 

9 Substance Abuse Prevention and Treatment Act of 

10 1986 (25 U.S.C. 2412). 

11 ‘‘(8) Providing for an annual review of such 

12 agreement by the Secretaries which shall be provided 

13 to Congress and Indian Tribes and Tribal Organiza14 tions. 

15 ‘‘(b) SPECIFIC PROVISIONS REQUIRED.—The memo16 randa of agreement updated or entered into pursuant to 

17 subsection (a) shall include specific provisions pursuant to 

18 which the Service shall assume responsibility for— 

19 ‘‘(1) the determination of the scope of the prob20 lem of alcohol and substance abuse among Indians, 

21 including the number of Indians within the jurisdic22 tion of the Service who are directly or indirectly af23 fected by alcohol and substance abuse and the finan24 cial and human cost; 
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1 ‘‘(2) an assessment of the existing and needed 

2 resources necessary for the prevention of alcohol and 

3 substance abuse and the treatment of Indians af4 fected by alcohol and substance abuse; and 

5 ‘‘(3) an estimate of the funding necessary to 

6 adequately support a program of prevention of alco7 hol and substance abuse and treatment of Indians 

8 affected by alcohol and substance abuse. 

9 ‘‘(c) PUBLICATION.—Each memorandum of agree10 ment entered into or renewed (and amendments or modi11 fications thereto) under subsection (a) shall be published 

12 in the Federal Register. At the same time as publication 

13 in the Federal Register, the Secretary shall provide a copy 

14 of such memoranda, amendment, or modification to each 

15 Indian Tribe, Tribal Organization, and urban Indian orga16 nization. 

17 ‘‘SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PRE18 VENTION AND TREATMENT PROGRAM. 

19 ‘‘(a) ESTABLISHMENT.— 

20 ‘‘(1) IN GENERAL.—The Secretary, acting 

21 through the Service, shall provide a program of com22 prehensive behavioral health, prevention, treatment, 

23 and aftercare, including Systems of Care, which 

24 shall include— 
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1 ‘‘(A) prevention, through educational inter2 vention, in Indian communities; 

3 ‘‘(B) acute detoxification, psychiatric hos4 pitalization, residential, and intensive outpatient 

5 treatment; 

6 ‘‘(C) community-based rehabilitation and 

7 aftercare; 

8 ‘‘(D) community education and involve9 ment, including extensive training of health 

10 care, educational, and community-based per11 sonnel; 

12 ‘‘(E) specialized residential treatment pro13 grams for high-risk populations, including preg14 nant and postpartum women and their children; 

15 and 

16 ‘‘(F) diagnostic services. 

17 ‘‘(2) TARGET POPULATIONS.—The target popu18 lation of such programs shall be members of Indian 

19 Tribes. Efforts to train and educate key members of 

20 the Indian community shall also target employees of 

21 health, education, judicial, law enforcement, legal, 

22 and social service programs. 

23 ‘‘(b) CONTRACT HEALTH SERVICES.— 

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

25 through the Service, may enter into contracts with 
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1 public or private providers of behavioral health treat2 ment services for the purpose of carrying out the 

3 program required under subsection (a). 

4 ‘‘(2) PROVISION OF ASSISTANCE.—In carrying 

5 out this subsection, the Secretary shall provide as6 sistance to Indian Tribes and Tribal Organizations 

7 to develop criteria for the certification of behavioral 

8 health service providers and accreditation of service 

9 facilities which meet minimum standards for such 

10 services and facilities. 

11 ‘‘SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM. 

12 ‘‘(a) IN GENERAL.—Under the authority of the Act 

13 of November 2, 1921 (25 U.S.C. 13) (commonly known 

14 as the ‘Snyder Act’), the Secretary shall establish and 

15 maintain a mental health technician program within the 

16 Service which— 

17 ‘‘(1) provides for the training of Indians as 

18 mental health technicians; and 

19 ‘‘(2) employs such technicians in the provision 

20 of community-based mental health care that includes 

21 identification, prevention, education, referral, and 

22 treatment services. 

23 ‘‘(b) PARAPROFESSIONAL TRAINING.—In carrying 

24 out subsection (a), the Secretary, acting through the Serv25 ice, shall provide high-standard paraprofessional training 
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1 in mental health care necessary to provide quality care to 

2 the Indian communities to be served. Such training shall 

3 be based upon a curriculum developed or approved by the 

4 Secretary which combines education in the theory of men5 tal health care with supervised practical experience in the 

6 provision of such care. 

7 ‘‘(c) SUPERVISION AND EVALUATION OF TECHNI8 CIANS.—The Secretary, acting through the Service, shall 

9 supervise and evaluate the mental health technicians in 

10 the training program. 

11 ‘‘(d) TRADITIONAL HEALTH CARE PRACTICES.—The 

12 Secretary, acting through the Service, shall ensure that 

13 the program established pursuant to this subsection in14 volves the use and promotion of the traditional health care 

15 practices of the Indian Tribes to be served. 

16 ‘‘SEC. 705. LICENSING REQUIREMENT FOR MENTAL 

17 HEALTH CARE WORKERS. 

18 ‘‘(a) IN GENERAL.—Subject to the provisions of sec19 tion 221, and except as provided in subsection (b), any 

20 individual employed as a psychologist, social worker, or 

21 marriage and family therapist for the purpose of providing 

22 mental health care services to Indians in a clinical setting 

23 under this Act is required to be licensed as a psychologist, 

24 social worker, or marriage and family therapist, respec25 tively. 
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1 ‘‘(b) TRAINEES.—An individual may be employed as 

2 a trainee in psychology, social work, or marriage and fam3 ily therapy to provide mental health care services de4 scribed in subsection (a) if such individual— 

5 ‘‘(1) works under the direct supervision of a li6 censed psychologist, social worker, or marriage and 

7 family therapist, respectively; 

8 ‘‘(2) is enrolled in or has completed at least 2 

9 years of course work at a post-secondary, accredited 

10 education program for psychology, social work, mar11 riage and family therapy, or counseling; and 

12 ‘‘(3) meets such other training, supervision, and 

13 quality review requirements as the Secretary may es14 tablish. 

15 ‘‘SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS. 

16 ‘‘(a) GRANTS.—The Secretary, consistent with sec17 tion 701, may make grants to Indian Tribes, Tribal Orga18 nizations, and urban Indian organizations to develop and 

19 implement a comprehensive behavioral health program of 

20 prevention, intervention, treatment, and relapse preven21 tion services that specifically addresses the cultural, his22 torical, social, and child care needs of Indian women, re23 gardless of age. 

24 ‘‘(b) USE OF GRANT FUNDS.—A grant made pursu25 ant to this section may be used to— 
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1 ‘‘(1) develop and provide community training, 

2 education, and prevention programs for Indian 

3 women relating to behavioral health issues, including 

4 fetal alcohol disorders; 

5 ‘‘(2) identify and provide psychological services, 

6 counseling, advocacy, support, and relapse preven7 tion to Indian women and their families; and 

8 ‘‘(3) develop prevention and intervention models 

9 for Indian women which incorporate traditional 

10 health care practices, cultural values, and commu11 nity and family involvement. 

12 ‘‘(c) CRITERIA.—The Secretary, in consultation with 

13 Indian Tribes and Tribal Organizations, shall establish 

14 criteria for the review and approval of applications and 

15 proposals for funding under this section. 

16 ‘‘(d) ALLOCATION OF FUNDS FOR URBAN INDIAN

17 ORGANIZATIONS.—Twenty percent of the funds appro18 priated pursuant to this section shall be used to make 

19 grants to urban Indian organizations. 

20 ‘‘SEC. 707. INDIAN YOUTH PROGRAM. 

21 ‘‘(a) DETOXIFICATION AND REHABILITATION.—The 

22 Secretary, acting through the Service, consistent with sec23 tion 701, shall develop and implement a program for acute 

24 detoxification and treatment for Indian youths, including 

25 behavioral health services. The program shall include re-
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1 gional treatment centers designed to include detoxification 

2 and rehabilitation for both sexes on a referral basis and 

3 programs developed and implemented by Indian Tribes or 

4 Tribal Organizations at the local level under the Indian 

5 Self-Determination and Education Assistance Act (25 

6 U.S.C. 450 et seq.). Regional centers shall be integrated 

7 with the intake and rehabilitation programs based in the 

8 referring Indian community. 

9 ‘‘(b) ALCOHOL AND SUBSTANCE ABUSE TREATMENT

10 CENTERS OR FACILITIES.— 

11 ‘‘(1) ESTABLISHMENT.— 

12 ‘‘(A) IN GENERAL.—The Secretary, acting 

13 through the Service, shall construct, renovate, 

14 or, as necessary, purchase, and appropriately 

15 staff and operate, at least 1 youth regional 

16 treatment center or treatment network in each 

17 area under the jurisdiction of an Area Office. 

18 ‘‘(B) AREA OFFICE IN CALIFORNIA.—For 

19 the purposes of this subsection, the Area Office 

20 in California shall be considered to be 2 Area 

21 Offices, 1 office whose jurisdiction shall be con22 sidered to encompass the northern area of the 

23 State of California, and 1 office whose jurisdic24 tion shall be considered to encompass the re25 mainder of the State of California for the pur-
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•HR 3962 EH

1 pose of implementing California treatment net2 works. 

3 ‘‘(2) FUNDING.—For the purpose of staffing 

4 and operating such centers or facilities, funding 

5 shall be pursuant to the Act of November 2, 1921 

6 (25 U.S.C. 13). 

7 ‘‘(3) LOCATION.—A youth treatment center 

8 constructed or purchased under this subsection shall 

9 be constructed or purchased at a location within the 

10 area described in paragraph (1) agreed upon (by ap11 propriate tribal resolution) by a majority of the In12 dian Tribes to be served by such center. 

13 ‘‘(4) SPECIFIC PROVISION OF FUNDS.— 

14 ‘‘(A) IN GENERAL.—Notwithstanding any 

15 other provision of this title, the Secretary may, 

16 from amounts authorized to be appropriated for 

17 the purposes of carrying out this section, make 

18 funds available to— 

19 ‘‘(i) the Tanana Chiefs Conference, 

20 Incorporated, for the purpose of leasing, 

21 constructing, renovating, operating, and 

22 maintaining a residential youth treatment 

23 facility in Fairbanks, Alaska; and 

24 ‘‘(ii) the Southeast Alaska Regional 

25 Health Corporation to staff and operate a 
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1 residential youth treatment facility without 

2 regard to the proviso set forth in section 

3 4(l) of the Indian Self-Determination and 

4 Education Assistance Act (25 U.S.C. 

5 450b(l)). 

6 ‘‘(B) PROVISION OF SERVICES TO ELIGI7 BLE YOUTHS.—Until additional residential 

8 youth treatment facilities are established in 

9 Alaska pursuant to this section, the facilities 

10 specified in subparagraph (A) shall make every 

11 effort to provide services to all eligible Indian 

12 youths residing in Alaska. 

13 ‘‘(c) INTERMEDIATE ADOLESCENT BEHAVIORAL

14 HEALTH SERVICES.— 

15 ‘‘(1) IN GENERAL.—The Secretary, acting 

16 through the Service, may provide intermediate be17 havioral health services, which may incorporate Sys18 tems of Care, to Indian children and adolescents, in19 cluding— 

20 ‘‘(A) pretreatment assistance; 

21 ‘‘(B) inpatient, outpatient, and aftercare 

22 services; 

23 ‘‘(C) emergency care; 

24 ‘‘(D) suicide prevention and crisis interven25 tion; and 
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1 ‘‘(E) prevention and treatment of mental 

2 illness and dysfunctional and self-destructive 

3 behavior, including child abuse and family vio4 lence. 

5 ‘‘(2) USE OF FUNDS.—Funds provided under 

6 this subsection may be used— 

7 ‘‘(A) to construct or renovate an existing 

8 health facility to provide intermediate behav9 ioral health services; 

10 ‘‘(B) to hire behavioral health profes11 sionals; 

12 ‘‘(C) to staff, operate, and maintain an in13 termediate mental health facility, group home, 

14 sober housing, transitional housing or similar 

15 facilities, or youth shelter where intermediate 

16 behavioral health services are being provided; 

17 ‘‘(D) to make renovations and hire appro18 priate staff to convert existing hospital beds 

19 into adolescent psychiatric units; and 

20 ‘‘(E) for intensive home- and community21 based services. 

22 ‘‘(3) CRITERIA.—The Secretary, acting through 

23 the Service, shall, in consultation with Indian Tribes 

24 and Tribal Organizations, establish criteria for the 
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1 review and approval of applications or proposals for 

2 funding made available pursuant to this subsection. 

3 ‘‘(d) FEDERALLY OWNED STRUCTURES.— 

4 ‘‘(1) IN GENERAL.—The Secretary, in consulta5 tion with Indian Tribes and Tribal Organizations, 

6 shall— 

7 ‘‘(A) identify and use, where appropriate, 

8 federally owned structures suitable for local res9 idential or regional behavioral health treatment 

10 for Indian youths; and 

11 ‘‘(B) establish guidelines for determining 

12 the suitability of any such federally owned 

13 structure to be used for local residential or re14 gional behavioral health treatment for Indian 

15 youths. 

16 ‘‘(2) TERMS AND CONDITIONS FOR USE OF

17 STRUCTURE.—Any structure described in paragraph 

18 (1) may be used under such terms and conditions as 

19 may be agreed upon by the Secretary and the agency 

20 having responsibility for the structure and any In21 dian Tribe or Tribal Organization operating the pro22 gram. 

23 ‘‘(e) REHABILITATION AND AFTERCARE SERVICES.— 

24 ‘‘(1) IN GENERAL.—The Secretary, Indian 

25 Tribes, or Tribal Organizations, in cooperation with 
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1 the Secretary of the Interior, shall develop and im2 plement within each Service Unit, community-based 

3 rehabilitation and follow-up services for Indian 

4 youths who are having significant behavioral health 

5 problems, and require long-term treatment, commu6 nity reintegration, and monitoring to support the In7 dian youths after their return to their home commu8 nity. 

9 ‘‘(2) ADMINISTRATION.—Services under para10 graph (1) shall be provided by trained staff within 

11 the community who can assist the Indian youths in 

12 their continuing development of self-image, positive 

13 problem-solving skills, and nonalcohol or substance 

14 abusing behaviors. Such staff may include alcohol 

15 and substance abuse counselors, mental health pro16 fessionals, and other health professionals and para17 professionals, including community health represent18 atives. 

19 ‘‘(f) INCLUSION OF FAMILY IN YOUTH TREATMENT

20 PROGRAM.—In providing the treatment and other services 

21 to Indian youths authorized by this section, the Secretary, 

22 acting through the Service, shall provide for the inclusion 

23 of family members of such youths in the treatment pro24 grams or other services as may be appropriate. Not less 

25 than 10 percent of the funds appropriated for the pur-
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•HR 3962 EH

1 poses of carrying out subsection (e) shall be used for out2 patient care of adult family members related to the treat3 ment of an Indian youth under that subsection. 

4 ‘‘(g) MULTIDRUG ABUSE PROGRAM.—The Secretary, 

5 acting through the Service, shall provide, consistent with 

6 section 701, programs and services to prevent and treat 

7 the abuse of multiple forms of substances, including alco8 hol, drugs, inhalants, and tobacco, among Indian youths 

9 residing in Indian communities, on or near reservations, 

10 and in urban areas and provide appropriate mental health 

11 services to address the incidence of mental illness among 

12 such youths. 

13 ‘‘(h) INDIAN YOUTH MENTAL HEALTH.—The Sec14 retary, acting through the Service, shall collect data for 

15 the report under section 801 with respect to— 

16 ‘‘(1) the number of Indian youth who are being 

17 provided mental health services through the Service 

18 and Tribal Health Programs; 

19 ‘‘(2) a description of, and costs associated with, 

20 the mental health services provided for Indian youth 

21 through the Service and Tribal Health Programs; 

22 ‘‘(3) the number of youth referred to the Serv23 ice or Tribal Health Programs for mental health 

24 services; 
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1 ‘‘(4) the number of Indian youth provided resi2 dential treatment for mental health and behavioral 

3 problems through the Service and Tribal Health 

4 Programs, reported separately for on- and off-res5 ervation facilities; and 

6 ‘‘(5) the costs of the services described in para7 graph (4). 

8 ‘‘SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEM9 ONSTRATION PROJECT. 

10 ‘‘(a) PURPOSE.—The purpose of this section is to au11 thorize the Secretary to carry out a demonstration project 

12 to test the use of telemental health services in suicide pre13 vention, intervention and treatment of Indian youth, in14 cluding through— 

15 ‘‘(1) the use of psychotherapy, psychiatric as16 sessments, diagnostic interviews, therapies for men17 tal health conditions predisposing to suicide, and al18 cohol and substance abuse treatment; 

19 ‘‘(2) the provision of clinical expertise to, con20 sultation services with, and medical advice and train21 ing for frontline health care providers working with 

22 Indian youth; 

23 ‘‘(3) training and related support for commu24 nity leaders, family members and health and edu25 cation workers who work with Indian youth; 
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1 ‘‘(4) the development of culturally relevant edu2 cational materials on suicide; and 

3 ‘‘(5) data collection and reporting. 

4 ‘‘(b) DEFINITIONS.—For the purpose of this section, 

5 the following definitions shall apply: 

6 ‘‘(1) DEMONSTRATION PROJECT.—The term 

7 ‘demonstration project’ means the Indian youth tele8 mental health demonstration project authorized 

9 under subsection (c). 

10 ‘‘(2) TELEMENTAL HEALTH.—The term ‘tele11 mental health’ means the use of electronic informa12 tion and telecommunications technologies to support 

13 long distance mental health care, patient and profes14 sional-related education, public health, and health 

15 administration. 

16 ‘‘(c) AUTHORIZATION.— 

17 ‘‘(1) IN GENERAL.—The Secretary is authorized 

18 to award grants under the demonstration project for 

19 the provision of telemental health services to Indian 

20 youth who— 

21 ‘‘(A) have expressed suicidal ideas; 

22 ‘‘(B) have attempted suicide; or 

23 ‘‘(C) have mental health conditions that in24 crease or could increase the risk of suicide. 
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1 ‘‘(2) ELIGIBILITY FOR GRANTS.—Such grants 

2 shall be awarded to Indian Tribes and Tribal Orga3 nizations that operate 1 or more facilities— 

4 ‘‘(A) located in Alaska and part of the 

5 Alaska Federal Health Care Access Network; 

6 ‘‘(B) reporting active clinical telehealth ca7 pabilities; or 

8 ‘‘(C) offering school-based telemental 

9 health services relating to psychiatry to Indian 

10 youth. 

11 ‘‘(3) GRANT PERIOD.—The Secretary shall 

12 award grants under this section for a period of up 

13 to 4 years. 

14 ‘‘(4) AWARDING OF GRANTS.—Not more than 5 

15 grants shall be provided under paragraph (1), with 

16 priority consideration given to Indian Tribes and 

17 Tribal Organizations that— 

18 ‘‘(A) serve a particular community or geo19 graphic area where there is a demonstrated 

20 need to address Indian youth suicide; 

21 ‘‘(B) enter in to collaborative partnerships 

22 with Indian Health Service or Tribal Health 

23 Programs or facilities to provide services under 

24 this demonstration project; 
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•HR 3962 EH

1 ‘‘(C) serve an isolated community or geo2 graphic area which has limited or no access to 

3 behavioral health services; or 

4 ‘‘(D) operate a detention facility at which 

5 Indian youth are detained. 

6 ‘‘(d) USE OF FUNDS.— 

7 ‘‘(1) IN GENERAL.—An Indian Tribe or Tribal 

8 Organization shall use a grant received under sub9 section (c) for the following purposes: 

10 ‘‘(A) To provide telemental health services 

11 to Indian youth, including the provision of— 

12 ‘‘(i) psychotherapy; 

13 ‘‘(ii) psychiatric assessments and di14 agnostic interviews, therapies for mental 

15 health conditions predisposing to suicide, 

16 and treatment; and 

17 ‘‘(iii) alcohol and substance abuse 

18 treatment. 

19 ‘‘(B) To provide clinician-interactive med20 ical advice, guidance and training, assistance in 

21 diagnosis and interpretation, crisis counseling 

22 and intervention, and related assistance to 

23 Service, tribal, or urban clinicians and health 

24 services providers working with youth being 

25 served under this demonstration project. 
1938 

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1 ‘‘(C) To assist, educate and train commu2 nity leaders, health education professionals and 

3 paraprofessionals, tribal outreach workers, and 

4 family members who work with the youth re5 ceiving telemental health services under this 

6 demonstration project, including with identifica7 tion of suicidal tendencies, crisis intervention 

8 and suicide prevention, emergency skill develop9 ment, and building and expanding networks 

10 among these individuals and with State and 

11 local health services providers. 

12 ‘‘(D) To develop and distribute culturally 

13 appropriate community educational materials 

14 on— 

15 ‘‘(i) suicide prevention; 

16 ‘‘(ii) suicide education; 

17 ‘‘(iii) suicide screening; 

18 ‘‘(iv) suicide intervention; and 

19 ‘‘(v) ways to mobilize communities 

20 with respect to the identification of risk 

21 factors for suicide. 

22 ‘‘(E) For data collection and reporting re23 lated to Indian youth suicide prevention efforts. 

24 ‘‘(2) TRADITIONAL HEALTH CARE PRAC25 TICES.—In carrying out the purposes described in 
1939 

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1 paragraph (1), an Indian Tribe or Tribal Organiza2 tion may use and promote the traditional health care 

3 practices of the Indian Tribes of the youth to be 

4 served. 

5 ‘‘(e) APPLICATIONS.—To be eligible to receive a grant 

6 under subsection (c), an Indian Tribe or Tribal Organiza7 tion shall prepare and submit to the Secretary an applica8 tion, at such time, in such manner, and containing such 

9 information as the Secretary may require, including— 

10 ‘‘(1) a description of the project that the Indian 

11 Tribe or Tribal Organization will carry out using the 

12 funds provided under the grant; 

13 ‘‘(2) a description of the manner in which the 

14 project funded under the grant would— 

15 ‘‘(A) meet the telemental health care needs 

16 of the Indian youth population to be served by 

17 the project; or 

18 ‘‘(B) improve the access of the Indian 

19 youth population to be served to suicide preven20 tion and treatment services; 

21 ‘‘(3) evidence of support for the project from 

22 the local community to be served by the project; 

23 ‘‘(4) a description of how the families and lead24 ership of the communities or populations to be 
1940 

•HR 3962 EH

1 served by the project would be involved in the devel2 opment and ongoing operations of the project; 

3 ‘‘(5) a plan to involve the tribal community of 

4 the youth who are provided services by the project 

5 in planning and evaluating the mental health care 

6 and suicide prevention efforts provided, in order to 

7 ensure the integration of community, clinical, envi8 ronmental, and cultural components of the treat9 ment; and 

10 ‘‘(6) a plan for sustaining the project after Fed11 eral assistance for the demonstration project has ter12 minated. 

13 ‘‘(f) COLLABORATION; REPORTING TO NATIONAL

14 CLEARINGHOUSE.— 

15 ‘‘(1) COLLABORATION.—The Secretary, acting 

16 through the Service, shall encourage Indian Tribes 

17 and Tribal Organizations receiving grants under this 

18 section to collaborate to enable comparisons about 

19 best practices across projects. 

20 ‘‘(2) REPORTING TO NATIONAL CLEARING21 HOUSE.—The Secretary, acting through the Service, 

22 shall also encourage Indian Tribes and Tribal Orga23 nizations receiving grants under this section to sub24 mit relevant, declassified project information to the 

25 national clearinghouse authorized under section 
1941 

•HR 3962 EH

1 701(b)(2) in order to better facilitate program per2 formance and improve suicide prevention, interven3 tion, and treatment services. 

4 ‘‘(g) ANNUAL REPORT.—Each grant recipient shall 

5 submit to the Secretary an annual report that— 

6 ‘‘(1) describes the number of telemental health 

7 services provided; and 

8 ‘‘(2) includes any other information that the 

9 Secretary may require. 

10 ‘‘(h) REPORT TO CONGRESS.—Not later than 270 

11 days after the termination of the demonstration project, 

12 the Secretary shall submit to the Committee on Indian Af13 fairs of the Senate and the Committee on Natural Re14 sources and Committee on Energy and Commerce of the 

15 House of Representatives a final report, based on the an16 nual reports provided by grant recipients under subsection 

17 (h), that— 

18 ‘‘(1) describes the results of the projects funded 

19 by grants awarded under this section, including any 

20 data available which indicates the number of at21 tempted suicides; 

22 ‘‘(2) evaluates the impact of the telemental 

23 health services funded by the grants in reducing the 

24 number of completed suicides among Indian youth; 
1942 

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1 ‘‘(3) evaluates whether the demonstration 

2 project should be— 

3 ‘‘(A) expanded to provide more than 5 

4 grants; and 

5 ‘‘(B) designated a permanent program; 

6 and 

7 ‘‘(4) evaluates the benefits of expanding the 

8 demonstration project to include urban Indian orga9 nizations. 

10 ‘‘(i) AUTHORIZATION OF APPROPRIATIONS.—There is 

11 authorized to be appropriated such sums as may be nec12 essary to carry out this section. 

13 ‘‘SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL 

14 HEALTH FACILITIES DESIGN, CONSTRUC15 TION, AND STAFFING. 

16 ‘‘Not later than 1 year after the date of enactment 

17 of the Indian Health Care Improvement Act Amendments 

18 of 2009, the Secretary, acting through the Service, may 

19 provide, in each area of the Service, not less than 1 inpa20 tient mental health care facility, or the equivalent, for In21 dians with behavioral health problems. For the purposes 

22 of this subsection, California shall be considered to be 2 

23 Area Offices, 1 office whose location shall be considered 

24 to encompass the northern area of the State of California 

25 and 1 office whose jurisdiction shall be considered to en-
1943 

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1 compass the remainder of the State of California. The Sec2 retary shall consider the possible conversion of existing, 

3 underused Service hospital beds into psychiatric units to 

4 meet such need. 

5 ‘‘SEC. 710. TRAINING AND COMMUNITY EDUCATION. 

6 ‘‘(a) PROGRAM.—The Secretary, in cooperation with 

7 the Secretary of the Interior, shall develop and implement 

8 or assist Indian Tribes and Tribal Organizations to de9 velop and implement, within each Service Unit or tribal 

10 program, a program of community education and involve11 ment which shall be designed to provide concise and timely 

12 information to the community leadership of each tribal 

13 community. Such program shall include education about 

14 behavioral health issues to political leaders, Tribal judges, 

15 law enforcement personnel, members of tribal health and 

16 education boards, health care providers including tradi17 tional practitioners, and other critical members of each 

18 tribal community. Such program may also include commu19 nity-based training to develop local capacity and tribal 

20 community provider training for prevention, intervention, 

21 treatment, and aftercare. 

22 ‘‘(b) INSTRUCTION.—The Secretary, acting through 

23 the Service, shall provide instruction in the area of behav24 ioral health issues, including instruction in crisis interven25 tion and family relations in the context of alcohol and sub-
1944 

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1 stance abuse, child sexual abuse, youth alcohol and sub2 stance abuse, and the causes and effects of fetal alcohol 

3 disorders to appropriate employees of the Bureau of In4 dian Affairs and the Service, and to personnel in schools 

5 or programs operated under any contract with the Bureau 

6 of Indian Affairs or the Service, including supervisors of 

7 emergency shelters and halfway houses described in sec8 tion 4213 of the Indian Alcohol and Substance Abuse Pre9 vention and Treatment Act of 1986 (25 U.S.C. 2433). 

10 ‘‘(c) TRAINING MODELS.—In carrying out the edu11 cation and training programs required by this section, the 

12 Secretary, in consultation with Indian Tribes, Tribal Or13 ganizations, Indian behavioral health experts, and Indian 

14 alcohol and substance abuse prevention experts, shall de15 velop and provide community-based training models. Such 

16 models shall address— 

17 ‘‘(1) the elevated risk of alcohol and behavioral 

18 health problems faced by children of alcoholics; 

19 ‘‘(2) the cultural, spiritual, and 

20 multigenerational aspects of behavioral health prob21 lem prevention and recovery; and 

22 ‘‘(3) community-based and multidisciplinary 

23 strategies, including Systems of Care, for preventing 

24 and treating behavioral health problems. 
1945 

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1 ‘‘SEC. 711. BEHAVIORAL HEALTH PROGRAM. 

2 ‘‘(a) INNOVATIVE PROGRAMS.—The Secretary, acting 

3 through the Service, consistent with section 701, may 

4 plan, develop, implement, and carry out programs to de5 liver innovative community-based behavioral health serv6 ices to Indians. 

7 ‘‘(b) AWARDS; CRITERIA.—The Secretary may award 

8 a grant for a project under subsection (a) to an Indian 

9 Tribe or Tribal Organization and may consider the fol10 lowing criteria: 

11 ‘‘(1) The project will address significant unmet 

12 behavioral health needs among Indians. 

13 ‘‘(2) The project will serve a significant number 

14 of Indians. 

15 ‘‘(3) The project has the potential to deliver 

16 services in an efficient and effective manner. 

17 ‘‘(4) The Indian Tribe or Tribal Organization 

18 has the administrative and financial capability to ad19 minister the project. 

20 ‘‘(5) The project may deliver services in a man21 ner consistent with traditional health care practices. 

22 ‘‘(6) The project is coordinated with, and avoids 

23 duplication of, existing services. 

24 ‘‘(c) EQUITABLE TREATMENT.—For purposes of this 

25 subsection, the Secretary shall, in evaluating project appli26 cations or proposals, use the same criteria that the Sec-
1946 

•HR 3962 EH

1 retary uses in evaluating any other application or proposal 

2 for such funding. 

3 ‘‘SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS. 

4 ‘‘(a) PROGRAMS.— 

5 ‘‘(1) ESTABLISHMENT.—The Secretary, con6 sistent with section 701 and acting through the 

7 Service, is authorized to establish and operate fetal 

8 alcohol disorder programs as provided in this section 

9 for the purposes of meeting the health status objec10 tives specified in section 3. 

11 ‘‘(2) USE OF FUNDS.— 

12 ‘‘(A) IN GENERAL.—Funding provided 

13 pursuant to this section shall be used for the 

14 following: 

15 ‘‘(i) To develop and provide for Indi16 ans community and in-school training, edu17 cation, and prevention programs relating 

18 to fetal alcohol disorders. 

19 ‘‘(ii) To identify and provide behav20 ioral health treatment to high-risk Indian 

21 women and high-risk women pregnant with 

22 an Indian’s child. 

23 ‘‘(iii) To identify and provide appro24 priate psychological services, educational 

25 and vocational support, counseling, advo-
1947 

•HR 3962 EH

1 cacy, and information to fetal alcohol dis2 order affected Indians and their families or 

3 caretakers. 

4 ‘‘(iv) To develop and implement coun5 seling and support programs in schools for 

6 fetal alcohol disorder affected Indian chil7 dren. 

8 ‘‘(v) To develop prevention and inter9 vention models which incorporate practi10 tioners of traditional health care practices, 

11 cultural values, and community involve12 ment. 

13 ‘‘(vi) To develop, print, and dissemi14 nate education and prevention materials on 

15 fetal alcohol disorder. 

16 ‘‘(vii) To develop and implement, in 

17 consultation with Indian Tribes, Tribal Or18 ganizations, and urban Indian organiza19 tions, culturally sensitive assessment and 

20 diagnostic tools including dysmorphology 

21 clinics and multidisciplinary fetal alcohol 

22 disorder clinics for use in Indian commu23 nities and Urban Centers. 

24 ‘‘(B) ADDITIONAL USES.—In addition to 

25 any purpose under subparagraph (A), funding 
1948 

•HR 3962 EH

1 provided pursuant to this section may be used 

2 for 1 or more of the following: 

3 ‘‘(i) Early childhood intervention 

4 projects from birth on to mitigate the ef5 fects of fetal alcohol disorder among Indi6 ans. 

7 ‘‘(ii) Community-based support serv8 ices for Indians and women pregnant with 

9 Indian children. 

10 ‘‘(iii) Community-based housing for 

11 adult Indians with fetal alcohol disorder. 

12 ‘‘(3) CRITERIA FOR APPLICATIONS.—The Sec13 retary shall establish criteria for the review and ap14 proval of applications for funding under this section. 

15 ‘‘(b) SERVICES.—The Secretary, acting through the 

16 Service, shall— 

17 ‘‘(1) develop and provide services for the pre18 vention, intervention, treatment, and aftercare for 

19 those affected by fetal alcohol disorder in Indian 

20 communities; and 

21 ‘‘(2) provide supportive services, including serv22 ices to meet the special educational, vocational, 

23 school-to-work transition, and independent living 

24 needs of adolescent and adult Indians with fetal al25 cohol disorder. 
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•HR 3962 EH

1 ‘‘(c) TASK FORCE.—The Secretary shall establish a 

2 task force to be known as the Fetal Alcohol Disorder Task 

3 Force to advise the Secretary in carrying out subsection 

4 (b). Such task force shall be composed of representatives 

5 from the following: 

6 ‘‘(1) The National Institute on Drug Abuse. 

7 ‘‘(2) The National Institute on Alcohol and Al8 coholism. 

9 ‘‘(3) The Office of Substance Abuse Prevention. 

10 ‘‘(4) The National Institute of Mental Health. 

11 ‘‘(5) The Service. 

12 ‘‘(6) The Office of Minority Health of the De13 partment of Health and Human Services. 

14 ‘‘(7) The Administration for Native Americans. 

15 ‘‘(8) The National Institute of Child Health 

16 and Human Development (NICHD). 

17 ‘‘(9) The Centers for Disease Control and Pre18 vention. 

19 ‘‘(10) The Bureau of Indian Affairs. 

20 ‘‘(11) Indian Tribes. 

21 ‘‘(12) Tribal Organizations. 

22 ‘‘(13) Urban Indian organizations. 

23 ‘‘(14) Indian fetal alcohol spectrum disorders 

24 experts. 
1950 

•HR 3962 EH

1 ‘‘(d) APPLIED RESEARCH PROJECTS.—The Sec2 retary, acting through the Substance Abuse and Mental 

3 Health Services Administration, shall make grants to In4 dian Tribes, Tribal Organizations, and urban Indian orga5 nizations for applied research projects which propose to 

6 elevate the understanding of methods to prevent, inter7 vene, treat, or provide rehabilitation and behavioral health 

8 aftercare for Indians and urban Indians affected by fetal 

9 alcohol spectrum disorders. 

10 ‘‘(e) FUNDING FOR URBAN INDIAN ORGANIZA11 TIONS.—Ten percent of the funds appropriated pursuant 

12 to this section shall be used to make grants to urban In13 dian organizations funded under title V. 

14 ‘‘SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREAT15 MENT PROGRAMS. 

16 ‘‘(a) ESTABLISHMENT.—The Secretary, acting 

17 through the Service, shall establish, consistent with section 

18 701, in every Service Area, programs involving treatment 

19 for— 

20 ‘‘(1) victims of sexual abuse who are Indian 

21 children or children in an Indian household; and 

22 ‘‘(2) perpetrators of child sexual abuse who are 

23 Indian or members of an Indian household. 

24 ‘‘(b) USE OF FUNDS.—Funding provided pursuant to 

25 this section shall be used for the following: 
1951 

•HR 3962 EH

1 ‘‘(1) To develop and provide community edu2 cation and prevention programs related to sexual 

3 abuse of Indian children or children in an Indian 

4 household. 

5 ‘‘(2) To identify and provide behavioral health 

6 treatment to victims of sexual abuse who are Indian 

7 children or children in an Indian household, and to 

8 their family members who are affected by sexual 

9 abuse. 

10 ‘‘(3) To develop prevention and intervention 

11 models which incorporate traditional health care 

12 practices, cultural values, and community involve13 ment. 

14 ‘‘(4) To develop and implement culturally sen15 sitive assessment and diagnostic tools for use in In16 dian communities and Urban Centers. 

17 ‘‘(5) To identify and provide behavioral health 

18 treatment to Indian perpetrators and perpetrators 

19 who are members of an Indian household— 

20 ‘‘(A) making efforts to begin offender and 

21 behavioral health treatment while the perpe22 trator is incarcerated or at the earliest possible 

23 date if the perpetrator is not incarcerated; and 
1952 

•HR 3962 EH

1 ‘‘(B) providing treatment after the perpe2 trator is released, until it is determined that the 

3 perpetrator is not a threat to children. 

4 ‘‘(c) COORDINATION.—The programs established 

5 under subsection (a) shall be carried out in coordination 

6 with programs and services authorized under the Indian 

7 Child Protection and Family Violence Prevention Act (25 

8 U.S.C. 3201 et seq.). 

9 ‘‘SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION 

10 AND TREATMENT. 

11 ‘‘(a) IN GENERAL.—The Secretary, in accordance 

12 with section 701, is authorized to establish in each Service 

13 Area programs involving the prevention and treatment 

14 of— 

15 ‘‘(1) Indian victims of domestic violence or sex16 ual abuse; and 

17 ‘‘(2) perpetrators of domestic violence or sexual 

18 abuse who are Indian or members of an Indian 

19 household. 

20 ‘‘(b) USE OF FUNDS.—Funds made available to carry 

21 out this section shall be used— 

22 ‘‘(1) to develop and implement prevention pro23 grams and community education programs relating 

24 to domestic violence and sexual abuse; 
1953 

•HR 3962 EH

1 ‘‘(2) to provide behavioral health services, in2 cluding victim support services, and medical treat3 ment (including examinations performed by sexual 

4 assault nurse examiners) to Indian victims of domes5 tic violence or sexual abuse; 

6 ‘‘(3) to purchase rape kits; 

7 ‘‘(4) to develop prevention and intervention 

8 models, which may incorporate traditional health 

9 care practices; and 

10 ‘‘(5) to identify and provide behavioral health 

11 treatment to perpetrators who are Indian or mem12 bers of an Indian household. 

13 ‘‘(c) TRAINING AND CERTIFICATION.— 

14 ‘‘(1) IN GENERAL.—Not later than 1 year after 

15 the date of enactment of the Indian Health Care Im16 provement Act Amendments of 2009, the Secretary 

17 shall establish appropriate protocols, policies, proce18 dures, standards of practice, and, if not available 

19 elsewhere, training curricula and training and cer20 tification requirements for services for victims of do21 mestic violence and sexual abuse. 

22 ‘‘(2) REPORT.—Not later than 18 months after 

23 the date of enactment of the Indian Health Care Im24 provement Act Amendments of 2008, the Secretary 

25 shall submit to the Committee on Indian Affairs of 
1954 

•HR 3962 EH

1 the Senate and the Committee on Natural Resources 

2 of the House of Representatives a report that de3 scribes the means and extent to which the Secretary 

4 has carried out paragraph (1). 

5 ‘‘(d) COORDINATION.— 

6 ‘‘(1) IN GENERAL.—The Secretary, in coordina7 tion with the Attorney General, Federal and tribal 

8 law enforcement agencies, Indian Health Programs, 

9 and domestic violence or sexual assault victim orga10 nizations, shall develop appropriate victim services 

11 and victim advocate training programs— 

12 ‘‘(A) to improve domestic violence or sex13 ual abuse responses; 

14 ‘‘(B) to improve forensic examinations and 

15 collection; 

16 ‘‘(C) to identify problems or obstacles in 

17 the prosecution of domestic violence or sexual 

18 abuse; and 

19 ‘‘(D) to meet other needs or carry out 

20 other activities required to prevent, treat, and 

21 improve prosecutions of domestic violence and 

22 sexual abuse. 

23 ‘‘(2) REPORT.—Not later than 2 years after the 

24 date of enactment of the Indian Health Care Im25 provement Act Amendments of 2008, the Secretary 
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•HR 3962 EH

1 shall submit to the Committee on Indian Affairs of 

2 the Senate and the Committee on Natural Resources 

3 of the House of Representatives a report that de4 scribes, with respect to the matters described in 

5 paragraph (1), the improvements made and needed, 

6 problems or obstacles identified, and costs necessary 

7 to address the problems or obstacles, and any other 

8 recommendations that the Secretary determines to 

9 be appropriate. 

10 ‘‘SEC. 715. BEHAVIORAL HEALTH RESEARCH. 

11 ‘‘The Secretary, in consultation with appropriate 

12 Federal agencies, shall make grants to, or enter into con13 tracts with, Indian Tribes, Tribal Organizations, and 

14 urban Indian organizations or enter into contracts with, 

15 or make grants to appropriate institutions for, the conduct 

16 of research on the incidence and prevalence of behavioral 

17 health problems among Indians served by the Service, In18 dian Tribes, or Tribal Organizations and among Indians 

19 in urban areas. Research priorities under this section shall 

20 include— 

21 ‘‘(1) the multifactorial causes of Indian youth 

22 suicide, including— 

23 ‘‘(A) protective and risk factors and sci24 entific data that identifies those factors; and 
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•HR 3962 EH

1 ‘‘(B) the effects of loss of cultural identity 

2 and the development of scientific data on those 

3 effects; 

4 ‘‘(2) the interrelationship and interdependence 

5 of behavioral health problems with alcoholism and 

6 other substance abuse, suicide, homicides, other in7 juries, and the incidence of family violence; and 

8 ‘‘(3) the development of models of prevention 

9 techniques. 

10 The effect of the interrelationships and interdependencies 

11 referred to in paragraph (2) on children, and the develop12 ment of prevention techniques under paragraph (3) appli13 cable to children, shall be emphasized. 

14 ‘‘SEC. 716. DEFINITIONS. 

15 ‘‘For the purpose of this title, the following defini16 tions shall apply: 

17 ‘‘(1) ASSESSMENT.—The term ‘assessment’ 

18 means the systematic collection, analysis, and dis19 semination of information on health status, health 

20 needs, and health problems. 

21 ‘‘(2) ALCOHOL-RELATED

22 NEURODEVELOPMENTAL DISORDERS OR ARND.—The 

23 term ‘alcohol-related neurodevelopmental disorders’ 

24 or ‘ARND’ means, with a history of maternal alco25 hol consumption during pregnancy, central nervous 
1957 

•HR 3962 EH

1 system involvement such as developmental delay, in2 tellectual deficit, or neurologic abnormalities. Behav3 iorally, there can be problems with irritability, and 

4 failure to thrive as infants. As children become older 

5 there will likely be hyperactivity, attention deficit, 

6 language dysfunction, and perceptual and judgment 

7 problems. 

8 ‘‘(3) BEHAVIORAL HEALTH AFTERCARE.—The 

9 term ‘behavioral health aftercare’ includes those ac10 tivities and resources used to support recovery fol11 lowing inpatient, residential, intensive substance 

12 abuse, or mental health outpatient or outpatient 

13 treatment. The purpose is to help prevent or deal 

14 with relapse by ensuring that by the time a client or 

15 patient is discharged from a level of care, such as 

16 outpatient treatment, an aftercare plan has been de17 veloped with the client. An aftercare plan may use 

18 such resources as a community-based therapeutic 

19 group, transitional living facilities, a 12-step spon20 sor, a local 12-step or other related support group, 

21 and other community-based providers. 

22 ‘‘(4) DUAL DIAGNOSIS.—The term ‘dual diag23 nosis’ means coexisting substance abuse and mental 

24 illness conditions or diagnosis. Such clients are 
1958 

•HR 3962 EH

1 sometimes referred to as mentally ill chemical abus2 ers (MICAs). 

3 ‘‘(5) FETAL ALCOHOL SPECTRUM DIS4 ORDERS.— 

5 ‘‘(A) IN GENERAL.—The term ‘fetal alco6 hol spectrum disorders’ includes a range of ef7 fects that can occur in an individual whose 

8 mother drank alcohol during pregnancy, includ9 ing physical, mental, behavioral, and/or learning 

10 disabilities with possible lifelong implications. 

11 ‘‘(B) INCLUSIONS.—The term ‘fetal alcohol 

12 spectrum disorders’ may include— 

13 ‘‘(i) fetal alcohol syndrome (FAS); 

14 ‘‘(ii) fetal alcohol effect (FAE); 

15 ‘‘(iii) alcohol-related birth defects; and 

16 ‘‘(iv) alcohol-related 

17 neurodevelopmental disorders (ARND). 

18 ‘‘(6) FETAL ALCOHOL SYNDROME OR FAS.— 

19 The term ‘fetal alcohol syndrome’ or ‘FAS’ means 

20 any 1 of a spectrum of effects that may occur when 

21 a woman drinks alcohol during pregnancy, the diag22 nosis of which involves the confirmed presence of the 

23 following 3 criteria: 

24 ‘‘(A) Craniofacial abnormalities. 

25 ‘‘(B) Growth deficits. 
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•HR 3962 EH

1 ‘‘(C) Central nervous system abnormalities. 

2 ‘‘(7) REHABILITATION.—The term ‘rehabilita3 tion’ means medical and health care services that— 

4 ‘‘(A) are recommended by a physician or 

5 licensed practitioner of the healing arts within 

6 the scope of their practice under applicable law; 

7 ‘‘(B) are furnished in a facility, home, or 

8 other setting in accordance with applicable 

9 standards; and 

10 ‘‘(C) have as their purpose any of the fol11 lowing: 

12 ‘‘(i) The maximum attainment of 

13 physical, mental, and developmental func14 tioning. 

15 ‘‘(ii) Averting deterioration in physical 

16 or mental functional status. 

17 ‘‘(iii) The maintenance of physical or 

18 mental health functional status. 

19 ‘‘(8) SUBSTANCE ABUSE.—The term ‘substance 

20 abuse’ includes inhalant abuse. 

21 ‘‘(9) SYSTEMS OF CARE.—The term ‘Systems of 

22 Care’ means a system for delivering services to chil23 dren and their families that is child-centered, family24 focused and family-driven, community-based, and 

25 culturally competent and responsive to the needs of 
1960 

•HR 3962 EH

1 the children and families being served. The systems 

2 of care approach values prevention and early identi3 fication, smooth transitions for children and fami4 lies, child and family participation and advocacy, 

5 comprehensive array of services, individualized serv6 ice planning, services in the least restrictive environ7 ment, and integrated services with coordinated plan8 ning across the child-serving systems. 

9 ‘‘SEC. 717. AUTHORIZATION OF APPROPRIATIONS. 

10 ‘‘There is authorized to be appropriated such sums 

11 as may be necessary to carry out the provisions of this 

12 title. 

13 ‘‘TITLE VIII—MISCELLANEOUS 

14 ‘‘SEC. 801. REPORTS. 

15 ‘‘For each fiscal year following the date of enactment 

16 of the Indian Health Care Improvement Act Amendments 

17 of 2009, the Secretary shall transmit to Congress a report 

18 containing the following: 

19 ‘‘(1) A report on the progress made in meeting 

20 the objectives of this Act, including a review of pro21 grams established or assisted pursuant to this Act 

22 and assessments and recommendations of additional 

23 programs or additional assistance necessary to, at a 

24 minimum, provide health services to Indians and en25 sure a health status for Indians, which are at a par-
1961 

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1 ity with the health services available to and the 

2 health status of the general population. 

3 ‘‘(2) A report on whether, and to what extent, 

4 new national health care programs, benefits, initia5 tives, or financing systems have had an impact on 

6 the purposes of this Act and any steps that the Sec7 retary may have taken to consult with Indian Tribes, 

8 Tribal Organizations, and urban Indian organiza9 tions to address such impact, including a report on 

10 proposed changes in allocation of funding pursuant 

11 to section 807. 

12 ‘‘(3) A report on the use of health services by 

13 Indians— 

14 ‘‘(A) on a national and area or other rel15 evant geographical basis; 

16 ‘‘(B) by gender and age; 

17 ‘‘(C) by source of payment and type of 

18 service; 

19 ‘‘(D) comparing such rates of use with 

20 rates of use among comparable non-Indian pop21 ulations; and 

22 ‘‘(E) provided under contracts. 

23 ‘‘(4) A report of contractors to the Secretary on 

24 Health Care Educational Loan Repayments every 6 

25 months required by section 110. 
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1 ‘‘(5) A general audit report of the Secretary on 

2 the Health Care Educational Loan Repayment Pro3 gram as required by section 110(m). 

4 ‘‘(6) A report of the findings and conclusions of 

5 demonstration programs on development of edu6 cational curricula for substance abuse counseling as 

7 required in section 125(f). 

8 ‘‘(7) A separate statement which specifies the 

9 amount of funds requested to carry out the provi10 sions of section 201. 

11 ‘‘(8) A report of the evaluations of health pro12 motion and disease prevention as required in section 

13 203(c). 

14 ‘‘(9) A biennial report to Congress on infectious 

15 diseases as required by section 212. 

16 ‘‘(10) A report on environmental and nuclear 

17 health hazards as required by section 215. 

18 ‘‘(11) An annual report on the status of all 

19 health care facilities needs as required by section 

20 301(c)(2)(B) and 301(d). 

21 ‘‘(12) Reports on safe water and sanitary waste 

22 disposal facilities as required by section 302(h). 

23 ‘‘(13) An annual report on the expenditure of 

24 non-Service funds for renovation as required by sec25 tions 304(b)(2). 
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1 ‘‘(14) A report identifying the backlog of main2 tenance and repair required at Service and tribal fa3 cilities required by section 313(a). 

4 ‘‘(15) A report providing an accounting of reim5 bursement funds made available to the Secretary 

6 under titles XVIII, XIX, and XXI of the Social Se7 curity Act. 

8 ‘‘(16) A report on any arrangements for the 

9 sharing of medical facilities or services, as author10 ized by section 406. 

11 ‘‘(17) A report on evaluation and renewal of 

12 urban Indian programs under section 505. 

13 ‘‘(18) A report on the evaluation of programs 

14 as required by section 513(d). 

15 ‘‘(19) A report on alcohol and substance abuse 

16 as required by section 701(f). 

17 ‘‘(20) A report on Indian youth mental health 

18 services as required by section 707(h). 

19 ‘‘(21) A report on the reallocation of base re20 sources if required by section 807. 

21 ‘‘(22) A report on the movement of patients be22 tween Service Units, including— 

23 ‘‘(A) a list of those Service Units that have 

24 a net increase and those that have a net de25 crease of patients due to patients assigned to 
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1 one Service Unit voluntarily choosing to receive 

2 service at another Service Unit; 

3 ‘‘(B) an analysis of the effect of patient 

4 movement on the quality of services for those 

5 Service Units experiencing an increase in the 

6 number of patients served; and 

7 ‘‘(C) what funding changes are necessary 

8 to maintain a consistent quality of service at 

9 Service Units that have an increase in the num10 ber of patients served. 

11 ‘‘(23) A report on the extent to which health 

12 care facilities of the Service, Indian Tribes, Tribal 

13 Organizations, and urban Indian organizations com14 ply with credentialing requirements of the Service or 

15 licensure requirements of States. 

16 ‘‘SEC. 802. REGULATIONS. 

17 ‘‘(a) DEADLINES.— 

18 ‘‘(1) PROCEDURES.—Not later than 90 days 

19 after the date of enactment of the Indian Health 

20 Care Improvement Act Amendments of 2009, the 

21 Secretary shall initiate procedures under subchapter 

22 III of chapter 5 of title 5, United States Code, to 

23 negotiate and promulgate such regulations or 

24 amendments thereto that are necessary to carry out 

25 this Act, except sections 105, 115, 117, 202, and 
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1 409 through 414. The Secretary may promulgate 

2 regulations to carry out such sections using the pro3 cedures required by chapter 5 of title 5, United 

4 States Code (commonly known as the ‘Administra5 tive Procedure Act’). 

6 ‘‘(2) PROPOSED REGULATIONS.—Proposed reg7 ulations to implement this Act shall be published in 

8 the Federal Register by the Secretary no later than 

9 2 years after the date of enactment of the Indian 

10 Health Care Improvement Act Amendments of 2009 

11 and shall have no less than a 120-day comment pe12 riod. 

13 ‘‘(3) FINAL REGULATIONS.—The Secretary 

14 shall publish in the Federal Register final regula15 tions to implement this Act by not later than 3 years 

16 after the date of enactment of the Indian Health 

17 Care Improvement Act Amendments of 2009. 

18 ‘‘(b) COMMITTEE.—A negotiated rulemaking com19 mittee established pursuant to section 565 of title 5, 

20 United States Code, to carry out this section shall have 

21 as its members only representatives of the Federal Gov22 ernment and representatives of Indian Tribes, and Tribal 

23 Organizations, a majority of whom shall be nominated by 

24 and be representatives of Indian Tribes and Tribal Orga25 nizations from each Service Area. 
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1 ‘‘(c) ADAPTATION OF PROCEDURES.—The Secretary 

2 shall adapt the negotiated rulemaking procedures to the 

3 unique context of self-governance and the government-to4 government relationship between the United States and 

5 Indian Tribes. 

6 ‘‘(d) LACK OF REGULATIONS.—The lack of promul7 gated regulations shall not limit the effect of this Act. 

8 ‘‘SEC. 803. PLAN OF IMPLEMENTATION. 

9 ‘‘(a) IN GENERAL.—Not later than 1 year after the 

10 date of enactment of the Indian Health Care Improvement 

11 Act Amendments of 2009, the Secretary, in consultation 

12 with Indian Tribes, Tribal Organizations, and urban In13 dian organizations, shall submit to Congress a plan ex14 plaining the manner and schedule, by title and section, 

15 by which the Secretary will implement the provisions of 

16 this Act. This consultation may be conducted jointly with 

17 the annual budget consultation pursuant to the Indian 

18 Self-Determination and Education Assistance Act (25 

19 U.S.C. 450 et seq.). 

20 ‘‘(b) LACK OF PLAN.—The lack of (or failure to sub21 mit) such a plan shall not limit the effect, or prevent the 

22 implementation, of this Act. 
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1 ‘‘SEC. 804. LIMITATION ON USE OF FUNDS APPROPRIATED 

2 TO INDIAN HEALTH SERVICE. 

3 ‘‘Any limitation on the use of funds contained in an 

4 Act providing appropriations for the Department for a pe5 riod with respect to the performance of abortions shall 

6 apply for that period with respect to the performance of 

7 abortions using funds contained in an Act providing ap8 propriations for the Service. 

9 ‘‘SEC. 805. ELIGIBILITY OF CALIFORNIA INDIANS. 

10 ‘‘(a) IN GENERAL.—The following California Indians 

11 shall be eligible for health services provided by the Service: 

12 ‘‘(1) Any member of a federally recognized In13 dian Tribe. 

14 ‘‘(2) Any descendant of an Indian who was re15 siding in California on June 1, 1852, if such de16 scendant— 

17 ‘‘(A) is a member of the Indian community 

18 served by a local program of the Service; and 

19 ‘‘(B) is regarded as an Indian by the com20 munity in which such descendant lives. 

21 ‘‘(3) Any Indian who holds trust interests in 

22 public domain, national forest, or reservation allot23 ments in California. 

24 ‘‘(4) Any Indian in California who is listed on 

25 the plans for distribution of the assets of rancherias 

26 and reservations located within the State of Cali-
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1 fornia under the Act of August 18, 1958 (72 Stat. 

2 619), and any descendant of such an Indian. 

3 ‘‘(b) CLARIFICATION.—Nothing in this section may 

4 be construed as expanding the eligibility of California Indi5 ans for health services provided by the Service beyond the 

6 scope of eligibility for such health services that applied on 

7 May 1, 1986. 

8 ‘‘SEC. 806. HEALTH SERVICES FOR INELIGIBLE PERSONS. 

9 ‘‘(a) CHILDREN.—Any individual who— 

10 ‘‘(1) has not attained 19 years of age; 

11 ‘‘(2) is the natural or adopted child, stepchild, 

12 foster child, legal ward, or orphan of an eligible In13 dian; and 

14 ‘‘(3) is not otherwise eligible for health services 

15 provided by the Service, 

16 shall be eligible for all health services provided by the 

17 Service on the same basis and subject to the same rules 

18 that apply to eligible Indians until such individual attains 

19 19 years of age. The existing and potential health needs 

20 of all such individuals shall be taken into consideration 

21 by the Service in determining the need for, or the alloca22 tion of, the health resources of the Service. If such an indi23 vidual has been determined to be legally incompetent prior 

24 to attaining 19 years of age, such individual shall remain 
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1 eligible for such services until 1 year after the date of a 

2 determination of competency. 

3 ‘‘(b) SPOUSES.—Any spouse of an eligible Indian who 

4 is not an Indian, or who is of Indian descent but is not 

5 otherwise eligible for the health services provided by the 

6 Service, shall be eligible for such health services if all such 

7 spouses or spouses who are married to members of each 

8 Indian Tribe being served are made eligible, as a class, 

9 by an appropriate resolution of the governing body of the 

10 Indian Tribe or Tribal Organization providing such serv11 ices. The health needs of persons made eligible under this 

12 paragraph shall not be taken into consideration by the 

13 Service in determining the need for, or allocation of, its 

14 health resources. 

15 ‘‘(c) PROVISION OF SERVICES TO OTHER INDIVID16 UALS.— 

17 ‘‘(1) IN GENERAL.—The Secretary is authorized 

18 to provide health services under this subsection 

19 through health programs operated directly by the 

20 Service to individuals who reside within the Service 

21 area of the Service Unit and who are not otherwise 

22 eligible for such health services if— 

23 ‘‘(A) the Indian Tribes served by such 

24 Service Unit request such provision of health 

25 services to such individuals; and 
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1 ‘‘(B) the Secretary and the served Indian 

2 Tribes have jointly determined that— 

3 ‘‘(i) the provision of such health serv4 ices will not result in a denial or diminu5 tion of health services to eligible Indians; 

6 and 

7 ‘‘(ii) there is no reasonable alternative 

8 health facilities or services, within or with9 out the Service Unit, available to meet the 

10 health needs of such individuals. 

11 ‘‘(2) ISDEAA PROGRAMS.—In the case of 

12 health programs and facilities operated under a con13 tract or compact entered into under the Indian Self14 Determination and Education Assistance Act (25 

15 U.S.C. 450 et seq.), the governing body of the In16 dian Tribe or Tribal Organization providing health 

17 services under such contract or compact is author18 ized to determine whether health services should be 

19 provided under such contract to individuals who are 

20 not eligible for such health services under any other 

21 subsection of this section or under any other provi22 sion of law. In making such determinations, the gov23 erning body of the Indian Tribe or Tribal Organiza24 tion shall take into account the considerations de25 scribed in paragraph (1)(B). 
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1 ‘‘(3) PAYMENT FOR SERVICES.— 

2 ‘‘(A) IN GENERAL.—Persons receiving 

3 health services provided by the Service under 

4 this subsection shall be liable for payment of 

5 such health services under a schedule of charges 

6 prescribed by the Secretary which, in the judg7 ment of the Secretary, results in reimbursement 

8 in an amount not less than the actual cost of 

9 providing the health services. Notwithstanding 

10 section 404 of this Act or any other provision 

11 of law, amounts collected under this subsection, 

12 including Medicare, Medicaid, or SCHIP reim13 bursements under titles XVIII, XIX, and XXI 

14 of the Social Security Act, shall be credited to 

15 the account of the program providing the serv16 ice and shall be used for the purposes listed in 

17 section 401(d)(2) and amounts collected under 

18 this subsection shall be available for expendi19 ture within such program. 

20 ‘‘(B) INDIGENT PEOPLE.—Health services 

21 may be provided by the Secretary through the 

22 Service under this subsection to an indigent in23 dividual who would not be otherwise eligible for 

24 such health services but for the provisions of 

25 paragraph (1) only if an agreement has been 
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1 entered into with a State or local government 

2 under which the State or local government 

3 agrees to reimburse the Service for the expenses 

4 incurred by the Service in providing such health 

5 services to such indigent individual. 

6 ‘‘(4) REVOCATION OF CONSENT FOR SERV7 ICES.— 

8 ‘‘(A) SINGLE TRIBE SERVICE AREA.—In 

9 the case of a Service Area which serves only 1 

10 Indian Tribe, the authority of the Secretary to 

11 provide health services under paragraph (1) 

12 shall terminate at the end of the fiscal year suc13 ceeding the fiscal year in which the governing 

14 body of the Indian Tribe revokes its concur15 rence to the provision of such health services. 

16 ‘‘(B) MULTITRIBAL SERVICE AREA.—In 

17 the case of a multitribal Service Area, the au18 thority of the Secretary to provide health serv19 ices under paragraph (1) shall terminate at the 

20 end of the fiscal year succeeding the fiscal year 

21 in which at least 51 percent of the number of 

22 Indian Tribes in the Service Area revoke their 

23 concurrence to the provisions of such health 

24 services. 
1973 

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1 ‘‘(d) OTHER SERVICES.—The Service may provide 

2 health services under this subsection to individuals who 

3 are not eligible for health services provided by the Service 

4 under any other provision of law in order to— 

5 ‘‘(1) achieve stability in a medical emergency; 

6 ‘‘(2) prevent the spread of a communicable dis7 ease or otherwise deal with a public health hazard; 

8 ‘‘(3) provide care to non-Indian women preg9 nant with an eligible Indian’s child for the duration 

10 of the pregnancy through postpartum; or 

11 ‘‘(4) provide care to immediate family members 

12 of an eligible individual if such care is directly re13 lated to the treatment of the eligible individual. 

14 ‘‘(e) HOSPITAL PRIVILEGES FOR PRACTITIONERS.— 

15 ‘‘(1) IN GENERAL.—Hospital privileges in 

16 health facilities operated and maintained by the 

17 Service or operated under a contract or compact 

18 pursuant to the Indian Self-Determination and Edu19 cation Assistance Act (25 U.S.C. 450 et seq.) may 

20 be extended to non-Service health care practitioners 

21 who provide services to individuals described in sub22 section (a), (b), (c), or (d). Such non-Service health 

23 care practitioners may, as part of the privileging 

24 process, be designated as employees of the Federal 

25 Government for purposes of section 1346(b) and 
1974 

•HR 3962 EH

1 chapter 171 of title 28, United States Code (relating 

2 to Federal tort claims) only with respect to acts or 

3 omissions which occur in the course of providing 

4 services to eligible individuals as a part of the condi5 tions under which such hospital privileges are ex6 tended. 

7 ‘‘(2) DEFINITION.—For purposes of this sub8 section, the term ‘non-Service health care practi9 tioner’ means a practitioner who is not— 

10 ‘‘(A) an employee of the Service; or 

11 ‘‘(B) an employee of an Indian tribe or 

12 tribal organization operating a contract or com13 pact under the Indian Self-Determination and 

14 Education Assistance Act or an individual who 

15 provides health care services pursuant to a per16 sonal services contract with such Indian tribe or 

17 tribal organization. 

18 ‘‘(f) ELIGIBLE INDIAN.—For purposes of this sec19 tion, the term ‘eligible Indian’ means any Indian who is 

20 eligible for health services provided by the Service without 

21 regard to the provisions of this section. 

22 ‘‘SEC. 807. REALLOCATION OF BASE RESOURCES. 

23 ‘‘(a) REPORT REQUIRED.—Notwithstanding any 

24 other provision of law, any allocation of Service funds for 

25 a fiscal year that reduces by 5 percent or more from the 
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•HR 3962 EH

1 previous fiscal year the funding for any recurring pro2 gram, project, or activity of a Service Unit may be imple3 mented only after the Secretary has submitted to Con4 gress, under section 801, a report on the proposed change 

5 in allocation of funding, including the reasons for the 

6 change and its likely effects. 

7 ‘‘(b) EXCEPTION.—Subsection (a) shall not apply if 

8 the total amount appropriated to the Service for a fiscal 

9 year is at least 5 percent less than the amount appro10 priated to the Service for the previous fiscal year. 

11 ‘‘SEC. 808. RESULTS OF DEMONSTRATION PROJECTS. 

12 ‘‘The Secretary shall provide for the dissemination to 

13 Indian Tribes, Tribal Organizations, and urban Indian or14 ganizations of the findings and results of demonstration 

15 projects conducted under this Act. 

16 ‘‘SEC. 809. MORATORIUM. 

17 ‘‘During the period of the moratorium imposed on 

18 implementation of the final rule published in the Federal 

19 Register on September 16, 1987, by the Department of 

20 Health and Human Services, relating to eligibility for the 

21 health care services of the Indian Health Service, the In22 dian Health Service shall provide services pursuant to the 

23 criteria for eligibility for such services that were in effect 

24 on September 15, 1987, subject to the provisions of sec25 tions 805 and 806, until the Service has submitted to the 
1976 

•HR 3962 EH

1 Committees on Appropriations of the Senate and the 

2 House of Representatives a budget request reflecting the 

3 increased costs associated with the proposed final rule, 

4 and the request has been included in an appropriations 

5 Act and enacted into law. 

6 ‘‘SEC. 810. SEVERABILITY PROVISIONS. 

7 ‘‘If any provision of this Act, any amendment made 

8 by the Act, or the application of such provision or amend9 ment to any person or circumstances is held to be invalid, 

10 the remainder of this Act, the remaining amendments 

11 made by this Act, and the application of such provisions 

12 to persons or circumstances other than those to which it 

13 is held invalid, shall not be affected thereby. 

14 ‘‘SEC. 811. USE OF PATIENT SAFETY ORGANIZATIONS. 

15 ‘‘The Service, an Indian Tribe, Tribal Organization, 

16 or urban Indian organization may provide for quality as17 surance activities through the use of a patient safety orga18 nization in accordance with title IX of the Public Health 

19 Service Act. 

20 ‘‘SEC. 812. CONFIDENTIALITY OF MEDICAL QUALITY ASSUR21 ANCE RECORDS; QUALIFIED IMMUNITY FOR 

22 PARTICIPANTS. 

23 ‘‘(a) CONFIDENTIALITY OF RECORDS.—Medical qual24 ity assurance records created by or for any Indian Health 

25 Program or a health program of an Urban Indian Organi-
1977 

•HR 3962 EH

1 zation as part of a medical quality assurance program are 

2 confidential and privileged. Such records may not be dis3 closed to any person or entity, except as provided in sub4 section (c). 

5 ‘‘(b) PROHIBITION ON DISCLOSURE AND TESTI6 MONY.— 

7 ‘‘(1) IN GENERAL.—No part of any medical 

8 quality assurance record described in subsection (a) 

9 may be subject to discovery or admitted into evi10 dence in any judicial or administrative proceeding, 

11 except as provided in subsection (c). 

12 ‘‘(2) TESTIMONY.—A person who reviews or 

13 creates medical quality assurance records for any In14 dian Health Program or Urban Indian Organization 

15 who participates in any proceeding that reviews or 

16 creates such records may not be permitted or re17 quired to testify in any judicial or administrative 

18 proceeding with respect to such records or with re19 spect to any finding, recommendation, evaluation, 

20 opinion, or action taken by such person or body in 

21 connection with such records except as provided in 

22 this section. 

23 ‘‘(c) AUTHORIZED DISCLOSURE AND TESTIMONY.— 

24 ‘‘(1) IN GENERAL.—Subject to paragraph (2), a 

25 medical quality assurance record described in sub-
1978 

•HR 3962 EH

1 section (a) may be disclosed, and a person referred 

2 to in subsection (b) may give testimony in connec3 tion with such a record, only as follows: 

4 ‘‘(A) To a Federal executive agency or pri5 vate organization, if such medical quality assur6 ance record or testimony is needed by such 

7 agency or organization to perform licensing or 

8 accreditation functions related to any Indian 

9 Health Program or to a health program of an 

10 Urban Indian Organization to perform moni11 toring, required by law, of such program or or12 ganization. 

13 ‘‘(B) To an administrative or judicial pro14 ceeding commenced by a present or former In15 dian Health Program or Urban Indian Organi16 zation provider concerning the termination, sus17 pension, or limitation of clinical privileges of 

18 such health care provider. 

19 ‘‘(C) To a governmental board or agency 

20 or to a professional health care society or orga21 nization, if such medical quality assurance 

22 record or testimony is needed by such board, 

23 agency, society, or organization to perform li24 censing, credentialing, or the monitoring of pro25 fessional standards with respect to any health 
1979 

•HR 3962 EH

1 care provider who is or was an employee of any 

2 Indian Health Program or Urban Indian Orga3 nization. 

4 ‘‘(D) To a hospital, medical center, or 

5 other institution that provides health care serv6 ices, if such medical quality assurance record or 

7 testimony is needed by such institution to as8 sess the professional qualifications of any health 

9 care provider who is or was an employee of any 

10 Indian Health Program or Urban Indian Orga11 nization and who has applied for or been grant12 ed authority or employment to provide health 

13 care services in or on behalf of such program or 

14 organization. 

15 ‘‘(E) To an officer, employee, or contractor 

16 of the Indian Health Program or Urban Indian 

17 Organization that created the records or for 

18 which the records were created. If that officer, 

19 employee, or contractor has a need for such 

20 record or testimony to perform official duties. 

21 ‘‘(F) To a criminal or civil law enforce22 ment agency or instrumentality charged under 

23 applicable law with the protection of the public 

24 health or safety, if a qualified representative of 

25 such agency or instrumentality makes a written 
1980 

•HR 3962 EH

1 request that such record or testimony be pro2 vided for a purpose authorized by law. 

3 ‘‘(G) In an administrative or judicial pro4 ceeding commenced by a criminal or civil law 

5 enforcement agency or instrumentality referred 

6 to in subparagraph (F), but only with respect 

7 to the subject of such proceeding. 

8 ‘‘(2) IDENTITY OF PARTICIPANTS.—With the 

9 exception of the subject of a quality assurance ac10 tion, the identity of any person receiving health care 

11 services from any Indian Health Program or Urban 

12 Indian Organization or the identity of any other per13 son associated with such program or organization 

14 for purposes of a medical quality assurance program 

15 that is disclosed in a medical quality assurance 

16 record described in subsection (a) shall be deleted 

17 from that record or document before any disclosure 

18 of such record is made outside such program or or19 ganization. 

20 ‘‘(d) DISCLOSURE FOR CERTAIN PURPOSES.— 

21 ‘‘(1) IN GENERAL.—Nothing in this section 

22 shall be construed as authorizing or requiring the 

23 withholding from any person or entity aggregate sta24 tistical information regarding the results of any In-
1981 

•HR 3962 EH

1 dian Health Program or Urban Indian 

2 Organizations’s medical quality assurance programs. 

3 ‘‘(2) WITHHOLDING FROM CONGRESS.—Noth4 ing in this section shall be construed as authority to 

5 withhold any medical quality assurance record from 

6 a committee of either House of Congress, any joint 

7 committee of Congress, or the Government Account8 ability Office if such record pertains to any matter 

9 within their respective jurisdictions. 

10 ‘‘(e) PROHIBITION ON DISCLOSURE OF RECORD OR

11 TESTIMONY.—A person or entity having possession of or 

12 access to a record or testimony described by this section 

13 may not disclose the contents of such record or testimony 

14 in any manner or for any purpose except as provided in 

15 this section. 

16 ‘‘(f) EXEMPTION FROM FREEDOM OF INFORMATION

17 ACT.—Medical quality assurance records described in sub18 section (a) may not be made available to any person under 

19 section 552 of title 5, United States Code. 

20 ‘‘(g) LIMITATION ON CIVIL LIABILITY.—A person 

21 who participates in or provides information to a person 

22 or body that reviews or creates medical quality assurance 

23 records described in subsection (a) shall not be civilly lia24 ble for such participation or for providing such informa25 tion if the participation or provision of information was 
1982 

•HR 3962 EH

1 in good faith based on prevailing professional standards 

2 at the time the medical quality assurance program activity 

3 took place. 

4 ‘‘(h) APPLICATION TO INFORMATION IN CERTAIN

5 OTHER RECORDS.—Nothing in this section shall be con6 strued as limiting access to the information in a record 

7 created and maintained outside a medical quality assur8 ance program, including a patient’s medical records, on 

9 the grounds that the information was presented during 

10 meetings of a review body that are part of a medical qual11 ity assurance program. 

12 ‘‘(i) REGULATIONS.—The Secretary, acting through 

13 the Service, shall promulgate regulations pursuant to sec14 tion 802. 

15 ‘‘(j) DEFINITIONS.—In this section: 

16 ‘‘(1) The term ‘health care provider’ means any 

17 health care professional, including community health 

18 aides and practitioners certified under section 121, 

19 who are granted clinical practice privileges or em20 ployed to provide health care services in an Indian 

21 Health Program or health program of an Urban In22 dian Organization, who is licensed or certified to 

23 perform health care services by a governmental 

24 board or agency or professional health care society 

25 or organization. 
1983 

•HR 3962 EH

1 ‘‘(2) The term ‘medical quality assurance pro2 gram’ means any activity carried out before, on, or 

3 after the date of enactment of this Act by or for any 

4 Indian Health Program or Urban Indian Organiza5 tion to assess the quality of medical care, including 

6 activities conducted by or on behalf of individuals, 

7 Indian Health Program or Urban Indian Organiza8 tion medical or dental treatment review committees, 

9 or other review bodies responsible for quality assur10 ance, credentials, infection control, patient safety, 

11 patient care assessment (including treatment proce12 dures, blood, drugs, and therapeutics), medical 

13 records, health resources management review and 

14 identification and prevention of medical or dental in15 cidents and risks. 

16 ‘‘(3) The term ‘medical quality assurance 

17 record’ means the proceedings, records, minutes, and 

18 reports that emanate from quality assurance pro19 gram activities described in paragraph (2) and are 

20 produced or compiled by or for an Indian Health 

21 Program or Urban Indian Organization as part of a 

22 medical quality assurance program. 

23 ‘‘(k) CONTINUED PROTECTION.—Disclosure under 

24 subsection (c) does not permit redisclosure except to the 

25 extent such further disclosure is authorized under sub-
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1 section (c) or is otherwise authorized to be disclosed under 

2 this section. 

3 ‘‘(l) INCONSISTENCIES.—To the extent that the pro4 tections under the Patient Safety and Quality Improve5 ment Act of 2005 and this section are inconsistent, the 

6 provisions of whichever is more protective shall control. 

7 ‘‘(m) RELATIONSHIP TO OTHER LAW.—This section 

8 shall continue in force and effect, except as otherwise spe9 cifically provided in any Federal law enacted after the date 

10 of enactment of the Indian Health Care Improvement Act 

11 Amendments of 2009. 

12 ‘‘SEC. 813. CLAREMORE INDIAN HOSPITAL. 

13 ‘‘The Claremore Indian Hospital shall be deemed to 

14 be a dependant Indian community for the purposes of sec15 tion 1151 of title 18, United States Code. 

16 ‘‘SEC. 814. SENSE OF CONGRESS REGARDING LAW EN17 FORCEMENT AND METHAMPHETAMINE 

18 ISSUES IN INDIAN COUNTRY. 

19 ‘‘It is the sense of Congress that Congress encourages 

20 State, local, and Indian tribal law enforcement agencies 

21 to enter into memoranda of agreement between and 

22 among those agencies for purposes of streamlining law en23 forcement activities and maximizing the use of limited re24 sources— 
1985 

•HR 3962 EH

1 ‘‘(1) to improve law enforcement services pro2 vided to Indian tribal communities; and 

3 ‘‘(2) to increase the effectiveness of measures to 

4 address problems relating to methamphetamine use 

5 in Indian country (as defined in section 1151 of title 

6 18, United States Code). 

7 ‘‘SEC. 815. PERMITTING IMPLEMENTATION THROUGH CON8 TRACTS WITH TRIBAL HEALTH PROGRAMS. 

9 ‘‘Nothing in this Act shall be construed as preventing 

10 the Secretary from— 

11 ‘‘(1) carrying out any section of this Act 

12 through contracts with Tribal Health Programs; and 

13 ‘‘(2) carrying out sections through 214, 

14 701(a)(1), 701(b)(1), 701(c), 707(g), and 712(b), 

15 through contracts with urban Indian organizations. 

16 The previous sentence shall not affect the authority the 

17 Secretary may otherwise have to carry out other provisions 

18 of this Act through such contracts. 

19 ‘‘SEC. 816. AUTHORIZATION OF APPROPRIATIONS; AVAIL20 ABILITY. 

21 ‘‘(a) AUTHORIZATION OF APPROPRIATIONS.—There 

22 are authorized to be appropriated such sums as may be 

23 necessary to carry out this title. 

24 ‘‘(b) LIMITATION ON NEW SPENDING AUTHORITY.— 

25 Any new spending authority (described in subparagraph 
1986 

•HR 3962 EH

1 (A) or (B) of section 401(c)(2) of the Congressional Budg2 et Act of 1974 (Public Law 93–344; 88 Stat. 317)) which 

3 is provided under this Act shall be effective for any fiscal 

4 year only to such extent or in such amounts as are pro5 vided in appropriation Acts. 

6 ‘‘(c) AVAILABILITY.—The funds appropriated pursu7 ant to this Act shall remain available until expended.’’. 

8 (b) RATE OF PAY.— 

9 (1) POSITIONS AT LEVEL IV.—Section 5315 of 

10 title 5, United States Code, is amended by striking 

11 ‘‘Assistant Secretaries of Health and Human Serv12 ices (6).’’ and inserting ‘‘Assistant Secretaries of 

13 Health and Human Services (7)’’. 

14 (2) POSITIONS AT LEVEL V.—Section 5316 of 

15 title 5, United States Code, is amended by striking 

16 ‘‘Director, Indian Health Service, Department of 

17 Health and Human Services’’. 

18 (c) AMENDMENTS TO OTHER PROVISIONS OF LAW.— 

19 (1) Section 3307(b)(1)(C) of the Children’s 

20 Health Act of 2000 (25 U.S.C. 1671 note; Public 

21 Law 106–310) is amended by striking ‘‘Director of 

22 the Indian Health Service’’ and inserting ‘‘Assistant 

23 Secretary for Indian Health’’. 

24 (2) The Indian Lands Open Dump Cleanup Act 

25 of 1994 is amended— 
1987 

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1 (A) in section 3 (25 U.S.C. 3902)— 

2 (i) by striking paragraph (2); 

3 (ii) by redesignating paragraphs (1), 

4 (3), (4), (5), and (6) as paragraphs (4), 

5 (5), (2), (6), and (1), respectively, and 

6 moving those paragraphs so as to appear 

7 in numerical order; and 

8 (iii) by inserting before paragraph (4) 

9 (as redesignated by subclause (II)) the fol10 lowing: 

11 ‘‘(3) ASSISTANT SECRETARY.—The term ‘As12 sistant Secretary’ means the Assistant Secretary for 

13 Indian Health.’’; 

14 (B) in section 5 (25 U.S.C. 3904), by 

15 striking the section designation and heading 

16 and inserting the following: 

17 ‘‘SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR IN18 DIAN HEALTH.’’; 

19 (C) in section 6(a) (25 U.S.C. 3905(a)), in 

20 the subsection heading, by striking ‘‘DIREC21 TOR’’ and inserting ‘‘ASSISTANT SECRETARY’’; 

22 (D) in section 9(a) (25 U.S.C. 3908(a)), in 

23 the subsection heading, by striking ‘‘DIREC24 TOR’’ and inserting ‘‘ASSISTANT SECRETARY’’; 

25 and 
1988 

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1 (E) by striking ‘‘Director’’ each place it 

2 appears and inserting ‘‘Assistant Secretary’’. 

3 (3) Section 5504(d)(2) of the Augustus F. 

4 Hawkins-Robert T. Stafford Elementary and Sec5 ondary School Improvement Amendments of 1988 

6 (25 U.S.C. 2001 note; Public Law 100–297) is 

7 amended by striking ‘‘Director of the Indian Health 

8 Service’’ and inserting ‘‘Assistant Secretary for In9 dian Health’’. 

10 (4) Section 203(a)(1) of the Rehabilitation Act 

11 of 1973 (29 U.S.C. 763(a)(1)) is amended by strik12 ing ‘‘Director of the Indian Health Service’’ and in13 serting ‘‘Assistant Secretary for Indian Health’’. 

14 (5) Subsections (b) and (e) of section 518 of 

15 the Federal Water Pollution Control Act (33 U.S.C. 

16 1377) are amended by striking ‘‘Director of the In17 dian Health Service’’ each place it appears and in18 serting ‘‘Assistant Secretary for Indian Health’’. 

19 (6) Section 317M(b) of the Public Health Serv20 ice Act (42 U.S.C. 247b–14(b)) is amended— 

21 (A) by striking ‘‘Director of the Indian 

22 Health Service’’ each place it appears and in23 serting ‘‘Assistant Secretary for Indian 

24 Health’’; and 
1989 

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1 (B) in paragraph (2)(A), by striking ‘‘the 

2 Directors referred to in such paragraph’’ and 

3 inserting ‘‘the Director of the Centers for Dis4 ease Control and Prevention and the Assistant 

5 Secretary for Indian Health’’. 

6 (7) Section 417C(b) of the Public Health Serv7 ice Act (42 U.S.C. 285–9(b)) is amended by striking 

8 ‘‘Director of the Indian Health Service’’ and insert9 ing ‘‘Assistant Secretary for Indian Health’’. 

10 (8) Section 1452(i) of the Safe Drinking Water 

11 Act (42 U.S.C. 300j–12(i)) is amended by striking 

12 ‘‘Director of the Indian Health Service’’ each place 

13 it appears and inserting ‘‘Assistant Secretary for In14 dian Health’’. 

15 (9) Section 803B(d)(1) of the Native American 

16 Programs Act of 1974 (42 U.S.C. 2991b–2(d)(1)) is 

17 amended in the last sentence by striking ‘‘Director 

18 of the Indian Health Service’’ and inserting ‘‘Assist19 ant Secretary for Indian Health’’. 

20 (10) Section 203(b) of the Michigan Indian 

21 Land Claims Settlement Act (Public Law 105–143; 

22 111 Stat. 2666) is amended by striking ‘‘Director of 

23 the Indian Health Service’’ and inserting ‘‘Assistant 

24 Secretary for Indian Health’’. 
1990 

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1 SEC. 3102. NATIVE AMERICAN HEALTH AND WELLNESS 

2 FOUNDATION. 

3 (a) IN GENERAL.—The Indian Self-Determination 

4 and Education Assistance Act (25 U.S.C. 450 et seq.) is 

5 amended by adding at the end the following: 

6 ‘‘TITLE VIII—NATIVE AMERICAN 

7 HEALTH AND WELLNESS 

8 FOUNDATION 

9 ‘‘SEC. 801. DEFINITIONS. 

10 ‘‘In this title: 

11 ‘‘(1) BOARD.—The term ‘Board’ means the 

12 Board of Directors of the Foundation. 

13 ‘‘(2) COMMITTEE.—The term ‘Committee’ 

14 means the Committee for the Establishment of Na15 tive American Health and Wellness Foundation es16 tablished under section 802(f). 

17 ‘‘(3) FOUNDATION.—The term ‘Foundation’ 

18 means the Native American Health and Wellness 

19 Foundation established under section 802. 

20 ‘‘(4) SECRETARY.—The term ‘Secretary’ means 

21 the Secretary of Health and Human Services. 

22 ‘‘(5) SERVICE.—The term ‘Service’ means the 

23 Indian Health Service of the Department of Health 

24 and Human Services. 
1991 

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1 ‘‘SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS 

2 FOUNDATION. 

3 ‘‘(a) ESTABLISHMENT.— 

4 ‘‘(1) IN GENERAL.—As soon as practicable 

5 after the date of enactment of this title, the Sec6 retary shall establish, under the laws of the District 

7 of Columbia and in accordance with this title, the 

8 Native American Health and Wellness Foundation. 

9 ‘‘(2) FUNDING DETERMINATIONS.—No funds, 

10 gift, property, or other item of value (including any 

11 interest accrued on such an item) acquired by the 

12 Foundation shall— 

13 ‘‘(A) be taken into consideration for pur14 poses of determining Federal appropriations re15 lating to the provision of health care and serv16 ices to Indians; or 

17 ‘‘(B) otherwise limit, diminish, or affect 

18 the Federal responsibility for the provision of 

19 health care and services to Indians. 

20 ‘‘(b) PERPETUAL EXISTENCE.—The Foundation 

21 shall have perpetual existence. 

22 ‘‘(c) NATURE OF CORPORATION.—The Foundation— 

23 ‘‘(1) shall be a charitable and nonprofit feder24 ally chartered corporation; and 

25 ‘‘(2) shall not be an agency or instrumentality 

26 of the United States. 
1992 

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1 ‘‘(d) PLACE OF INCORPORATION AND DOMICILE.— 

2 The Foundation shall be incorporated and domiciled in the 

3 District of Columbia. 

4 ‘‘(e) DUTIES.—The Foundation shall— 

5 ‘‘(1) encourage, accept, and administer private 

6 gifts of real and personal property, and any income 

7 from or interest in such gifts, for the benefit of, or 

8 in support of, the mission of the Service; 

9 ‘‘(2) undertake and conduct such other activi10 ties as will further the health and wellness activities 

11 and opportunities of Native Americans; and 

12 ‘‘(3) participate with and assist Federal, State, 

13 and tribal governments, agencies, entities, and indi14 viduals in undertaking and conducting activities that 

15 will further the health and wellness activities and op16 portunities of Native Americans. 

17 ‘‘(f) COMMITTEE FOR THE ESTABLISHMENT OF NA18 TIVE AMERICAN HEALTH AND WELLNESS FOUNDA19 TION.— 

20 ‘‘(1) IN GENERAL.—The Secretary shall estab21 lish the Committee for the Establishment of Native 

22 American Health and Wellness Foundation to assist 

23 the Secretary in establishing the Foundation. 
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1 ‘‘(2) DUTIES.—Not later than 180 days after 

2 the date of enactment of this section, the Committee 

3 shall— 

4 ‘‘(A) carry out such activities as are nec5 essary to incorporate the Foundation under the 

6 laws of the District of Columbia, including act7 ing as incorporators of the Foundation; 

8 ‘‘(B) ensure that the Foundation qualifies 

9 for and maintains the status required to carry 

10 out this section, until the Board is established; 

11 ‘‘(C) establish the constitution and initial 

12 bylaws of the Foundation; 

13 ‘‘(D) provide for the initial operation of 

14 the Foundation, including providing for tem15 porary or interim quarters, equipment, and 

16 staff; and 

17 ‘‘(E) appoint the initial members of the 

18 Board in accordance with the constitution and 

19 initial bylaws of the Foundation. 

20 ‘‘(g) BOARD OF DIRECTORS.— 

21 ‘‘(1) IN GENERAL.—The Board of Directors 

22 shall be the governing body of the Foundation. 

23 ‘‘(2) POWERS.—The Board may exercise, or 

24 provide for the exercise of, the powers of the Foun25 dation. 
1994 

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1 ‘‘(3) SELECTION.— 

2 ‘‘(A) IN GENERAL.—Subject to subpara3 graph (B), the number of members of the 

4 Board, the manner of selection of the members 

5 (including the filling of vacancies), and the 

6 terms of office of the members shall be as pro7 vided in the constitution and bylaws of the 

8 Foundation. 

9 ‘‘(B) REQUIREMENTS.— 

10 ‘‘(i) NUMBER OF MEMBERS.—The 

11 Board shall have at least 11 members, who 

12 shall have staggered terms. 

13 ‘‘(ii) INITIAL VOTING MEMBERS.—The 

14 initial voting members of the Board— 

15 ‘‘(I) shall be appointed by the 

16 Committee not later than 180 days 

17 after the date on which the Founda18 tion is established; and 

19 ‘‘(II) shall have staggered terms. 

20 ‘‘(iii) QUALIFICATION.—The members 

21 of the Board shall be United States citi22 zens who are knowledgeable or experienced 

23 in Native American health care and related 

24 matters. 
1995 

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1 ‘‘(C) COMPENSATION.—A member of the 

2 Board shall not receive compensation for service 

3 as a member, but shall be reimbursed for actual 

4 and necessary travel and subsistence expenses 

5 incurred in the performance of the duties of the 

6 Foundation. 

7 ‘‘(h) OFFICERS.— 

8 ‘‘(1) IN GENERAL.—The officers of the Founda9 tion shall be— 

10 ‘‘(A) a secretary, elected from among the 

11 members of the Board; and 

12 ‘‘(B) any other officers provided for in the 

13 constitution and bylaws of the Foundation. 

14 ‘‘(2) CHIEF OPERATING OFFICER.—The sec15 retary of the Foundation may serve, at the direction 

16 of the Board, as the chief operating officer of the 

17 Foundation, or the Board may appoint a chief oper18 ating officer, who shall serve at the direction of the 

19 Board. 

20 ‘‘(3) ELECTION.—The manner of election, term 

21 of office, and duties of the officers of the Founda22 tion shall be as provided in the constitution and by23 laws of the Foundation. 

24 ‘‘(i) POWERS.—The Foundation— 
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1 ‘‘(1) shall adopt a constitution and bylaws for 

2 the management of the property of the Foundation 

3 and the regulation of the affairs of the Foundation; 

4 ‘‘(2) may adopt and alter a corporate seal; 

5 ‘‘(3) may enter into contracts; 

6 ‘‘(4) may acquire (through a gift or otherwise), 

7 own, lease, encumber, and transfer real or personal 

8 property as necessary or convenient to carry out the 

9 purposes of the Foundation; 

10 ‘‘(5) may sue and be sued; and 

11 ‘‘(6) may perform any other act necessary and 

12 proper to carry out the purposes of the Foundation. 

13 ‘‘(j) PRINCIPAL OFFICE.— 

14 ‘‘(1) IN GENERAL.—The principal office of the 

15 Foundation shall be in the District of Columbia. 

16 ‘‘(2) ACTIVITIES; OFFICES.—The activities of 

17 the Foundation may be conducted, and offices may 

18 be maintained, throughout the United States in ac19 cordance with the constitution and bylaws of the 

20 Foundation. 

21 ‘‘(k) SERVICE OF PROCESS.—The Foundation shall 

22 comply with the law on service of process of each State 

23 in which the Foundation is incorporated and of each State 

24 in which the Foundation carries on activities. 
1997 

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1 ‘‘(l) LIABILITY OF OFFICERS, EMPLOYEES, AND

2 AGENTS.— 

3 ‘‘(1) IN GENERAL.—The Foundation shall be 

4 liable for the acts of the officers, employees, and 

5 agents of the Foundation acting within the scope of 

6 their authority. 

7 ‘‘(2) PERSONAL LIABILITY.—A member of the 

8 Board shall be personally liable only for gross neg9 ligence in the performance of the duties of the mem10 ber. 

11 ‘‘(m) RESTRICTIONS.— 

12 ‘‘(1) LIMITATION ON SPENDING.—Beginning 

13 with the fiscal year following the first full fiscal year 

14 during which the Foundation is in operation, the ad15 ministrative costs of the Foundation shall not exceed 

16 the percentage described in paragraph (2) of the 

17 sum of— 

18 ‘‘(A) the amounts transferred to the Foun19 dation under subsection (o) during the pre20 ceding fiscal year; and 

21 ‘‘(B) donations received from private 

22 sources during the preceding fiscal year. 

23 ‘‘(2) PERCENTAGES.—The percentages referred 

24 to in paragraph (1) are— 
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1 ‘‘(A) for the first fiscal year described in 

2 that paragraph, 20 percent; 

3 ‘‘(B) for the following fiscal year, 15 per4 cent; and 

5 ‘‘(C) for each fiscal year thereafter, 10 

6 percent. 

7 ‘‘(3) APPOINTMENT AND HIRING.—The ap8 pointment of officers and employees of the Founda9 tion shall be subject to the availability of funds. 

10 ‘‘(4) STATUS.—A member of the Board or offi11 cer, employee, or agent of the Foundation shall not 

12 by reason of association with the Foundation be con13 sidered to be an officer, employee, or agent of the 

14 United States. 

15 ‘‘(n) AUDITS.—The Foundation shall comply with 

16 section 10101 of title 36, United States Code, as if the 

17 Foundation were a corporation under part B of subtitle 

18 II of that title. 

19 ‘‘(o) FUNDING.— 

20 ‘‘(1) AUTHORIZATION OF APPROPRIATIONS.— 

21 There is authorized to be appropriated to carry out 

22 subsection (e)(1) $500,000 for each fiscal year, as 

23 adjusted to reflect changes in the Consumer Price 

24 Index for all-urban consumers published by the De25 partment of Labor. 
1999 

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1 ‘‘(2) TRANSFER OF DONATED FUNDS.—The 

2 Secretary shall transfer to the Foundation funds 

3 held by the Department of Health and Human Serv4 ices under the Act of August 5, 1954 (42 U.S.C. 

5 2001 et seq.), if the transfer or use of the funds is 

6 not prohibited by any term under which the funds 

7 were donated. 

8 ‘‘SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT. 

9 ‘‘(a) PROVISION OF SUPPORT BY SECRETARY.—Sub10 ject to subsection (b), during the 5-year period beginning 

11 on the date on which the Foundation is established, the 

12 Secretary— 

13 ‘‘(1) may provide personnel, facilities, and other 

14 administrative support services to the Foundation; 

15 ‘‘(2) may provide funds for initial operating 

16 costs and to reimburse the travel expenses of the 

17 members of the Board; and 

18 ‘‘(3) shall require and accept reimbursements 

19 from the Foundation for— 

20 ‘‘(A) services provided under paragraph 

21 (1); and 

22 ‘‘(B) funds provided under paragraph (2). 

23 ‘‘(b) REIMBURSEMENT.—Reimbursements accepted 

24 under subsection (a)(3)— 
2000 

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1 ‘‘(1) shall be deposited in the Treasury of the 

2 United States to the credit of the applicable appro3 priations account; and 

4 ‘‘(2) shall be chargeable for the cost of pro5 viding services described in subsection (a)(1) and 

6 travel expenses described in subsection (a)(2). 

7 ‘‘(c) CONTINUATION OF CERTAIN SERVICES.—The 

8 Secretary may continue to provide facilities and necessary 

9 support services to the Foundation after the termination 

10 of the 5-year period specified in subsection (a) if the facili11 ties and services— 

12 ‘‘(1) are available; and 

13 ‘‘(2) are provided on reimbursable cost basis.’’. 

14 (b) TECHNICAL AMENDMENTS.—The Indian Self-De15 termination and Education Assistance Act is amended— 

16 (1) by redesignating title V (25 U.S.C. 458bbb 

17 et seq.) as title VII; 

18 (2) by redesignating sections 501, 502, and 503 

19 (25 U.S.C. 458bbb, 458bbb–1, 458bbb–2) as sec20 tions 701, 702, and 703, respectively; and 

21 (3) in subsection (a)(2) of section 702 and 

22 paragraph (2) of section 703 (as redesignated by 

23 paragraph (2)), by striking ‘‘section 501’’ and in24 serting ‘‘section 701’’. 
2001 

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1 SEC. 3103. GAO STUDY AND REPORT ON PAYMENTS FOR 

2 CONTRACT HEALTH SERVICES. 

3 (a) STUDY.— 

4 (1) IN GENERAL.—The Comptroller General of 

5 the United States (in this section referred to as the 

6 ‘‘Comptroller General’’) shall conduct a study on the 

7 utilization of health care furnished by health care 

8 providers under the contract health services program 

9 funded by the Indian Health Service and operated 

10 by the Indian Health Service, an Indian Tribe, or a 

11 Tribal Organization (as those terms are defined in 

12 section 4 of the Indian Health Care Improvement 

13 Act). 

14 (2) ANALYSIS.—The study conducted under 

15 paragraph (1) shall include an analysis of— 

16 (A) the amounts reimbursed under the 

17 contract health services program described in 

18 paragraph (1) for health care furnished by enti19 ties, individual providers, and suppliers, includ20 ing a comparison of reimbursement for such 

21 health care through other public programs and 

22 in the private sector; 

23 (B) barriers to accessing care under such 

24 contract health services program, including, but 

25 not limited to, barriers relating to travel dis26 tances, cultural differences, and public and pri-
2002 

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1 vate sector reluctance to furnish care to pa2 tients under such program; 

3 (C) the adequacy of existing Federal fund4 ing for health care under such contract health 

5 services program; and 

6 (D) any other items determined appro7 priate by the Comptroller General. 

8 (b) REPORT.—Not later than 18 months after the 

9 date of enactment of this Act, the Comptroller General 

10 shall submit to Congress a report on the study conducted 

11 under subsection (a), together with recommendations re12 garding— 

13 (1) the appropriate level of Federal funding 

14 that should be established for health care under the 

15 contract health services program described in sub16 section (a)(1); and 

17 (2) how to most efficiently utilize such funding. 

18 (c) CONSULTATION.—In conducting the study under 

19 subsection (a) and preparing the report under subsection 

20 (b), the Comptroller General shall consult with the Indian 

21 Health Service, Indian Tribes, and Tribal Organizations. 
2003 

•HR 3962 EH

1 TITLE II—IMPROVEMENT OF IN2 DIAN HEALTH CARE PRO3 VIDED UNDER THE SOCIAL 

4 SECURITY ACT 

5 SEC. 3201. EXPANSION OF PAYMENTS UNDER MEDICARE, 

6 MEDICAID, AND SCHIP FOR ALL COVERED 

7 SERVICES FURNISHED BY INDIAN HEALTH 

8 PROGRAMS. 

9 (a) MEDICAID.— 

10 (1) EXPANSION TO ALL COVERED SERVICES.— 

11 Section 1911 of the Social Security Act (42 U.S.C. 

12 1396j) is amended— 

13 (A) by amending the heading to read as 

14 follows: 

15 ‘‘SEC. 1911. INDIAN HEALTH PROGRAMS.’’; 

16 and 

17 (B) by amending subsection (a) to read as 

18 follows: 

19 ‘‘(a) ELIGIBILITY FOR PAYMENT FOR MEDICAL AS20 SISTANCE.—An Indian Health Program shall be eligible 

21 for payment for medical assistance provided under a State 

22 plan or under waiver authority with respect to items and 

23 services furnished by the Program if the furnishing of 

24 such services meets all the conditions and requirements 

25 which are applicable generally to the furnishing of items 
2004 

•HR 3962 EH

1 and services under this title and under such plan or waiver 

2 authority.’’. 

3 (2) REPEAL OF OBSOLETE PROVISION.—Sub4 section (b) of such section is repealed. 

5 (3) REVISION OF AUTHORITY TO ENTER INTO

6 AGREEMENTS.—Subsection (c) of such section is 

7 amended to read as follows: 

8 ‘‘(c) AUTHORITY TO ENTER INTO AGREEMENTS.— 

9 The Secretary may enter into an agreement with a State 

10 for the purpose of reimbursing the State for medical as11 sistance provided by the Indian Health Service, an Indian 

12 Tribe, Tribal Organization, or an Urban Indian Organiza13 tion (as so defined), directly, through referral, or under 

14 contracts or other arrangements between the Indian 

15 Health Service, an Indian Tribe, Tribal Organization, or 

16 an Urban Indian Organization and another health care 

17 provider to Indians who are eligible for medical assistance 

18 under the State plan or under waiver authority. This sub19 section shall not be construed to impair the entitlement 

20 of a State to reimbursement for such medical assistance 

21 under this title.’’. 

22 (4) CROSS-REFERENCES TO SPECIAL FUND FOR

23 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

24 OPTION; DEFINITIONS.—Such section is further 
2005 

•HR 3962 EH

1 amended by striking subsection (d) and adding at 

2 the end the following new subsections: 

3 ‘‘(c) SPECIAL FUND FOR IMPROVEMENT OF IHS FA4 CILITIES.—For provisions relating to the authority of the 

5 Secretary to place payments to which a facility of the In6 dian Health Service is eligible for payment under this title 

7 into a special fund established under section 401(c)(1) of 

8 the Indian Health Care Improvement Act, see subpara9 graphs (A) and (B) of section 401(c)(1) of such Act. 

10 ‘‘(d) DIRECT BILLING.—For provisions relating to 

11 the authority of an Tribal Health Program to elect to di12 rectly bill for, and receive payment for, health care items 

13 and services provided by such Program for which payment 

14 is made under this title, see section 401(d) of the Indian 

15 Health Care Improvement Act.’’. 

16 (5) DEFINITIONS.—Section 1101(a) of such Act 

17 (42 U.S.C. 1301(a)) is amended by adding at the 

18 end the following new paragraph: 

19 ‘‘(11) For purposes of this title and titles 

20 XVIII, XIX, and XXI, the terms ‘Indian Health 

21 Program’, ‘Indian Tribe’ (and ‘Indian tribe’), ‘Tribal 

22 Health Program’, ‘Tribal Organization’ (and ‘tribal 

23 organization’), and ‘urban Indian organization’ (and 

24 ‘urban Indian organization’) have the meanings 
2006 

•HR 3962 EH

1 given those terms in section 4 of the Indian Health 

2 Care Improvement Act.’’. 

3 (b) MEDICARE.— 

4 (1) EXPANSION TO ALL COVERED SERVICES.— 

5 Section 1880 of such Act (42 U.S.C. 1395qq) is 

6 amended— 

7 (A) by amending the heading to read as 

8 follows: 

9 ‘‘SEC. 1880. INDIAN HEALTH PROGRAMS.’’; 

10 and 

11 (B) by amending subsection (a) to read as 

12 follows: 

13 ‘‘(a) ELIGIBILITY FOR PAYMENTS.—Subject to sub14 section (e), an Indian Health Program shall be eligible for 

15 payments under this title with respect to items and serv16 ices furnished by the Program if the furnishing of such 

17 services meets all the conditions and requirements which 

18 are applicable generally to the furnishing of items and 

19 services under this title.’’. 

20 (2) REPEAL OF OBSOLETE PROVISION.—Sub21 section (b) of such section is repealed. 

22 (3) CROSS-REFERENCES TO SPECIAL FUND FOR

23 IMPROVEMENT OF IHS FACILITIES; DIRECT BILLING

24 OPTION; DEFINITIONS.— 
2007 

•HR 3962 EH

1 (A) IN GENERAL.—Such section is further 

2 amended by striking subsections (c) and (d) 

3 and inserting the following new subsections: 

4 ‘‘(b) SPECIAL FUND FOR IMPROVEMENT OF IHS FA5 CILITIES.—For provisions relating to the authority of the 

6 Secretary to place payments to which a facility of the In7 dian Health Service is eligible for payment under this title 

8 into a special fund established under section 401(c)(1) of 

9 the Indian Health Care Improvement Act, and the require10 ment to use amounts paid from such fund for making im11 provements in accordance with subsection (b), see sub12 paragraphs (A) and (B) of section 401(c)(1) of such Act. 

13 ‘‘(c) DIRECT BILLING.—For provisions relating to 

14 the authority of a Tribal Health Program to elect to di15 rectly bill for, and receive payment for, health care items 

16 and services provided by such Program for which payment 

17 is made under this title, see section 401(d) of the Indian 

18 Health Care Improvement Act.’’. 

19 (B) CONFORMING AMENDMENTS.—Such 

20 section is further amended— 

21 (i) in subsection (e)(3), by striking 

22 ‘‘Subsection (c)’’ and inserting ‘‘Subsection 

23 (b) and section 401(b)(1) of the Indian 

24 Health Care Improvement Act’’; 
2008 

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1 (ii) by redesignating subsection (e) as 

2 subsection (d); and 

3 (iii) by striking subsection (f). 

4 (4) DEFINITIONS.—Such section is further 

5 amended by amending adding at the end the fol6 lowing new subsection: 

7 ‘‘(e) DEFINITIONS.—In this section, the terms ‘In8 dian Health Program’, ‘Indian Tribe’, ‘Service Unit’, 

9 ‘Tribal Health Program’, ‘Tribal Organization’, and 

10 ‘Urban Indian Organization’ have the meanings given 

11 those terms in section 4 of the Indian Health Care Im12 provement Act.’’. 

13 (c) APPLICATION TO SCHIP.—Section 2107(e)(1) of 

14 the Social Security Act (42 U.S.C. 1397gg(e)(1)) is 

15 amended— 

16 (1) by redesignating subparagraphs (K) 

17 through (M) as subparagraphs (L) through (N), re18 spectively; and 

19 (2) by inserting after subparagraph (J), the fol20 lowing new subparagraph: 

21 ‘‘(K) Section 1911 (relating to Indian 

22 Health Programs, other than subsection (c) of 

23 such section).’’. 
2009 

•HR 3962 EH

1 SEC. 3202. ADDITIONAL PROVISIONS TO INCREASE OUT2 REACH TO, AND ENROLLMENT OF, INDIANS 

3 IN SCHIP AND MEDICAID. 

4 (a) ASSURANCE OF PAYMENTS TO INDIAN HEALTH

5 CARE PROVIDERS FOR CHILD HEALTH ASSISTANCE.— 

6 Section 2102(b)(3)(D) of the Social Security Act (42 

7 U.S.C. 1397bb(b)(3)(D)) is amended by striking ‘‘(as de8 fined in section 4(c) of the Indian Health Care Improve9 ment Act, 25 U.S.C. 1603(c))’’ and inserting ‘‘, including 

10 how the State will ensure that payments are made to In11 dian Health Programs and urban Indian organizations op12 erating in the State for the provision of such assistance’’. 

13 (b) INCLUSION OF OTHER INDIAN FINANCED

14 HEALTH CARE PROGRAMS IN EXEMPTION FROM PROHI15 BITION ON CERTAIN PAYMENTS.—Section 2105(c)(6)(B) 

16 of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by 

17 striking ‘‘insurance program, other than an insurance pro18 gram operated or financed by the Indian Health Service’’ 

19 and inserting ‘‘program, other than a health care program 

20 operated or financed by the Indian Health Service or by 

21 an Indian Tribe, Tribal Organization, or urban Indian or22 ganization’’. 

23 (c) DEFINITIONS.—Section 2110(c) of such Act (42 

24 U.S.C. 1397jj(c)) is amended by adding at the end the 

25 following new paragraph: 
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•HR 3962 EH

1 ‘‘(9) INDIAN; INDIAN HEALTH PROGRAM; IN2 DIAN TRIBE; ETC.—The terms ‘Indian’, ‘Indian 

3 Health Program’, ‘Indian Tribe’, ‘Tribal Organiza4 tion’, and ‘Urban Indian Organization’ have the 

5 meanings given those terms in section 4 of the In6 dian Health Care Improvement Act.’’. 

7 SEC. 3203. SOLICITATION OF PROPOSALS FOR SAFE HAR8 BORS UNDER THE SOCIAL SECURITY ACT 

9 FOR FACILITIES OF INDIAN HEALTH PRO10 GRAMS AND URBAN INDIAN ORGANIZATIONS. 

11 The Secretary of Health and Human Services, acting 

12 through the Office of the Inspector General of the Depart13 ment of Health and Human Services, shall publish a no14 tice, described in section 1128D(a)(1)(A) of the Social Se15 curity Act (42 U.S.C. 1320a–7d(a)(1)(A)), soliciting a 

16 proposal, not later than July 1, 2010, on the development 

17 of safe harbors described in such section relating to health 

18 care items and services provided by facilities of Indian 

19 Health Programs or an urban Indian organization (as 

20 such terms are defined in section 4 of the Indian Health 

21 Care Improvement Act). Such a safe harbor may relate 

22 to areas such as transportation, housing, or cost-sharing, 

23 assistance provided through such facilities or contract 

24 health services for Indians. 
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1 SEC. 3204. ANNUAL REPORT ON INDIANS SERVED BY SO2 CIAL SECURITY ACT HEALTH BENEFIT PRO3 GRAMS. 

4 Section 1139 of the Social Security Act (42 U.S.C. 

5 1320b–9), as amended by the sections 3203 and 3204, 

6 is amended by redesignating subsection (e) as subsection 

7 (f), and inserting after subsection (d) the following new 

8 subsection: 

9 ‘‘(e) ANNUAL REPORT ON INDIANS SERVED BY

10 HEALTH BENEFIT PROGRAMS FUNDED UNDER THIS

11 ACT.—Beginning January 1, 2011, and annually there12 after, the Secretary, acting through the Administrator of 

13 the Centers for Medicare & Medicaid Services and the Di14 rector of the Indian Health Service, shall submit a report 

15 to Congress regarding the enrollment and health status 

16 of Indians receiving items or services under health benefit 

17 programs funded under this Act during the preceding 

18 year. Each such report shall include the following: 

19 ‘‘(1) The total number of Indians enrolled in, or 

20 receiving items or services under, such programs, 

21 disaggregated with respect to each such program. 

22 ‘‘(2) The number of Indians described in para23 graph (1) that also received health benefits under 

24 programs funded by the Indian Health Service. 

25 ‘‘(3) General information regarding the health 

26 status of the Indians described in paragraph (1), 
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1 disaggregated with respect to specific diseases or 

2 conditions and presented in a manner that is con3 sistent with protections for privacy of individually 

4 identifiable health information under section 264(c) 

5 of the Health Insurance Portability and Account6 ability Act of 1996. 

7 ‘‘(4) A detailed statement of the status of facili8 ties of the Indian Health Service or an Indian Tribe, 

9 Tribal Organization, or an Urban Indian Organiza10 tion with respect to such facilities’ compliance with 

11 the applicable conditions and requirements of titles 

12 XVIII, XIX, and XXI, and, in the case of title XIX 

13 or XXI, under a State plan under such title or 

14 under waiver authority, and of the progress being 

15 made by such facilities (under plans submitted 

16 under 1911(b) or otherwise) toward the achievement 

17 and maintenance of such compliance. 

18 ‘‘(5) Such other information as the Secretary 

19 determines is appropriate.’’. 
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1 SEC. 3205. DEVELOPMENT OF RECOMMENDATIONS TO IM2 PROVE INTERSTATE COORDINATION OF MED3 ICAID AND SCHIP COVERAGE OF INDIAN 

4 CHILDREN AND OTHER CHILDREN WHO ARE 

5 OUTSIDE OF THEIR STATE OF RESIDENCY BE6 CAUSE OF EDUCATIONAL OR OTHER NEEDS. 

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

8 identify barriers to interstate coordination of enrollment 

9 and coverage under the Medicaid program under title XIX 

10 of the Social Security Act and the State Children’s Health 

11 Insurance Program under title XXI of such Act of chil12 dren who are eligible for medical assistance or child health 

13 assistance under such programs and who, because of edu14 cational needs, migration of families, emergency evacu15 ations, or otherwise, frequently change their State of resi16 dency or otherwise are temporarily present outside of the 

17 State of their residency. Such study shall include an exam18 ination of the enrollment and coverage coordination issues 

19 faced by Indian children who are eligible for medical as20 sistance or child health assistance under such programs 

21 in their State of residence and who temporarily reside in 

22 an out-of-State boarding school or peripheral dormitory 

23 funded by the Bureau of Indian Affairs. 

24 (b) REPORT.—Not later than 18 months after the 

25 date of enactment of this Act, the Secretary, in consulta26 tion with directors of State Medicaid programs under title 
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1 XIX of the Social Security Act and directors of State Chil2 dren’s Health Insurance Programs under title XXI of such 

3 Act, shall submit a report to Congress that contains rec4 ommendations for such legislative and administrative ac5 tions as the Secretary determines appropriate to address 

6 the enrollment and coverage coordination barriers identi7 fied through the study required under subsection (a). 

Passed the House of Representatives November 7, 

2009. 

Attest: 

Clerk. 

111TH CONGRESS 

1ST SESSION H. R. 3962 

AN ACT 

To provide affordable, quality health care for all 

spending, and for other purposes. Americans and reduce the growth in health care