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[Congressional Bills 111th Congress]
[From the U.S. Government Publishing Office]
[H.R. 3962 Introduced in House (IH)]

111th CONGRESS
  1st Session
                                H. R. 3962

To provide affordable, quality health care for all Americans and reduce 
      the growth in health care spending, and for other purposes.

_______________________________________________________________________

                    IN THE HOUSE OF REPRESENTATIVES

                            October 29, 2009

Mr. Dingell (for himself, Mr. Rangel, Mr. Waxman, Mr. George Miller of 
  California, Mr. Stark, Mr. Pallone, and Mr. Andrews) introduced the 
   following bill; which was referred to the Committee on Energy and 
  Commerce, and in addition to the Committees on Education and Labor, 
  Ways and Means, Oversight and Government Reform, the Budget, Rules, 
 Natural Resources, and the Judiciary, for a period to be subsequently 
   determined by the Speaker, in each case for consideration of such 
 provisions as fall within the jurisdiction of the committee concerned

_______________________________________________________________________

                                 A BILL

 
To provide affordable, quality health care for all Americans and reduce 
      the growth in health care spending, and for other purposes.

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

SECTION 1. SHORT TITLE; TABLE OF DIVISIONS, TITLES, AND SUBTITLES.

    (a) Short Title.--This Act may be cited as the ``Affordable Health 
Care for America Act''.
    (b) Table of Divisions, Titles, and Subtitles.--This Act is divided 
into divisions, titles, and 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
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

               DIVISION A--AFFORDABLE HEALTH CARE CHOICES

SEC. 100. PURPOSE; TABLE OF CONTENTS OF DIVISION; GENERAL DEFINITIONS.

    (a) Purpose.--
            (1) In general.--The purpose of this division is to provide 
        affordable, quality health care for all Americans and reduce 
        the growth in health care spending.
            (2) Building on current system.--This division achieves 
        this purpose by building on what works in today's health care 
        system, while repairing the aspects that are broken.
            (3) Insurance reforms.--This division--
                    (A) enacts strong insurance market reforms;
                    (B) creates a new Health Insurance Exchange, with a 
                public health insurance option alongside private plans;
                    (C) includes sliding scale affordability credits; 
                and
                    (D) initiates shared responsibility among workers, 
                employers, and the Government;
        so that all Americans have coverage of essential health 
        benefits.
            (4) Health delivery reform.--This division institutes 
        health delivery system reforms both to increase quality and to 
        reduce growth in health spending so that health care becomes 
        more affordable for businesses, families, and Government.
    (b) Table of Contents of Division.--The table 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.
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.
      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.
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.
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. Delay in application of worldwide allocation of interest.
                  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.
    (c) General Definitions.--Except as otherwise provided, in this 
division:
            (1) Acceptable coverage.--The term ``acceptable coverage'' 
        has the meaning given such term in section 302(d)(2).
            (2) Basic plan.--The term ``basic plan'' has the meaning 
        given such term in section 303(c).
            (3) Commissioner.--The term ``Commissioner'' means the 
        Health Choices Commissioner established under section 241.
            (4) Cost-sharing.--The term ``cost-sharing'' includes 
        deductibles, coinsurance, copayments, and similar charges, but 
        does not include premiums, balance billing amounts for non-
        network providers, or spending for non-covered services.
            (5) Dependent.--The term ``dependent'' has the meaning 
        given such term by the Commissioner and includes a spouse.
            (6) Employment-based health plan.--The term ``employment-
        based health plan''--
                    (A) means a group health plan (as defined in 
                section 733(a)(1) of the Employee Retirement Income 
                Security Act of 1974);
                    (B) includes such a plan that is the following:
                            (i) Federal, state, and tribal governmental 
                        plans.--A governmental plan (as defined in 
                        section 3(32) of the Employee Retirement Income 
                        Security Act of 1974), including a health 
                        benefits plan offered under chapter 89 of title 
                        5, United States Code.
                            (ii) Church plans.--A church plan (as 
                        defined in section 3(33) of the Employee 
                        Retirement Income Security Act of 1974); and
                    (C) excludes coverage described in section 
                302(d)(2)(E) (relating to TRICARE).
            (7) Enhanced plan.--The term ``enhanced plan'' has the 
        meaning given such term in section 303(c).
            (8) Essential benefits package.--The term ``essential 
        benefits package'' is defined in section 222(a).
            (9) Exchange-participating health benefits plan.--The term 
        ``Exchange-participating health benefits plan'' means a 
        qualified health benefits plan that is offered through the 
        Health Insurance Exchange and may be purchased directly from 
        the entity offering the plan or through enrollment agents and 
        brokers.
            (10) Family.--The term ``family'' means an individual and 
        includes the individual's dependents.
            (11) Federal poverty level; fpl.--The terms ``Federal 
        poverty level'' and ``FPL'' have the meaning given the term 
        ``poverty line'' in section 673(2) of the Community Services 
        Block Grant Act (42 U.S.C. 9902(2)), including any revision 
        required by such section.
            (12) Health benefits plan.--The term ``health benefits 
        plan'' means health insurance coverage and an employment-based 
        health plan and includes the public health insurance option.
            (13) Health insurance coverage.--The term ``health 
        insurance coverage'' has the meaning given such term in section 
        2791 of the Public Health Service Act, but does not include 
        coverage in relation to its provision of excepted benefits--
                    (A) described in paragraph (1) of subsection (c) of 
                such section; or
                    (B) described in paragraph (2), (3), or (4) of such 
                subsection if the benefits are provided under a 
                separate policy, certificate, or contract of insurance.
            (14) Health insurance issuer.--The term ``health insurance 
        issuer'' has the meaning given such term in section 2791(b)(2) 
        of the Public Health Service Act.
            (15) Health insurance exchange.--The term ``Health 
        Insurance Exchange'' means the Health Insurance Exchange 
        established under section 301.
            (16) Indian.--The term ``Indian'' has the meaning given 
        such term in section 4 of the Indian Health Care Improvement 
        Act (24 U.S.C. 1603).
            (17) Indian health care provider.--The term ``Indian health 
        care provider'' means a health care program operated by the 
        Indian Health Service, an Indian tribe, tribal organization, or 
        urban Indian organization as such terms are defined in section 
        4 of the Indian Health Care Improvement Act (25 U.S.C. 1603).
            (18) Medicaid.--The term ``Medicaid'' means a State plan 
        under title XIX of the Social Security Act (whether or not the 
        plan is operating under a waiver under section 1115 of such 
        Act).
            (19) Medicaid eligible individual.--The term ``Medicaid 
        eligible individual'' means an individual who is eligible for 
        medical assistance under Medicaid.
            (20) Medicare.--The term ``Medicare'' means the health 
        insurance programs under title XVIII of the Social Security 
        Act.
            (21) Plan sponsor.--The term ``plan sponsor'' has the 
        meaning given such term in section 3(16)(B) of the Employee 
        Retirement Income Security Act of 1974.
            (22) Plan year.--The term ``plan year'' means--
                    (A) with respect to an employment-based health 
                plan, a plan year as specified under such plan; or
                    (B) with respect to a health benefits plan other 
                than an employment-based health plan, a 12-month period 
                as specified by the Commissioner.
            (23) Premium plan; premium-plus plan.--The terms ``premium 
        plan'' and ``premium-plus plan'' have the meanings given such 
        terms in section 303(c).
            (24) QHBP offering entity.--The terms ``QHBP offering 
        entity'' means, with respect to a health benefits plan that 
        is--
                    (A) a group health plan (as defined, subject to 
                subsection (d), in section 733(a)(1) of the Employee 
                Retirement Income Security Act of 1974), the plan 
                sponsor in relation to such group health plan, except 
                that, in the case of a plan maintained jointly by 1 or 
                more employers and 1 or more employee organizations and 
                with respect to which an employer is the primary source 
                of financing, such term means such employer;
                    (B) health insurance coverage, the health insurance 
                issuer offering the coverage;
                    (C) the public health insurance option, the 
                Secretary of Health and Human Services;
                    (D) a non-Federal governmental plan (as defined in 
                section 2791(d) of the Public Health Service Act), the 
                State or political subdivision of a State (or agency or 
                instrumentality of such State or subdivision) which 
                establishes or maintains such plan; or
                    (E) a Federal governmental plan (as defined in 
                section 2791(d) of the Public Health Service Act), the 
                appropriate Federal official.
            (25) Qualified health benefits plan.--The term ``qualified 
        health benefits plan'' means a health benefits plan that--
                    (A) meets the requirements for such a plan under 
                title II and includes the public health insurance 
                option; and
                    (B) is offered by a QHBP offering entity that meets 
                the applicable requirements of such title with respect 
                to such plan.
            (26) Public health insurance option.--The term ``public 
        health insurance option'' means the public health insurance 
        option as provided under subtitle B of title III.
            (27) Service area; premium rating area.--The terms 
        ``service area'' and ``premium rating area'' mean with respect 
        to health insurance coverage--
                    (A) offered other than through the Health Insurance 
                Exchange, such an area as established by the QHBP 
                offering entity of such coverage in accordance with 
                applicable State law; and
                    (B) offered through the Health Insurance Exchange, 
                such an area as established by such entity in 
                accordance with applicable State law and applicable 
                rules of the Commissioner for Exchange-participating 
                health benefits plans.
            (28) State.--The term ``State'' means the 50 States and the 
        District of Columbia and includes--
                    (A) for purposes of title I, Puerto Rico, the 
                Virgin Islands, Guam, American Samoa, and the Northern 
                Mariana Islands; and
                    (B) for purposes of titles II and III, as elected 
                under and subject to section 346, Puerto Rico, the 
                Virgin Islands, Guam, American Samoa, and the Northern 
                Mariana Islands.
            (29) State medicaid agency.--The term ``State Medicaid 
        agency'' means, with respect to a Medicaid plan, the single 
        State agency responsible for administering such plan under 
        title XIX of the Social Security Act.
            (30) Y1, y2, etc.--The terms ``Y1'', ``Y2'', ``Y3'', 
        ``Y4'', ``Y5'', and similar subsequently numbered terms, mean 
        2013 and subsequent years, respectively.

                       TITLE I--IMMEDIATE REFORMS

SEC. 101. NATIONAL HIGH-RISK POOL PROGRAM.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall establish a 
temporary national high-risk pool program (in this section referred to 
as the ``program'') to provide health benefits to eligible individuals 
during the period beginning on January 1, 2010, and, subject to 
subsection (h)(3)(B), ending on the date on which the Health Insurance 
Exchange is established.
    (b) Administration.--The Secretary may carry out this section 
directly or, pursuant to agreements, grants, or contracts with States, 
through State high-risk pool programs provided that the requirements of 
this section are met.
    (c) Eligibility.--For purposes of this section, the term ``eligible 
individual'' means an individual--
            (1) who--
                    (A) is not eligible for--
                            (i) benefits under title XVIII, XIX, or XXI 
                        of the Social Security Act; or
                            (ii) coverage under an employment-based 
                        health plan (not including coverage under a 
                        COBRA continuation provision, as defined in 
                        section 107(d)(1)); and
                    (B) who--
                            (i) is an eligible individual under section 
                        2741(b) of the Public Health Service Act; or
                            (ii) is medically eligible for the program 
                        by virtue of being an individual described in 
                        subsection (d) at any time during the 6-month 
                        period ending on the date the individual 
                        applies for high-risk pool coverage under this 
                        section;
            (2) who is the spouse or dependent of an individual who is 
        described in paragraph (1); or
            (3) who has not had health insurance coverage or coverage 
        under an employment-based health plan for at least the 6-month 
        period immediately preceding the date of the individual's 
        application for high-risk pool coverage under this section.
For purposes of paragraph (1)(A)(ii), a person who is in a waiting 
period as defined in section 2701(b)(4) of the Public Health Service 
Act shall not be considered to be eligible for coverage under an 
employment-based health plan.
    (d) Medically Eligible Requirements.--For purposes of subsection 
(c)(1)(B)(ii), an individual described in this subsection is an 
individual--
            (1) who, during the 6-month period ending on the date the 
        individual applies for high-risk pool coverage under this 
        section applied for individual health insurance coverage and--
                    (A) was denied such coverage because of a 
                preexisting condition or health status; or
                    (B) was offered such coverage--
                            (i) under terms that limit the coverage for 
                        such a preexisting condition; or
                            (ii) at a premium rate that is above the 
                        premium rate for high risk pool coverage under 
                        this section; or
            (2) who has an eligible medical condition as defined by the 
        Secretary.
In making a determination under paragraph (1) of whether an individual 
was offered individual coverage at a premium rate above the premium 
rate for high risk pool coverage, the Secretary shall make adjustments 
to offset differences in premium rating that are attributable solely to 
differences in age rating.
    (e) Enrollment.--To enroll in coverage in the program, an 
individual shall--
            (1) submit to the Secretary an application for 
        participation in the program, at such time, in such manner, and 
        containing such information as the Secretary shall require;
            (2) attest that the individual is an eligible individual 
        and is a resident of one of the 50 States or the District of 
        Columbia; and
            (3) if the individual had other prior health insurance 
        coverage or coverage under an employment-based health plan 
        during the previous 6 months, provide information as to the 
        nature and source of such coverage and reasons for its 
        discontinuance.
    (f) Protection Against Dumping Risks by Insurers.--
            (1) In general.--The Secretary shall establish criteria for 
        determining whether health insurance issuers and employment-
        based health plans have discouraged an individual from 
        remaining enrolled in prior coverage based on that individual's 
        health status.
            (2) Sanctions.--An issuer or employment-based health plan 
        shall be responsible for reimbursing the program for the 
        medical expenses incurred by the program for an individual who, 
        based on criteria established by the Secretary, the Secretary 
        finds was encouraged by the issuer to disenroll from health 
        benefits coverage prior to enrolling in the program. The 
        criteria shall include at least the following circumstances:
                    (A) In the case of prior coverage obtained through 
                an employer, the provision by the employer, group 
                health plan, or the issuer of money or other financial 
                consideration for disenrolling from the coverage.
                    (B) In the case of prior coverage obtained directly 
                from an issuer or under an employment-based health 
                plan--
                            (i) the provision by the issuer or plan of 
                        money or other financial consideration for 
                        disenrolling from the coverage; or
                            (ii) in the case of an individual whose 
                        premium for the prior coverage exceeded the 
                        premium required by the program (adjusted based 
                        on the age factors applied to the prior 
                        coverage)--
                                    (I) the prior coverage is a policy 
                                that is no longer being actively 
                                marketed (as defined by the Secretary) 
                                by the issuer; or
                                    (II) the prior coverage is a policy 
                                for which duration of coverage form 
                                issue or health status are factors that 
                                can be considered in determining 
                                premiums at renewal.
            (3) Construction.--Nothing in this subsection shall be 
        construed as constituting exclusive remedies for violations of 
        criteria established under paragraph (1) or as preventing 
        States from applying or enforcing such paragraph or other 
        provisions under law with respect to health insurance issuers.
    (g) Covered Benefits, Cost-sharing, Premiums, and Consumer 
Protections.--
            (1) Premium.--The monthly premium charged to eligible 
        individuals for coverage under the program--
                    (A) may vary by age so long as the ratio of the 
                highest such premium to the lowest such premium does 
                not exceed the ratio of 2 to 1;
                    (B) shall be set at a level that does not exceed 
                125 percent of the prevailing standard rate for 
                comparable coverage in the individual market; and
                    (C) shall be adjusted for geographic variation in 
                costs.
        Health insurance issuers shall provide such information as the 
        Secretary may require to determine prevailing standard rates 
        under this paragraph. The Secretary shall establish standard 
        rates in consultation with the National Association of 
        Insurance Commissioners.
            (2) Covered benefits.--Covered benefits under the program 
        shall be determined by the Secretary and shall be consistent 
        with the basic categories in the essential benefits package 
        described in section 222. Under such benefits package--
                    (A) the annual deductible for such benefits may not 
                be higher than $1,500 for an individual or such higher 
                amount for a family as determined by the Secretary;
                    (B) there may not be annual or lifetime limits; and
                    (C) the maximum cost-sharing with respect to an 
                individual (or family) for a year shall not exceed 
                $5,000 for an individual (or $10,000 for a family).
            (3) No preexisting condition exclusion periods.--No 
        preexisting condition exclusion period shall be imposed on 
        coverage under the program.
            (4) Appeals.--The Secretary shall establish an appeals 
        process for individuals to appeal a determination of the 
        Secretary--
                    (A) with respect to claims submitted under this 
                section; and
                    (B) with respect to eligibility determinations made 
                by the Secretary under this section.
            (5) State contribution, maintenance of effort.--As a 
        condition of providing health benefits under this section to 
        eligible individual residing in a State--
                    (A) in the case of a State in which a qualified 
                high-risk pool (as defined under section 2744(c)(2) of 
                the Public Health Service Act) was in effect as of July 
                1, 2009, the Secretary shall require the State make a 
                maintenance of effort payment each year that the high-
                risk pool is in effect equal to an amount not less than 
                the amount of all sources of funding for high-risk pool 
                coverage made by that State in the year ending July 1, 
                2009; and
                    (B) in the case of a State which required health 
                insurance issuers to contribute to a State high-risk 
                pool or similar arrangement for the assessment against 
                such issuers for pool losses, the State shall maintain 
                such a contribution arrangement among such issuers.
            (6) Limiting program expenditures.--The Secretary shall, 
        with respect to the program--
                    (A) establish procedures to protect against fraud, 
                waste, and abuse under the program; and
                    (B) provide for other program integrity methods.
            (7) Treatment as creditable coverage.--Coverage under the 
        program shall be treated, for purposes of applying the 
        definition of ``creditable coverage'' under the provisions of 
        title XXVII of the Public Health Service Act, part 6 of 
        subtitle B of title I of Employee Retirement Income Security 
        Act of 1974, and chapter 100 of the Internal Revenue Code of 
        1986 (and any other provision of law that references such 
        provisions) in the same manner as if it were coverage under a 
        State health benefits risk pool described in section 
        2701(c)(1)(G) of the Public Health Service Act.
    (h) Funding; Termination of Authority.--
            (1) In general.--There is appropriated to the Secretary, 
        out of any moneys in the Treasury not otherwise appropriated, 
        $5,000,000,000 to pay claims against (and administrative costs 
        of) the high-risk pool under this section in excess of the 
        premiums collected with respect to eligible individuals 
        enrolled in the high-risk pool. Such funds shall be available 
        without fiscal year limitation.
            (2) Insufficient funds.--If the Secretary estimates for any 
        fiscal year that the aggregate amounts available for payment of 
        expenses of the high-risk pool will be less than the amount of 
        the expenses, the Secretary shall make such adjustments as are 
        necessary to eliminate such deficit, including reducing 
        benefits, increasing premiums, or establishing waiting lists.
            (3) Termination of authority.--
                    (A) In general.--Except as provided in subparagraph 
                (B), coverage of eligible individuals under a high-risk 
                pool shall terminate as of the date on which the Health 
                Insurance Exchange is established.
                    (B) Transition to exchange.--The Secretary shall 
                develop procedures to provide for the transition of 
                eligible individuals who are enrolled in health 
                insurance coverage offered through a high-risk pool 
                established under this section to be enrolled in 
                acceptable coverage. Such procedures shall ensure that 
                there is no lapse in coverage with respect to the 
                individual and may extend coverage offered through such 
                a high-risk pool beyond 2012 if the Secretary 
                determines necessary to avoid such a lapse.

SEC. 102. ENSURING VALUE AND LOWER PREMIUMS.

    (a) Group Health Insurance Coverage.--Title XXVII of the Public 
Health Service Act is amended by inserting after section 2713 the 
following new section:

``SEC. 2714. ENSURING VALUE AND LOWER PREMIUMS.

    ``(a) In General.--Each health insurance issuer that offers health 
insurance coverage in the small or large group market shall provide 
that for any plan year in which the coverage has a medical loss ratio 
below a level specified by the Secretary (but not less than 85 
percent), the issuer shall provide in a manner specified by the 
Secretary for rebates to enrollees of the amount by which the issuer's 
medical loss ratio is less than the level so specified.
    ``(b) Implementation.--The Secretary shall establish a uniform 
definition of medical loss ratio and methodology for determining how to 
calculate it based on the average medical loss ratio in a health 
insurance issuer's book of business for the small and large group 
market. Such methodology shall be designed to take into account the 
special circumstances of smaller plans, different types of plans, and 
newer plans. In determining the medical loss ratio, the Secretary shall 
exclude State taxes and licensing or regulatory fees. Such methodology 
shall be designed and exceptions shall be established to ensure 
adequate participation by health insurance issuers, competition in the 
health insurance market, and value for consumers so that their premiums 
are used for services.
    ``(c) Sunset.--Subsections (a) and (b) shall not apply to health 
insurance coverage on and after the first date that health insurance 
coverage is offered through the Health Insurance Exchange.''.
    (b) Individual Health Insurance Coverage.--Such title is further 
amended by inserting after section 2753 the following new section:

``SEC. 2754. ENSURING VALUE AND LOWER PREMIUMS.

    ``The provisions of section 2714 shall apply to health insurance 
coverage offered in the individual market in the same manner as such 
provisions apply to health insurance coverage offered in the small or 
large group market except to the extent the Secretary determines that 
the application of such section may destabilize the existing individual 
market.''.
    (c) Immediate Implementation.--The amendments made by this section 
shall apply in the group and individual market for plan years beginning 
on or after January 1, 2010, or as soon as practicable after such date.

SEC. 103. ENDING HEALTH INSURANCE RESCISSION ABUSE.

    (a) Clarification Regarding Application of Guaranteed Renewability 
of Individual and Group Health Insurance Coverage.--Sections 2712 and 
2742 of the Public Health Service Act (42 U.S.C. 300gg-12, 300gg-42) 
are each amended--
            (1) in its heading, by inserting ``and continuation in 
        force, including prohibition of rescission,'' after 
        ``guaranteed renewability''; and
            (2) in subsection (a), by inserting ``, including without 
        rescission,'' after ``continue in force''.
    (b) Secretarial Guidance Regarding Rescissions.--
            (1) Group health insurance market.--Section 2712 of such 
        Act (42 U.S.C. 300gg-12) is amended by adding at the end the 
        following:
    ``(f) Rescission.--A health insurance issuer may rescind group 
health insurance coverage only upon clear and convincing evidence of 
fraud described in subsection (b)(2), under procedures that provide for 
independent, external third-party review.''.
            (2) Individual health market.--Section 2742 of such Act (42 
        U.S.C. 300gg-42) is amended by adding at the end the following:
    ``(f) Rescission.--A health insurance issuer may rescind individual 
health insurance coverage only upon clear and convincing evidence of 
fraud described in subsection (b)(2), under procedures that provide for 
independent, external third-party review.''.
            (3) Guidance.--The Secretary of Health and Human Services, 
        no later than 90 days after the date of the enactment of this 
        Act, shall issue guidance implementing the amendments made by 
        paragraphs (1) and (2), including procedures for independent, 
        external third-party review.
    (c) Opportunity for Independent, External Third-party Review in 
Certain Cases.--
            (1) Individual market.--Subpart 1 of part B of title XXVII 
        of such Act (42 U.S.C. 300gg-41 et seq.) is amended by adding 
        at the end the following:

``SEC. 2746. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-PARTY REVIEW 
              IN CASES OF RESCISSION.

    ``(a) Notice and Review Right.--If a health insurance issuer 
determines to rescind health insurance coverage for an individual in 
the individual market, before such rescission may take effect the 
issuer shall provide the individual with notice of such proposed 
rescission and an opportunity for a review of such determination by an 
independent, external third-party under procedures specified by the 
Secretary under section 2742(f).
    ``(b) Independent Determination.--If the individual requests such 
review by an independent, external third-party of a rescission of 
health insurance coverage, the coverage shall remain in effect until 
such third party determines that the coverage may be rescinded under 
the guidance issued by the Secretary under section 2742(f).''.
            (2) Application to group health insurance.--Such title is 
        further amended by adding after section 2702 the following new 
        section:

``SEC. 2703. OPPORTUNITY FOR INDEPENDENT, EXTERNAL THIRD-PARTY REVIEW 
              IN CASES OF RESCISSION.

    ``The provisions of section 2746 shall apply to group health 
insurance coverage in the same manner as such provisions apply to 
individual health insurance coverage, except that any reference to 
section 2742(f) is deemed a reference to section 2712(f).''.
    (d) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act and shall apply to 
rescissions occurring on and after July 1, 2010, with respect to health 
insurance coverage issued before, on, or after such date.

SEC. 104. SUNSHINE ON PRICE GOUGING BY HEALTH INSURANCE ISSUERS.

    The Secretary of Health and Human Services, in conjunction with 
States, shall establish a process for the annual review of increases in 
premiums for health insurance coverage. Such process shall require 
health insurance issuers to submit a justification for any premium 
increases prior to implementation of the increase.

SEC. 105. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR 
              UNINSURED YOUNG ADULTS.

    (a) Under Group Health Plans.--
            (1) PHSA.--Title XXVII of the Public Health Service Act is 
        amended by inserting after section 2702 the following new 
        section:

``SEC. 2703. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE 
              FOR UNINSURED YOUNG ADULTS.

    ``(a) In General.--A group health plan and a health insurance 
issuer offering health insurance coverage in connection with a group 
health plan that provides coverage for dependent children shall make 
available such coverage, at the option of the participant involved, for 
one or more qualified children (as defined in subsection (b)) of the 
participant.
    ``(b) Qualified Child Defined.--In this section, the term 
`qualified child' means, with respect to a participant in a group 
health plan or group health insurance coverage, an individual who (but 
for age) would be treated as a dependent child of the participant under 
such plan or coverage and who--
            ``(1) is under 27 years of age; and
            ``(2) is not enrolled as a participant, beneficiary, or 
        enrollee (other than under this section, section 2746, or 
        section 704 of the Employee Retirement Income Security Act of 
        1974) under any health insurance coverage or group health plan.
    ``(c) Premiums.--Nothing in this section shall be construed as 
preventing a group health plan or health insurance issuer with respect 
to group health insurance coverage from increasing the premiums 
otherwise required for coverage provided under this section consistent 
with standards established by the Secretary based upon family size.''.
            (2) Employee retirement income security act of 1974.--
                    (A) In general.--Part 7 of subtitle B of title I of 
                the Employee Retirement Income Security Act of 1974 is 
                amended by inserting after section 703 the following 
                new section:

``SEC. 704. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR 
              UNINSURED YOUNG ADULTS.

    ``(a) In General.--A group health plan and a health insurance 
issuer offering health insurance coverage in connection with a group 
health plan that provides coverage for dependent children shall make 
available such coverage, at the option of the participant involved, for 
one or more qualified children (as defined in subsection (b)) of the 
participant.
    ``(b) Qualified Child Defined.--In this section, the term 
`qualified child' means, with respect to a participant in a group 
health plan or group health insurance coverage, an individual who (but 
for age) would be treated as a dependent child of the participant under 
such plan or coverage and who--
            ``(1) is under 27 years of age; and
            ``(2) is not enrolled as a participant, beneficiary, or 
        enrollee (other than under this section) under any health 
        insurance coverage or group health plan.
    ``(c) Premiums.--Nothing in this section shall be construed as 
preventing a group health plan or health insurance issuer with respect 
to group health insurance coverage from increasing the premiums 
otherwise required for coverage provided under this section consistent 
with standards established by the Secretary based upon family size.''.
                    (B) Clerical amendment.--The table of contents of 
                such Act is amended by inserting after the item 
                relating to section 703 the following new item:

``Sec. 704. Requiring the option of extension of dependent coverage for 
                            uninsured young adults.''.
            (3) IRC.--
                    (A) In general.--Subchapter A of chapter 100 of the 
                Internal Revenue Code of 1986 is amended by adding at 
                the end the following new section:

``SEC. 9804. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE 
              FOR UNINSURED YOUNG ADULTS.

    ``(a) In General.--A group health plan that provides coverage for 
dependent children shall make available such coverage, at the option of 
the participant involved, for one or more qualified children (as 
defined in subsection (b)) of the participant.
    ``(b) Qualified Child Defined.--In this section, the term 
`qualified child' means, with respect to a participant in a group 
health plan, an individual who (but for age) would be treated as a 
dependent child of the participant under such plan and who--
            ``(1) is under 27 years of age; and
            ``(2) is not enrolled as a participant, beneficiary, or 
        enrollee (other than under this section, section 704 of the 
        Employee Retirement Income Security Act of 1974, or section 
        2704 or 2746 of the Public Health Service Act) under any health 
        insurance coverage or group health plan.
    ``(c) Premiums.--Nothing in this section shall be construed as 
preventing a group health plan from increasing the premiums otherwise 
required for coverage provided under this section consistent with 
standards established by the Secretary based upon family size.''.
                    (B) Clerical amendment.--The table of sections of 
                such chapter is amended by inserting after the item 
                relating to section 9803 the following:

``Sec. 9804. Requiring the option of extension of dependent coverage 
                            for uninsured young adults.''.
    (b) Individual Health Insurance Coverage.--Title XXVII of the 
Public Health Service Act is amended by inserting after section 2745 
the following new section:

``SEC. 2746. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE 
              FOR UNINSURED YOUNG ADULTS.

    ``The provisions of section 2703 shall apply to health insurance 
coverage offered by a health insurance issuer in the individual market 
in the same manner as they apply to health insurance coverage offered 
by a health insurance issuer in connection with a group health plan in 
the small or large group market.''.
    (c) Effective Dates.--
            (1) Group health plans.--The amendments made by subsection 
        (a) shall apply to group health plans for plan years beginning 
        on or after January 1, 2010.
            (2) Individual health insurance coverage.--Section 2746 of 
        the Public Health Service Act, as inserted by subsection (b), 
        shall apply with respect to health insurance coverage offered, 
        sold, issued, renewed, in effect, or operated in the individual 
        market on or after January 1, 2010.

SEC. 106. LIMITATIONS ON PREEXISTING CONDITION EXCLUSIONS IN GROUP 
              HEALTH PLANS IN ADVANCE OF APPLICABILITY OF NEW 
              PROHIBITION OF PREEXISTING CONDITION EXCLUSIONS.

    (a) Amendments to the Employee Retirement Income Security Act of 
1974.--
            (1) Reduction in look-back period.--Section 701(a)(1) of 
        the Employee Retirement Income Security Act of 1974 (29 U.S.C. 
        1181(a)(1)) is amended by striking ``6-month period'' and 
        inserting ``30-day period''.
            (2) Reduction in permitted preexisting condition limitation 
        period.--Section 701(a)(2) of such Act (29 U.S.C. 1181(a)(2)) 
        is amended by striking ``12 months'' and inserting ``3 
        months'', and by striking ``18 months'' and inserting ``9 
        months''.
            (3) Sunset of interim limitation.--Section 701 of such Act 
        (29 U.S.C. 1181) is amended by adding at the end the following 
        new subsection:
    ``(h) Termination.--This section shall cease to apply to any group 
health plan as of the date that such plan becomes subject to the 
requirements of section 211 of the (relating to prohibiting preexisting 
condition exclusions).''.
    (b) Amendments to the Internal Revenue Code of 1986.--
            (1) Reduction in look-back period.--Section 9801(a)(1) of 
        the Internal Revenue Code of 1986 is amended by striking ``6-
        month period'' and inserting ``30-day period''.
            (2) Reduction in permitted preexisting condition limitation 
        period.--Section 9801(a)(2) of such Code is amended by striking 
        ``12 months'' and inserting ``3 months'', and by striking ``18 
        months'' and inserting ``9 months''.
            (3) Sunset of interim limitation.--Section 9801 of such 
        Code is amended by adding at the end the following new 
        subsection:
    ``(g) Termination.--This section shall cease to apply to any group 
health plan as of the date that such plan becomes subject to the 
requirements of section 211 of the (relating to prohibiting preexisting 
condition exclusions).''.
    (c) Amendments to Public Health Service Act.--
            (1) Reduction in look-back period.--Section 2701(a)(1) of 
        the Public Health Service Act (42 U.S.C. 300gg(a)(1)) is 
        amended by striking ``6-month period'' and inserting ``30-day 
        period''.
            (2) Reduction in permitted preexisting condition limitation 
        period.--Section 2701(a)(2) of such Act (42 U.S.C. 300gg(a)(2)) 
        is amended by striking ``12 months'' and inserting ``3 
        months'', and by striking ``18 months'' and inserting ``9 
        months''.
            (3) Sunset of interim limitation.--Section 2701 of such Act 
        (42 U.S.C. 300gg) is amended by adding at the end the following 
        new subsection:
    ``(h) Termination.--This section shall cease to apply to any group 
health plan as of the date that such plan becomes subject to the 
requirements of section 211 of the (relating to prohibiting preexisting 
condition exclusions).''.
            (4) Miscellaneous technical amendment.--Section 2702(a)(2) 
        of such Act (42 U.S.C. 300gg-1) is amended by striking ``701'' 
        and inserting ``2701''.
    (d) Effective Date.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall apply with respect to 
        group health plans for plan years beginning on or after January 
        1, 2010.
            (2) Special rule for collective bargaining agreements.--In 
        the case of a group health plan maintained pursuant to 1 or 
        more collective bargaining agreements between employee 
        representatives and 1 or more employers ratified before the 
        date of the enactment of this Act, the amendments made by this 
        section shall not apply to plan years beginning before the 
        earlier of--
                    (A) the date on which the last of the collective 
                bargaining agreements relating to the plan terminates 
                (determined without regard to any extension thereof 
                agreed to after the date of the enactment of this Act);
                    (B) 3 years after the date of the enactment of this 
                Act.

SEC. 107. PROHIBITING ACTS OF DOMESTIC VIOLENCE FROM BEING TREATED AS 
              PREEXISTING CONDITIONS.

    (a) ERISA.--Section 701(d)(3) of the Employee Retirement Income 
Security Act of 1974 (29 U.S.C. ) is amended--
            (1) in the heading, by inserting ``or domestic violence'' 
        after ``pregnancy''; and
            (2) by inserting ``or domestic violence'' after ``relating 
        to pregnancy''.
    (b) PHSA.--
            (1) Group market.--Section 2701(d)(3) of the Public Health 
        Service Act (42 U.S.C. 300gg(d)(3)) is amended--
                    (A) in the heading, by inserting ``or domestic 
                violence'' after ``pregnancy''; and
                    (B) by inserting ``or domestic violence'' after 
                ``relating to pregnancy''.
            (2) Individual market.--Title XXVII of such Act is amended 
        by inserting after section 2753 the following new section:

``SEC. 2754. PROHIBITION ON DOMESTIC VIOLENCE AS PREEXISTING CONDITION.

    ``A health insurance issuer offering health insurance coverage in 
the individual market may not, on the basis of domestic violence, 
impose any preexisting condition exclusion (as defined in section 
2701(b)(1)(A)) with respect to such coverage.''.
    (c) IRC.--Section 9801(d)(3) of the Internal Revenue Code of 1986 
is amended--
            (1) in the heading, by inserting ``or domestic violence'' 
        after ``pregnancy''; and
            (2) by inserting ``or domestic violence'' after ``relating 
        to pregnancy''.
    (d) Effective Dates.--
            (1) Except as otherwise provided in this subsection, the 
        amendments made by this section shall apply with respect to 
        group health plans (and health insurance issuers offering group 
        health insurance coverage) for plan years beginning on or after 
        January 1, 2010.
            (2) The amendment made by subsection (b)(2) shall apply 
        with respect to health insurance coverage offered, sold, 
        issued, renewed, in effect, or operated in the individual 
        market on or after such date.

SEC. 108. ENDING HEALTH INSURANCE DENIALS AND DELAYS OF NECESSARY 
              TREATMENT FOR CHILDREN WITH DEFORMITIES.

    (a) Amendments to the Employee Retirement Income Security Act of 
1974.--
            (1) In general.--Subpart B of part 7 of subtitle B of title 
        I of the Employee Retirement Income Security Act of 1974 is 
        amended by adding at the end the following new section:

``SEC. 715. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S CONGENITAL 
              OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Treatment for Children With Deformities.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for surgical benefits shall provide coverage 
        for outpatient and inpatient diagnosis and treatment of a minor 
        child's congenital or developmental deformity, disease, or 
        injury. A minor child shall include any individual who is 21 
        years of age or younger.
            ``(2) Treatment defined.--
                    ``(A) In general.--In this section, the term 
                `treatment' includes reconstructive surgical procedures 
                (procedures that are generally performed to improve 
                function, but may also be performed to approximate a 
                normal appearance) that are performed on abnormal 
                structures of the body caused by congenital defects, 
                developmental abnormalities, trauma, infection, tumors, 
                or disease, including--
                            ``(i) procedures that do not materially 
                        affect the function of the body part being 
                        treated; and
                            ``(ii) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(B) Exception.--Such term does not include 
                cosmetic surgery performed to reshape normal structures 
                of the body to improve appearance or self-esteem.
    ``(b) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 713(b) (other than paragraph 
(3)) with respect to the requirements of this section.''.
            (2) Conforming amendment.--
                    (A) Subsection (c) of section 731 of such Act is 
                amended by striking ``section 711'' and inserting 
                ``sections 711 and 715''.
                    (B) The table of contents in section 1 of such Act 
                is amended by inserting after the item relating to 
                section 714 the following new item:

``Sec. 715. Standards relating to benefits for minor child's congenital 
                            or developmental deformity or disorder.''.
    (b) Amendments to the Internal Revenue Code of 1986.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986 is amended by adding at the end 
        the following new section:

``SEC. 9814. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
              CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Treatment for Children With Deformities.--A 
group health plan that provides coverage for surgical benefits shall 
provide coverage for outpatient and inpatient diagnosis and treatment 
of a minor child's congenital or developmental deformity, disease, or 
injury. A minor child shall include any individual who is 21 years of 
age or younger.
    ``(b) Treatment Defined.--
            ``(1) In general.--In this section, the term `treatment' 
        includes reconstructive surgical procedures (procedures that 
        are generally performed to improve function, but may also be 
        performed to approximate a normal appearance) that are 
        performed on abnormal structures of the body caused by 
        congenital defects, developmental abnormalities, trauma, 
        infection, tumors, or disease, including--
                    ``(A) procedures that do not materially affect the 
                function of the body part being treated, and
                    ``(B) procedures for secondary conditions and 
                follow-up treatment.
            ``(2) Exception.--Such term does not include cosmetic 
        surgery performed to reshape normal structures of the body to 
        improve appearance or self-esteem.''.
            (2) Clerical amendment.--The table of sections for 
        subchapter B of chapter 100 of such Code is amended by adding 
        at the end the following new item:

``Sec. 9814. Standards relating to benefits for minor child's 
                            congenital or developmental deformity or 
                            disorder.''.
    (c) Amendments to the Public Health Service Act.--
            (1) In general.--Subpart 2 of part A of title XXVII of the 
        Public Health Service Act is amended by adding at the end the 
        following new section:

``SEC. 2708. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
              CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``(a) Requirements for Treatment for Children With Deformities.--
            ``(1) In general.--A group health plan, and a health 
        insurance issuer offering group health insurance coverage, that 
        provides coverage for surgical benefits shall provide coverage 
        for outpatient and inpatient diagnosis and treatment of a minor 
        child's congenital or developmental deformity, disease, or 
        injury. A minor child shall include any individual who is 21 
        years of age or younger.
            ``(2) Treatment defined.--
                    ``(A) In general.--In this section, the term 
                `treatment' includes reconstructive surgical procedures 
                (procedures that are generally performed to improve 
                function, but may also be performed to approximate a 
                normal appearance) that are performed on abnormal 
                structures of the body caused by congenital defects, 
                developmental abnormalities, trauma, infection, tumors, 
                or disease, including--
                            ``(i) procedures that do not materially 
                        affect the function of the body part being 
                        treated; and
                            ``(ii) procedures for secondary conditions 
                        and follow-up treatment.
                    ``(B) Exception.--Such term does not include 
                cosmetic surgery performed to reshape normal structures 
                of the body to improve appearance or self-esteem.
    ``(b) Notice.--A group health plan under this part shall comply 
with the notice requirement under section 715(b) of the Employee 
Retirement Income Security Act of 1974 with respect to the requirements 
of this section as if such section applied to such plan.''.
            (2) Individual health insurance.--Subpart 2 of part B of 
        title XXVII of the Public Health Service Act, as amended by 
        section 161(b), is further amended by adding at the end the 
        following new section:

``SEC. 2755. STANDARDS RELATING TO BENEFITS FOR MINOR CHILD'S 
              CONGENITAL OR DEVELOPMENTAL DEFORMITY OR DISORDER.

    ``The provisions of section 2708 shall apply to health insurance 
coverage offered by a health insurance issuer in the individual market 
in the same manner as such provisions apply to health insurance 
coverage offered by a health insurance issuer in connection with a 
group health plan in the small or large group market.''.
            (3) Conforming amendments.--
                    (A) Section 2723(c) of such Act (42 U.S.C. 300gg-
                23(c)) is amended by striking ``section 2704'' and 
                inserting ``sections 2704 and 2708''.
                    (B) Section 2762(b)(2) of such Act (42 U.S.C. 
                300gg-62(b)(2)) is amended by striking ``section 2751'' 
                and inserting ``sections 2751 and 2755''.
    (d) Effective Dates.--
            (1) The amendments made by this section shall apply with 
        respect to group health plans (and health insurance issuers 
        offering group health insurance coverage) for plan years 
        beginning on or after January 1, 2010.
            (2) The amendment made by subsection (c)(2) shall apply 
        with respect to health insurance coverage offered, sold, 
        issued, renewed, in effect, or operated in the individual 
        market on or after such date.
    (e) Coordination.--Section 104(1) of the Health Insurance 
Portability and Accountability Act of 1996 is amended by striking 
``(and the amendments made by this subtitle and section 401)'' and 
inserting ``, part 7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974, parts A and C of title XXVII of 
the Public Health Service Act, and chapter 100 of the Internal Revenue 
Code of 1986''.

SEC. 109. ELIMINATION OF LIFETIME LIMITS.

    (a) Amendments to the Employee Retirement Income Security Act of 
1974.--
            (1) In general.--Subpart B of part 7 of subtitle B of title 
        I of the Employee Retirement Income Security Act of 1974 (29 
        U.S.C. 1185 et seq.), as amended by section 108, is amended by 
        adding at the end the following:

``SEC. 716. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

    ``(a) In General.--A group health plan and a health insurance 
issuer providing health insurance coverage in connection with a group 
health plan, may not impose an aggregate dollar lifetime limit with 
respect to benefits payable under the plan or coverage.
    ``(b) Definition.--In this section, the term `aggregate dollar 
lifetime limit' means, with respect to benefits under a group health 
plan or health insurance coverage offered in connection with a group 
health plan, a dollar limitation on the total amount that may be paid 
with respect to such benefits under the plan or health insurance 
coverage with respect to an individual or other coverage unit on a 
lifetime basis.''.
            (2) Clerical amendment.--The table of contents in section 1 
        of such Act, is amended by inserting after the item relating to 
        section 715 the following new item:

``Sec. 716. Elimination of lifetime aggregate limits.''.
    (b) Amendments to the Internal Revenue Code of 1986.--
            (1) In general.--Subchapter B of chapter 100 of the 
        Internal Revenue Code of 1986, as amended by section 108(b), is 
        amended by adding at the end the following new section:

``SEC. 9815. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

    ``(a) In General.--A group health plan may not impose an aggregate 
dollar lifetime limit with respect to benefits payable under the plan.
    ``(b) Definition.--In this section, the term `aggregate dollar 
lifetime limit' means, with respect to benefits under a group health 
plan a dollar limitation on the total amount that may be paid with 
respect to such benefits under the plan with respect to an individual 
or other coverage unit on a lifetime basis.''.
            (2) Clerical amendment.--The table of sections for 
        subchapter B of chapter 100 of such Code, as amended by section 
        108(b), is amended by adding at the end the following new item:

``Sec. 9854. Standards relating to benefits for minor child's 
                            congenital or developmental deformity or 
                            disorder.''.
    (c) Amendment to the Public Health Service Act Relating to the 
Group Market.--
            (1) In general.--Subpart 2 of part A of title XXVII of the 
        Public Health Service Act (42 U.S.C. 300gg-4 et seq.) as 
        amended by section 108(c)(1), is amended by adding at the end 
        the following:

``SEC. 2709. ELIMINATION OF LIFETIME AGGREGATE LIMITS.

    ``(a) In General.--A group health plan and a health insurance 
issuer providing health insurance coverage in connection with a group 
health plan, may not impose an aggregate dollar lifetime limit with 
respect to benefits payable under the plan or coverage.
    ``(b) Definition.--In this section, the term `aggregate dollar 
lifetime limit' means, with respect to benefits under a group health 
plan or health insurance coverage, a dollar limitation on the total 
amount that may be paid with respect to such benefits under the plan or 
health insurance coverage with respect to an individual or other 
coverage unit on a lifetime basis.''.
            (2) Individual market.--Subpart 2 of part B of title XXVII 
        of the Public Health Service Act (42 U.S.C. 300gg-51 et seq.), 
        as amended by section 108(c)(2), is amended by adding at the 
        end the following:

``SEC. 2756. ELIMINATION OF ANNUAL OR LIFETIME AGGREGATE LIMITS.

    ``The provisions of section 2709 shall apply to health insurance 
coverage offered by a health insurance issuer in the individual market 
in the same manner as they apply to health insurance coverage offered 
by a health insurance issuer in connection with a group health plan in 
the small or large group market.''.
    (d) Effective Dates.--
            (1) The amendments made by this section shall apply with 
        respect to group health plans (and health insurance issuers 
        offering group health insurance coverage) for plan years 
        beginning on or after January 1, 2010.
            (2) The amendment made by subsection (c)(2) shall apply 
        with respect to health insurance coverage offered, sold, 
        issued, renewed, in effect, or operated in the individual 
        market on or after such date.

SEC. 110. PROHIBITION AGAINST POSTRETIREMENT REDUCTIONS OF RETIREE 
              HEALTH BENEFITS BY GROUP HEALTH PLANS.

    (a) In General.--Part 7 of subtitle B of title I of the Employee 
Retirement Income Security Act of 1974, as amended by sections 108 and 
109, is amended by inserting after section 716 the following new 
section:

``SEC. 717. PROTECTION AGAINST POSTRETIREMENT REDUCTION OF RETIREE 
              HEALTH BENEFITS.

    ``(a) In General.--Every group health plan shall contain a 
provision which expressly bars the plan, or any fiduciary of the plan, 
from reducing the benefits provided under the plan to a retired 
participant, or beneficiary of such participant, if such reduction 
affects the benefits provided to the participant or beneficiary as of 
the date the participant retired for purposes of the plan and such 
reduction occurs after the participant's retirement unless such 
reduction is also made with respect to active participants. Nothing in 
this section shall prohibit a plan from enforcing a total aggregate cap 
on amounts paid for retiree health coverage that is part of the plan at 
the time of retirement.
    ``(b) No Reduction.--Notwithstanding that a group health plan may 
contain a provision reserving the general power to amend or terminate 
the plan or a provision specifically authorizing the plan to make post-
retirement reductions in retiree health benefits, it shall be 
prohibited for any group health plan, whether through amendment or 
otherwise, to reduce the benefits provided to a retired participant or 
the participant's beneficiary under the terms of the plan if such 
reduction of benefits occurs after the date the participant retired for 
purposes of the plan and reduces benefits that were provided to the 
participant, or the participant's beneficiary, as of the date the 
participant retired unless such reduction is also made with respect to 
active participants.
    ``(c) Reduction Described.-- For purposes of this section, a 
reduction in benefits--
            ``(1) with respect to premiums occurs under a group health 
        plan when a participant's (or beneficiary's) share of the total 
        premium (or, in the case of a self-insured plan, the costs of 
        coverage) of the plan substantially increases; or
            ``(2) with respect to other cost-sharing and benefits under 
        a group health plan occurs when there is a substantial decrease 
        in the actuarial value of the benefit package under the plan.
For purposes of this section, the term `substantial' means an increase 
in the total premium share or a decrease in the actuarial value of the 
benefit package that is greater than 5 percent.''
    (b) Conforming Amendment.--The table of contents in section 1 of 
such Act, as amended by sections 108 and 109, is amended by inserting 
after the item relating to section 716 the following new item:

``Sec. 717. Protection against postretirement reduction of retiree 
                            health benefits.''.
    (c) Waiver.--An employer may, in a form and manner which shall be 
prescribed by the Secretary of Labor, apply for a waiver from this 
provision if the employer can reasonably demonstrate that meeting the 
requirements of this section would impose an undue hardship on the 
employer.
    (d) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act.

SEC. 111. REINSURANCE PROGRAM FOR RETIREES.

    (a) Establishment.--
            (1) In general.--Not later than 90 days after the date of 
        the enactment of this Act, the Secretary of Health and Human 
        Services shall establish a temporary reinsurance program (in 
        this section referred to as the ``reinsurance program'') to 
        provide reimbursement to assist participating employment-based 
        plans with the cost of providing health benefits to retirees 
        and to eligible spouses, surviving spouses and dependents of 
        such retirees.
            (2) Definitions.--For purposes of this section:
                    (A) The term ``eligible employment-based plan'' 
                means a group health plan or employment-based health 
                plan that--
                            (i) is --
                                    (I) maintained by one or more 
                                employers (including without limitation 
                                any State or political subdivision 
                                thereof, or any agency or 
                                instrumentality of any of the 
                                foregoing), former employers or 
                                employee organizations or associations, 
                                or a voluntary employees' beneficiary 
                                association, or a committee or board of 
                                individuals appointed to administer 
                                such plan; or
                                    (II) a multiemployer plan (as 
                                defined in section 3(37) of the 
                                Employee Retirement Income Security Act 
                                of 1974); and
                            (ii) provides health benefits to retirees.
                    (B) The term ``health benefits'' means medical, 
                surgical, hospital, prescription drug, and such other 
                benefits as shall be determined by the Secretary, 
                whether self-funded or delivered through the purchase 
                of insurance or otherwise.
                    (C) The term ``participating employment-based 
                plan'' means an eligible employment-based plan that is 
                participating in the reinsurance program.
                    (D) The term ``retiree'' means, with respect to a 
                participating employment-benefit plan, an individual 
                who--
                            (i) is 55 years of age or older;
                            (ii) is not eligible for coverage under 
                        title XVIII of the Social Security Act; and
                            (iii) is not an active employee of an 
                        employer maintaining the plan or of any 
                        employer that makes or has made substantial 
                        contributions to fund such plan.
                    (E) The term ``Secretary'' means Secretary of 
                Health and Human Services.
    (b) Participation.--To be eligible to participate in the 
reinsurance program, an eligible employment-based plan shall submit to 
the Secretary an application for participation in the program, at such 
time, in such manner, and containing such information as the Secretary 
shall require.
    (c) Payment.--
            (1) Submission of claims.--
                    (A) In general.--Under the reinsurance program, a 
                participating employment-based plan shall submit claims 
                for reimbursement to the Secretary which shall contain 
                documentation of the actual costs of the items and 
                services for which each claim is being submitted.
                    (B) Basis for claims.--Each claim submitted under 
                subparagraph (A) shall be based on the actual amount 
                expended by the participating employment-based plan 
                involved within the plan year for the appropriate 
                employment based health benefits provided to a retiree 
                or to the spouse, surviving spouse, or dependent of a 
                retiree. In determining the amount of any claim for 
                purposes of this subsection, the participating 
                employment-based plan shall take into account any 
                negotiated price concessions (such as discounts, direct 
                or indirect subsidies, rebates, and direct or indirect 
                remunerations) obtained by such plan with respect to 
                such health benefits. For purposes of calculating the 
                amount of any claim, the costs paid by the retiree or 
                by the spouse, surviving spouse, or dependent of the 
                retiree in the form of deductibles, copayments, and 
                coinsurance shall be included along with the amounts 
                paid by the participating employment-based plan.
            (2) Program payments and limit.--If the Secretary 
        determines that a participating employment-based plan has 
        submitted a valid claim under paragraph (1), the Secretary 
        shall reimburse such plan for 80 percent of that portion of the 
        costs attributable to such claim that exceeds $15,000, but is 
        less than $90,000. Such amounts shall be adjusted each year 
        based on the percentage increase in the medical care component 
        of the Consumer Price Index (rounded to the nearest multiple of 
        $1,000) for the year involved.
            (3) Use of payments.--Amounts paid to a participating 
        employment-based plan under this subsection shall only be used 
        to reduce the costs of health care provided by the plan by 
        reducing premium costs for the employer or employee association 
        maintaining the plan, and reducing premium contributions, 
        deductibles, copayments, coinsurance, or other out-of-pocket 
        costs for plan participants and beneficiaries. Where the 
        benefits are provided by an employer to members of a 
        represented bargaining unit, the allocation of payments among 
        these purposes shall be subject to collective bargaining. 
        Amounts paid to the plan under this subsection shall not be 
        used as general revenues by the employer or employee 
        association maintaining the plan or for any other purposes. The 
        Secretary shall develop a mechanism to monitor the appropriate 
        use of such payments by such plans.
            (4) Appeals and program protections.--The Secretary shall 
        establish--
                    (A) an appeals process to permit participating 
                employment-based plans to appeal a determination of the 
                Secretary with respect to claims submitted under this 
                section; and
                    (B) procedures to protect against fraud, waste, and 
                abuse under the program.
            (5) Audits.--The Secretary shall conduct annual audits of 
        claims data submitted by participating employment-based plans 
        under this section to ensure that they are in compliance with 
        the requirements of this section.
    (d) Retiree Reserve Trust Fund.--
            (1) Establishment.--
                    (A) In general.--There is established in the 
                Treasury of the United States a trust fund to be known 
                as the ``Retiree Reserve Trust Fund'' (referred to in 
                this section as the ``Trust Fund''), that shall consist 
                of such amounts as may be appropriated or credited to 
                the Trust Fund as provided for in this subsection to 
                enable the Secretary to carry out the reinsurance 
                program. Such amounts shall remain available until 
                expended.
                    (B) Funding.--There are hereby appropriated to the 
                Trust Fund, out of any moneys in the Treasury not 
                otherwise appropriated, an amount requested by the 
                Secretary as necessary to carry out this section, 
                except that the total of all such amounts requested 
                shall not exceed $10,000,000,000.
                    (C) Appropriations from the trust fund.--
                            (i) In general.--Amounts in the Trust Fund 
                        are appropriated to provide funding to carry 
                        out the reinsurance program and shall be used 
                        to carry out such program.
                            (ii) Limitation to available funds.--The 
                        Secretary has the authority to stop taking 
                        applications for participation in the program 
                        or take such other steps in reducing 
                        expenditures under the reinsurance program in 
                        order to ensure that expenditures under the 
                        reinsurance program do not exceed the funds 
                        available under this subsection.

SEC. 112. WELLNESS PROGRAM GRANTS.

    (a) Allowance of Grant.--
            (1) In general.--For purposes of this section, the 
        Secretaries of Health and Human Services and Labor shall 
        jointly award wellness grants as determined under this section. 
        Wellness program grants shall be awarded to small employers (as 
        defined by the Secretary) for any plan year in an amount equal 
        to 50 percent of the costs paid or incurred by such employers 
        in connection with a qualified wellness program during the plan 
        year. For purposes of the preceding sentence, in the case of 
        any qualified wellness program offered as part of an 
        employment-based health plan, only costs attributable to the 
        qualified wellness program and not to the health plan, or 
        health insurance coverage offered in connection with such a 
        plan, may be taken into account.
            (2) Limitations.--
                    (A) Period.--A wellness grant awarded to an 
                employer under this section shall be for up to 3 years.
                    (B) Amount.--The amount of the grant under 
                paragraph (1) for an employer shall not exceed--
                            (i) the product of $150 and the number of 
                        employees of the employer for any plan year; 
                        and
                            (ii) $50,000 for the entire period of the 
                        grant.
    (b) Qualified Wellness Program.--For purposes of this section:
            (1) Qualified wellness program.--The term ``qualified 
        wellness program'' means a program that --
                    (A) includes any 3 wellness components described in 
                subsection (c); and
                    (B) is to be certified jointly by the Secretary of 
                Health and Human Services and the Secretary of Labor, 
                in coordination with the Director of the Centers for 
                Disease Control and Prevention, as a qualified wellness 
                program under this section.
            (2) Programs must be consistent with research and best 
        practices.--
                    (A) In general.--The Secretary of Health and Human 
                Services and the Secretary of Labor shall not certify a 
                program as a qualified wellness program unless the 
                program--
                            (i) is consistent with evidence-based 
                        research and best practices, as identified by 
                        persons with expertise in employer health 
                        promotion and wellness programs;
                            (ii) includes multiple, evidence-based 
                        strategies which are based on the existing and 
                        emerging research and careful scientific 
                        reviews, including the Guide to Community 
                        Preventative Services, the Guide to Clinical 
                        Preventative Services, and the National 
                        Registry for Effective Programs, and
                            (iii) includes strategies which focus on 
                        prevention and support for employee populations 
                        at risk of poor health outcomes.
                    (B) Periodic updating and review.--The Secretaries 
                of Health and Human Services and Labor, in consultation 
                with other appropriate agencies shall jointly establish 
                procedures for periodic review, evaluation, and update 
                of the programs under this subsection.
            (3) Health literacy and accessibility.--The Secretaries of 
        Health and Human Services and Labor shall jointly, as part of 
        the certification process--
                    (A) ensure that employers make the programs 
                culturally competent, physically and programmatically 
                accessible (including for individuals with 
                disabilities), and appropriate to the health literacy 
                needs of the employees covered by the programs;
                    (B) require a health literacy component to provide 
                special assistance and materials to employees with low 
                literacy skills, limited English and from underserved 
                populations; and
                    (C) require the Secretaries to compile and 
                disseminate to employer health plans information on 
                model health literacy curricula, instructional 
                programs, and effective intervention strategies.
    (c) Wellness Program Components.--For purposes of this section, the 
wellness program components described in this subsection are the 
following:
            (1) Health awareness component.--A health awareness 
        component which provides for the following:
                    (A) Health education.--The dissemination of health 
                information which addresses the specific needs and 
                health risks of employees.
                    (B) Health screenings.--The opportunity for 
                periodic screenings for health problems and referrals 
                for appropriate follow-up measures.
            (2) Employee engagement component.--An employee engagement 
        component which provides for the active engagement of employees 
        in worksite wellness programs through worksite assessments and 
        program planning, onsite delivery, evaluation, and improvement 
        efforts.
            (3) Behavioral change component.--A behavioral change 
        component which encourages healthy living through counseling, 
        seminars, on-line programs, self-help materials, or other 
        programs which provide technical assistance and problem solving 
        skills. Such component may include programs relating to--
                    (A) tobacco use;
                    (B) obesity;
                    (C) stress management;
                    (D) physical fitness;
                    (E) nutrition;
                    (F) substance abuse;
                    (G) depression; and
                    (H) mental health promotion.
            (4) Supportive environment component.--A supportive 
        environment component which includes the following:
                    (A) On-site policies.--Policies and services at the 
                worksite which promote a healthy lifestyle, including 
                policies relating to--
                            (i) tobacco use at the worksite;
                            (ii) the nutrition of food available at the 
                        worksite through cafeterias and vending 
                        options;
                            (iii) minimizing stress and promoting 
                        positive mental health in the workplace; and
                            (iv) the encouragement of physical activity 
                        before, during, and after work hours.
    (d) Participation Requirement.--No grant shall be allowed under 
subsection (a) unless the Secretaries of Health and Human Services and 
Labor, in consultation with other appropriate agencies, jointly 
certify, as a part of any certification described in subsection (b), 
that each wellness program component of the qualified wellness 
program--
            (1) shall be available to all employees of the employer;
            (2) shall not mandate participation by employees; and
            (3) may provide a financial reward for participation of an 
        individual in such program so long as such reward is not tied 
        to the premium or cost-sharing of the individual under the 
        health benefits plan.
    (e) Privacy Protections.--Data gathered for purposes of the 
employer wellness program may be used solely for the purposes of 
administering the program. The Secretaries of Health and Human Services 
and Labor shall develop standards to ensure such data remain 
confidential and are not used for purposes beyond those for 
administering the program.
    (f) Certain Costs Not Included.--For purposes of this section, 
costs paid or incurred by an employer for food or health insurance 
shall not be taken into account under subsection (a).
    (g) Outreach.--The Secretaries of Health and Human Services and 
Labor, in conjunction with other appropriate agencies and members of 
the business community, shall jointly institute an outreach program to 
inform businesses about the availability of the wellness program grant 
as well as to educate businesses on how to develop programs according 
to recognized and promising practices and on how to measure the success 
of implemented programs.
    (h) Effective Date.--This section shall take effect on July 1, 
2010.
    (i) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as are necessary to carry out this section.

SEC. 113. EXTENSION OF COBRA CONTINUATION COVERAGE.

    (a) Extension of Current Periods of Continuation Coverage.--
            (1) In general.--In the case of any individual who is, 
        under a COBRA continuation coverage provision, covered under 
        COBRA continuation coverage on or after the date of the 
        enactment of this Act, the required period of any such coverage 
        which has not subsequently terminated under the terms of such 
        provision for any reason other than the expiration of a period 
        of a specified number of months shall, notwithstanding such 
        provision and subject to subsection (b), extend to the earlier 
        of the date on which such individual becomes eligible for 
        acceptable coverage or the date on which such individual 
        becomes eligible for health insurance coverage through the 
        Health Insurance Exchange (or a State-based Health Insurance 
        Exchange operating in a State or group of States).
            (2) Notice.--As soon as practicable after the date of the 
        enactment of this Act, the Secretary of Labor, in consultation 
        with the Secretary of the Treasury and the Secretary of Health 
        and Human Services, shall, in consultation with administrators 
        of the group health plans (or other entities) that provide or 
        administer the COBRA continuation coverage involved, provide 
        rules setting forth the form and manner in which prompt notice 
        to individuals of the continued availability of COBRA 
        continuation coverage to such individuals under paragraph (1).
    (b) Continued Effect of Other Terminating Events.--Notwithstanding 
subsection (a), any required period of COBRA continuation coverage 
which is extended under such subsection shall terminate upon the 
occurrence, prior to the date of termination otherwise provided in such 
subsection, of any terminating event specified in the applicable 
continuation coverage provision other than the expiration of a period 
of a specified number of months.
    (c) Access to State Health Benefits Risk Pools.--This section shall 
supersede any provision of the law of a State or political subdivision 
thereof to the extent that such provision has the effect of limiting or 
precluding access by a qualified beneficiary whose COBRA continuation 
coverage has been extended under this section to a State health 
benefits risk pool recognized by the Commissioner for purposes of this 
section solely by reason of the extension of such coverage beyond the 
date on which such coverage otherwise would have expired.
    (d) Definitions.--For purposes of this section--
            (1) COBRA continuation coverage.--The term ``COBRA 
        continuation coverage'' means continuation coverage provided 
        pursuant to part 6 of subtitle B of title I of the Employee 
        Retirement Income Security Act of 1974 (other than under 
        section 609), title XXII of the Public Health Service Act, 
        section 4980B of the Internal Revenue Code of 1986 (other than 
        subsection (f)(1) of such section insofar as it relates to 
        pediatric vaccines), or section 905a of title 5, United States 
        Code, or under a State program that provides comparable 
        continuation coverage. Such term does not include coverage 
        under a health flexible spending arrangement under a cafeteria 
        plan within the meaning of section 125 of the Internal Revenue 
        Code of 1986.
            (2) COBRA continuation provision.--The term ``COBRA 
        continuation provision'' means the provisions of law described 
        in paragraph (1).

SEC. 114. STATE HEALTH ACCESS PROGRAM GRANTS.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary'') shall provide grants to 
States (as defined for purposes of title XIX of the Social Security 
Act) to establish programs to expand access to affordable health care 
coverage for the uninsured populations in that State in a manner 
consistent with reforms to take effect under this division in Y1.
    (b) Types of Programs.--The types of programs for which grants are 
available under subsection (a) include the following:
            (1) State insurance exchanges.--State insurance exchanges 
        that develop new, less expensive, portable benefit packages for 
        small employers and part-time and seasonal workers.
            (2) Community coverage program.--Community coverage with 
        shared responsibility between employers, governmental or 
        nonprofit entity, and the individual.
            (3) Reinsurance plan program.--Reinsurance plans that 
        subsidize a certain share of carrier losses within a certain 
        risk corridor health insurance premium assistance.
            (4) Transparent marketplace program.--Transparent 
        marketplace that provides an organized structure for the sale 
        of insurance products such as a Web exchange or portal.
            (5) Automated enrollment program.--Statewide or automated 
        enrollment systems for public assistance programs.
            (6) Innovative strategies.--Innovative strategies to insure 
        low-income childless adults.
            (7) Purchasing collaboratives.--Business/consumer 
        collaborative that provides direct contract health care service 
        purchasing options for group plan sponsors.
    (c) Eligibility and Administration.--
            (1) Implementation of key statutory or regulatory 
        changes.--In order to be awarded a grant under this section for 
        a program, a State shall demonstrate that--
                    (A) it has achieved the key State and local 
                statutory or regulatory changes required to begin 
                implementing the new program within 1 year after the 
                initiation of funding under the grant; and
                    (B) it will be able to sustain the program without 
                Federal funding after the end of the period of the 
                grant.
            (2) Ineligibility.--A State that has already developed a 
        comprehensive health insurance access program is not eligible 
        for a grant under this section.
            (3) Application required.--No State shall receive a grant 
        under this section unless the State has approved by the 
        Secretary such an application, in such form and manner as the 
        Secretary specifies.
            (4) Administration based on current program.--The program 
        under this section is intended to build on the State Health 
        Access Program funded under the Omnibus Appropriations Act, 
        2009 (Public Law 111-8).
    (d) Funding Limitations.--
            (1) In general.--A grant under this section shall--
                    (A) only be available for expenditures before Y1; 
                and
                    (B) only be used to supplement, and not supplant, 
                funds otherwise provided.
            (2) Matching fund requirement.--
                    (A) In general.--Subject to subparagraph (B), no 
                grant may be awarded to a State unless the State 
                demonstrates the seriousness of its effort by matching 
                at least 20 percent of the grant amount through non-
                Federal resources, which may be a combination of State, 
                local, private dollars from insurers, providers, and 
                other private organizations.
                    (B) Waiver.--The Secretary may waive the 
                requirement of subparagraph (A) if the State 
                demonstrates to the Secretary financial hardship in 
                complying with such requirement.
    (e) Study.--The Secretary shall review, study, and benchmark the 
progress and results of the programs funded under this section.
    (f) Report.--Each State receiving a grant under this section shall 
submit to the Secretary a report on best practices and lessons learned 
through the grant to inform the health reform coverage expansions under 
this division beginning in Y1.
    (g) Funding.--There are authorized to be appropriated such sums as 
may be necessary to carry out this section.

SEC. 115. ADMINISTRATIVE SIMPLIFICATION.

    (a) Standardizing Electronic Administrative Transactions.--
            (1) In general.--Part C of title XI of the Social Security 
        Act (42 U.S.C. 1320d et seq.) is amended by inserting after 
        section 1173 the following new sections:

``SEC. 1173A. STANDARDIZE ELECTRONIC ADMINISTRATIVE TRANSACTIONS.

    ``(a) Standards for Financial and Administrative Transactions.--
            ``(1) In general.--The Secretary shall adopt and regularly 
        update standards consistent with the goals described in 
        paragraph (2).
            ``(2) Goals for financial and administrative 
        transactions.--The goals for standards under paragraph (1) are 
        that such standards shall, to the extent practicable--
                    ``(A) be unique with no conflicting or redundant 
                standards;
                    ``(B) be authoritative, permitting no additions or 
                constraints for electronic transactions, including 
                companion guides;
                    ``(C) be comprehensive, efficient and robust, 
                requiring minimal augmentation by paper transactions or 
                clarification by further communications;
                    ``(D) enable the real-time (or near real-time) 
                determination of an individual's financial 
                responsibility at the point of service and, to the 
                extent possible, prior to service, including whether 
                the individual is eligible for a specific service with 
                a specific physician at a specific facility, on a 
                specific date or range of dates, include utilization of 
                a machine-readable health plan beneficiary 
                identification card or similar mechanism;
                    ``(E) enable, where feasible, near real-time 
                adjudication of claims;
                    ``(F) provide for timely acknowledgment, response, 
                and status reporting applicable to any electronic 
                transaction deemed appropriate by the Secretary;
                    ``(G) describe all data elements (such as reason 
                and remark codes) in unambiguous terms, not permit 
                optional fields, require that data elements be either 
                required or conditioned upon set values in other 
                fields, and prohibit additional conditions except where 
                required by (or to implement) State or Federal law or 
                to protect against fraud and abuse; and
                    ``(H) harmonize all common data elements across 
                administrative and clinical transaction standards.
            ``(3) Time for adoption.--Not later than 2 years after the 
        date of the enactment of this section, the Secretary shall 
        adopt standards under this section by interim, final rule.
            ``(4) Requirements for specific standards.--The standards 
        under this section shall be developed, adopted, and enforced so 
        as to--
                    ``(A) clarify, refine, complete, and expand, as 
                needed, the standards required under section 1173;
                    ``(B) require paper versions of standardized 
                transactions to comply with the same standards as to 
                data content such that a fully compliant, equivalent 
                electronic transaction can be populated from the data 
                from a paper version;
                    ``(C) enable electronic funds transfers, in order 
                to allow automated reconciliation with the related 
                health care payment and remittance advice;
                    ``(D) require timely and transparent claim and 
                denial management processes, including uniform claim 
                edits, uniform reason and remark denial codes, 
                tracking, adjudication, and appeal processing;
                    ``(E) require the use of a standard electronic 
                transaction with which health care providers may 
                quickly and efficiently enroll with a health plan to 
                conduct the other electronic transactions provided for 
                in this part; and
                    ``(F) provide for other requirements relating to 
                administrative simplification as identified by the 
                Secretary, in consultation with stakeholders.
            ``(5) Building on existing standards.--In adopting the 
        standards under this section, the Secretary shall consider 
        existing and planned standards.
            ``(6) Implementation and enforcement.--Not later than 6 
        months after the date of the enactment of this section, the 
        Secretary shall submit to the appropriate committees of 
        Congress a plan for the implementation and enforcement, by not 
        later than 5 years after such date of enactment, of the 
        standards under this section. Such plan shall include--
                    ``(A) a process and timeframe with milestones for 
                developing the complete set of standards;
                    ``(B) a proposal for accommodating necessary 
                changes between version changes and a process for 
                upgrading standards as often as annually by interim, 
                final rulemaking;
                    ``(C) programs to provide incentives for, and ease 
                the burden of, implementation for certain health care 
                providers, with special consideration given to such 
                providers serving rural or underserved areas and ensure 
                coordination with standards, implementation 
                specifications, and certification criteria being 
                adopted under the HITECH Act;
                    ``(D) programs to provide incentives for, and ease 
                the burden of, health care providers who volunteer to 
                participate in the process of setting standards for 
                electronic transactions;
                    ``(E) an estimate of total funds needed to ensure 
                timely completion of the implementation plan; and
                    ``(F) an enforcement process that includes timely 
                investigation of complaints, random audits to ensure 
                compliance, civil monetary and programmatic penalties 
                for noncompliance consistent with existing laws and 
                regulations, and a fair and reasonable appeals process 
                building off of enforcement provisions under this part, 
                and concurrent State enforcement jurisdiction.
        The Secretary may promulgate an annual audit and certification 
        process to ensure that all health plans and clearinghouses are 
        both syntactically and functionally compliant with all the 
        standard transactions mandated pursuant to the administrative 
        simplification provisions of this part and the Health Insurance 
        Portability and Accountability Act of 1996.
    ``(b) Limitations on Use of Data.--Nothing in this section shall be 
construed to permit the use of information collected under this section 
in a manner that would violate State or Federal law.
    ``(c) Protection of Data.--The Secretary shall ensure (through the 
promulgation of regulations or otherwise) that all data collected 
pursuant to subsection (a) are used and disclosed in a manner that 
meets the HIPAA privacy and security law (as defined in section 
3009(a)(2) of the Public Health Service Act), including any privacy or 
security standard adopted under section 3004 of such Act.

``SEC. 1173B. INTERIM COMPANION GUIDES, INCLUDING OPERATING RULES.

    ``(a) In General.--The Secretary shall adopt a single, binding, 
comprehensive companion guide, that includes operating rules for each 
X12 Version 5010 transaction described in section 1173(a)(2), to be 
effective until the new version of these transactions which comply with 
section 1173A are adopted and implemented.
    ``(b) Companion Guide and Operating Rules Development.--In adopting 
such interim companion guide and rules, the Secretary shall comply with 
section 1172, except that a nonprofit entity that meets the following 
criteria shall also be consulted:
            ``(1) The entity focuses its mission on administrative 
        simplification.
            ``(2) The entity uses a multistakeholder process that 
        creates consensus-based companion guides, including operating 
        rules using a voting process that ensures balanced 
        representation by the critical stakeholders (including health 
        plans and health care providers) so that no one group dominates 
        the entity and shall include others such as standards 
        development organizations, and relevant Federal or State 
        agencies.
            ``(3) The entity has in place a public set of guiding 
        principles that ensure the companion guide and operating rules 
        and process are open and transparent.
            ``(4) The entity coordinates its activities with the HIT 
        Policy Committee, and the HIT Standards Committee (established 
        under title XXX of the Public Health Service Act) and 
        complements the efforts of the Office of the National 
        Healthcare Coordinator and its related health information 
        exchange goals.
            ``(5) The entity incorporates the standards issued under 
        Health Insurance Portability and Accountability Act of 1996 and 
        this part, and in developing the companion guide and operating 
        rules does not change the definition, data condition or use of 
        a data element or segment in a standard, add any elements or 
        segments to the maximum defined data set, use any codes or data 
        elements that are either marked `not used' in the standard's 
        implementation specifications or are not in the standard's 
        implementation specifications, or change the meaning or intent 
        of the standard's implementation specifications.
            ``(6) The entity uses existing market research and proven 
        best practices.
            ``(7) The entity has a set of measures that allow for the 
        evaluation of their market impact and public reporting of 
        aggregate stakeholder impact.
            ``(8) The entity supports nondiscrimination and conflict of 
        interest policies that demonstrate a commitment to open, fair, 
        and nondiscriminatory practices.
            ``(9) The entity allows for public reviews and comment on 
        updates of the companion guide, including the operating rules.
    ``(c) Implementation.--The Secretary shall adopt a single, binding 
companion guide, including operating rules under this section, for each 
transaction, to become effective with the X12 Version 5010 transaction 
implementation, or as soon thereafter as feasible. The companion guide, 
including operating rules for the transactions for eligibility for 
health plan and health claims status under this section shall be 
adopted not later than October 1, 2011, in a manner such that such set 
of rules is effective beginning not later than January 1, 2013. The 
companion guide, including operating rules for the remainder of the 
transactions described in section 1173(a)(2) shall be adopted not later 
than October 1, 2012, in a manner such that such set of rules is 
effective beginning not later than January 1, 2014.''.
            (2) Definitions.--Section 1171 of such Act (42 U.S.C. 
        1320d) is amended--
                    (A) in paragraph (1), by inserting ``, and 
                associated operational guidelines and instructions, as 
                determined appropriate by the Secretary'' after 
                ``medical procedure codes''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(10) Operating rules.--The term `operating rules' means 
        business rules for using and processing transactions, such as 
        service level requirements, which do not impact the 
        implementation specifications or other data content 
        requirements.''.
            (3) Conforming amendment.--Section 1179(a) of such Act (42 
        U.S.C. 1320d-8(a)) is amended, in the matter before paragraph 
        (1)--
                    (A) by inserting ``on behalf of an individual'' 
                after ``1978)''; and
                    (B) by inserting ``on behalf of an individual'' 
                after ``for a financial institution'' and
    (b) Standards for Claims Attachments and Coordination of 
Benefits.--
            (1) Standard for health claims attachments.--Not later than 
        1 year after the date of the enactment of this Act, the 
        Secretary of Health and Human Services shall promulgate an 
        interim, final rule to establish a standard for health claims 
        attachment transaction described in section 1173(a)(2)(B) of 
        the Social Security Act (42 U.S.C. 1320d-2(a)(2)(B)) and 
        coordination of benefits.
            (2) Revision in processing payment transactions by 
        financial institutions.--
                    (A) In general.--Section 1179 of the Social 
                Security Act (42 U.S.C. 1320d-8) is amended, in the 
                matter before paragraph (1)--
                            (i) by striking ``or is engaged'' and 
                        inserting ``and is engaged''; and
                            (ii) by inserting ``(other than as a 
                        business associate for a covered entity)'' 
                        after ``for a financial institution''.
                    (B) Compliance date.--The amendments made by 
                subparagraph (A) shall apply to transactions occurring 
                on or after such date (not later than January 1, 2014) 
                as the Secretary of Health and Human Services shall 
                specify.
    (c) Standards for First Report of Injury.--Not later than January 
1, 2014, the Secretary of Health and Human Services shall promulgate an 
interim final rule to establish a standard for the first report of 
injury transaction described in section 1173(a)(2)(G) of the Social 
Security Act (42 U.S.C. 1320d-2(a)(2)(G)).
    (d) Unique Health Plan Identifier.--Not later October 1, 2012, the 
Secretary of Health and Human Services shall promulgate an interim 
final rule to establish a unique health plan identifier described in 
section 1173(b) of the Social Security Act (42 U.S.C. 1320d-2(b)) based 
on the input of the National Committee of Vital and Health Statistics 
and consultation with health plans, health care providers, and other 
interested parties.
    (e) Expansion of Electronic Transactions in Medicare.--Section 
1862(a) of the Social Security Act (42 U.S.C. 1395y(a)) is amended--
            (1) in paragraph (23), by striking ``or'' at the end;
            (2) in paragraph (24), by striking the period and inserting 
        ``; or''; and
            (3) by inserting after paragraph (24) the following new 
        paragraph:
            ``(25) subject to subsection (h), not later than January 1, 
        2015, for which the payment is other than by electronic funds 
        transfer (EFT) so long as the Secretary has adopted and 
        implemented a standard for electronic funds transfer under 
        section 1173A.''.
    (f) Expansion of Penalties.--Section 1176 of such Act (42 U.S.C. 
1320d-5) is amended by adding at the end the following new subsection:
    ``(c) Expansion of Penalty Authority.--The Secretary may, in 
addition to the penalties provided under subsections (a) and (b), 
provide for the imposition of penalties for violations of this part 
that are comparable--
            ``(1) in the case of health plans, to the sanctions the 
        Secretary is authorized to impose under part C or D of title 
        XVIII in the case of a plan that violates a provision of such 
        part; or
            ``(2) in the case of a health care provider, to the 
        sanctions the Secretary is authorized to impose under part A, 
        B, or D of title XVIII in the case of a health care provider 
        that violations a provision of such part with respect to that 
        provider.''.

TITLE II--PROTECTIONS AND STANDARDS FOR QUALIFIED HEALTH BENEFITS PLANS

                     Subtitle A--General Standards

SEC. 201. REQUIREMENTS REFORMING HEALTH INSURANCE MARKETPLACE.

    (a) Purpose.--The purpose of this title is to establish standards 
to ensure that new health insurance coverage and employment-based 
health plans that are offered meet standards guaranteeing access to 
affordable coverage, essential benefits, and other consumer 
protections.
    (b) Requirements for Qualified Health Benefits Plans.--On or after 
the first day of Y1, a health benefits plan shall not be a qualified 
health benefits plan under this division unless the plan meets the 
applicable requirements of the following subtitles for the type of plan 
and plan year involved:
            (1) Subtitle B (relating to affordable coverage).
            (2) Subtitle C (relating to essential benefits).
            (3) Subtitle D (relating to consumer protection).
    (c) Terminology.--In this division:
            (1) Enrollment in employment-based health plans.--An 
        individual shall be treated as being ``enrolled'' in an 
        employment-based health plan if the individual is a participant 
        or beneficiary (as such terms are defined in section 3(7) and 
        3(8), respectively, of the Employee Retirement Income Security 
        Act of 1974) in such plan.
            (2) Individual and group health insurance coverage.--The 
        terms ``individual health insurance coverage'' and ``group 
        health insurance coverage'' mean health insurance coverage 
        offered in the individual market or large or small group 
        market, respectively, as defined in section 2791 of the Public 
        Health Service Act.

SEC. 202. PROTECTING THE CHOICE TO KEEP CURRENT COVERAGE.

    (a) Grandfathered Health Insurance Coverage Defined.--Subject to 
the succeeding provisions of this section, for purposes of establishing 
acceptable coverage under this division, the term ``grandfathered 
health insurance coverage'' means individual health insurance coverage 
that is offered and in force and effect before the first day of Y1 if 
the following conditions are met:
            (1) Limitation on new enrollment.--
                    (A) In general.--Except as provided in this 
                paragraph, the individual health insurance issuer 
                offering such coverage does not enroll any individual 
                in such coverage if the first effective date of 
                coverage is on or after the first day of Y1.
                    (B) Dependent coverage permitted.--Subparagraph (A) 
                shall not affect the subsequent enrollment of a 
                dependent of an individual who is covered as of such 
                first day.
            (2) Limitation on changes in terms or conditions.--Subject 
        to paragraph (3) and except as required by law, the issuer does 
        not change any of its terms or conditions, including benefits 
        and cost-sharing, from those in effect as of the day before the 
        first day of Y1.
            (3) Restrictions on premium increases.--The issuer cannot 
        vary the percentage increase in the premium for a risk group of 
        enrollees in specific grandfathered health insurance coverage 
        without changing the premium for all enrollees in the same risk 
        group at the same rate, as specified by the Commissioner.
    (b) Grace Period for Current Employment-Based Health Plans.--
            (1) Grace period.--
                    (A) In general.--The Commissioner shall establish a 
                grace period whereby, for plan years beginning after 
                the end of the 5-year period beginning with Y1, an 
                employment-based health plan in operation as of the day 
                before the first day of Y1 must meet the same 
                requirements as apply to a qualified health benefits 
                plan under section 201, including the essential benefit 
                package requirement under section 221.
                    (B) Exception for limited benefits plans.--
                Subparagraph (A) shall not apply to an employment-based 
                health plan in which the coverage consists only of one 
                or more of the following:
                            (i) Any coverage described in section 
                        3001(a)(1)(B)(ii)(IV) of division B of the 
                        American Recovery and Reinvestment Act of 2009 
                        (Public Law 111-5).
                            (ii) Excepted benefits (as defined in 
                        section 733(c) of the Employee Retirement 
                        Income Security Act of 1974), including 
                        coverage under a specified disease or illness 
                        policy described in paragraph (3)(A) of such 
                        section.
                            (iii) Such other limited benefits as the 
                        Commissioner may specify.
                In no case shall an employment-based health plan in 
                which the coverage consists only of one or more of the 
                coverage or benefits described in clauses (i) through 
                (iii) be treated as acceptable coverage under this 
                division.
            (2) Transitional treatment as acceptable coverage.--During 
        the grace period specified in paragraph (1)(A), an employment-
        based health plan (which may be a high deducible health plan, 
        as defined in section 223(c)(2) of the Internal Revenue Code of 
        1986) that is described in such paragraph shall be treated as 
        acceptable coverage under this division.
    (c) Limitation on Individual Health Insurance Coverage.--
            (1) In general.--Individual health insurance coverage that 
        is not grandfathered health insurance coverage under subsection 
        (a) may only be offered on or after the first day of Y1 as an 
        Exchange-participating health benefits plan.
            (2) Separate, excepted coverage permitted.--Nothing in--
                    (A) paragraph (1) shall prevent the offering of 
                excepted benefits described in section 2791(c) of the 
                Public Health Service Act so long as such benefits are 
                offered outside the Health Insurance Exchange and are 
                priced separately from health insurance coverage; and
                    (B) this division shall be construed--
                            (i) to prevent the offering of a stand-
                        alone plan that offers coverage of excepted 
                        benefits described in section 2791(c)(2)(A) of 
                        the Public Health Service Act (relating to 
                        limited scope dental or vision benefits) for 
                        individuals and families from a State-licensed 
                        dental and vision carrier; or
                            (ii) as applying requirements for a 
                        qualified health benefits plan to such a stand-
                        alone plan that is offered and priced 
                        separately from a qualified health benefits 
                        plan.

    Subtitle B--Standards Guaranteeing Access to Affordable Coverage

SEC. 211. PROHIBITING PREEXISTING CONDITION EXCLUSIONS.

    A qualified health benefits plan may not impose any preexisting 
condition exclusion (as defined in section 2701(b)(1)(A) of the Public 
Health Service Act) or otherwise impose any limit or condition on the 
coverage under the plan with respect to an individual or dependent 
based on any of the following: health status, medical condition, claims 
experience, receipt of health care, medical history, genetic 
information, evidence of insurability, disability, or source of injury 
(including conditions arising out of acts of domestic violence) or any 
similar factors.

SEC. 212. GUARANTEED ISSUE AND RENEWAL FOR INSURED PLANS AND 
              PROHIBITING RESCISSIONS.

    The requirements of sections 2711 (other than subsections (e) and 
(f)) and 2712 (other than paragraphs (3), and (6) of subsection (b) and 
subsection (e)) of the Public Health Service Act, relating to 
guaranteed availability and renewability of health insurance coverage, 
shall apply to individuals and employers in all individual and group 
health insurance coverage, whether offered to individuals or employers 
through the Health Insurance Exchange, through any employment-based 
health plan, or otherwise, in the same manner as such sections apply to 
employers and health insurance coverage offered in the small group 
market, except that such section 2712(b)(1) shall apply only if, before 
nonrenewal or discontinuation of coverage, the issuer has provided the 
enrollee with notice of nonpayment of premiums and there is a grace 
period during which the enrollee has an opportunity to correct such 
nonpayment. Rescissions of such coverage shall be prohibited except in 
cases of fraud as defined in section 2712(b)(2) of such Act.

SEC. 213. INSURANCE RATING RULES.

    (a) In General.--The premium rate charged for a qualified health 
benefits plan that is health insurance coverage may not vary except as 
follows:
            (1) Limited age variation permitted.--By age (within such 
        age categories as the Commissioner shall specify) so long as 
        the ratio of the highest such premium to the lowest such 
        premium does not exceed the ratio of 2 to 1.
            (2) By area.--By premium rating area (as permitted by State 
        insurance regulators or, in the case of Exchange-participating 
        health benefits plans, as specified by the Commissioner in 
        consultation with such regulators).
            (3) By family enrollment.--By family enrollment (such as 
        variations within categories and compositions of families) so 
        long as the ratio of the premium for family enrollment (or 
        enrollments) to the premium for individual enrollment is 
        uniform, as specified under State law and consistent with rules 
        of the Commissioner.
    (b) Actuarial Value of Optional Service Coverage.--
            (1) In general.--The Commissioner shall estimate the basic 
        per enrollee, per month cost, determined on an average 
        actuarial basis, for including coverage under a basic plan of 
        the services described in section 222(d)(4)(A).
            (2) Considerations.--In making such estimate the 
        Commissioner--
                    (A) may take into account the impact on overall 
                costs of the inclusion of such coverage, but may not 
                take into account any cost reduction estimated to 
                result from such services, including prenatal care, 
                delivery, or postnatal care;
                    (B) shall estimate such costs as if such coverage 
                were included for the entire population covered; and
                    (C) may not estimate such a cost at less than $1 
                per enrollee, per month.
    (c) Study and Reports.--
            (1) Study.--The Commissioner, in coordination with the 
        Secretary of Health and Human Services and the Secretary of 
        Labor, shall conduct a study of the large-group-insured and 
        self-insured employer health care markets. Such study shall 
        examine the following:
                    (A) The types of employers by key characteristics, 
                including size, that purchase insured products versus 
                those that self-insure.
                    (B) The similarities and differences between 
                typical insured and self-insured health plans.
                    (C) The financial solvency and capital reserve 
                levels of employers that self-insure by employer size.
                    (D) The risk of self-insured employers not being 
                able to pay obligations or otherwise becoming 
                financially insolvent.
                    (E) The extent to which rating rules are likely to 
                cause adverse selection in the large group market or to 
                encourage small and midsize employers to self-insure.
            (2) Reports.--Not later than 18 months after the date of 
        the enactment of this Act, the Commissioner shall submit to 
        Congress and the applicable agencies a report on the study 
        conducted under paragraph (1). Such report shall include any 
        recommendations the Commissioner deems appropriate to ensure 
        that the law does not provide incentives for small and midsize 
        employers to self-insure or create adverse selection in the 
        risk pools of large group insurers and self-insured employers. 
        Not later than 18 months after the first day of Y1, the 
        Commissioner shall submit to Congress and the applicable 
        agencies an updated report on such study, including updates on 
        such recommendations.

SEC. 214. NONDISCRIMINATION IN BENEFITS; PARITY IN MENTAL HEALTH AND 
              SUBSTANCE ABUSE DISORDER BENEFITS.

    (a) Nondiscrimination in Benefits.--A qualified health benefits 
plan shall comply with standards established by the Commissioner to 
prohibit discrimination in health benefits or benefit structures for 
qualifying health benefits plans, building from section 702 of the 
Employee Retirement Income Security Act of 1974, section 2702 of the 
Public Health Service Act, and section 9802 of the Internal Revenue 
Code of 1986.
    (b) Parity in Mental Health and Substance Abuse Disorder 
Benefits.--To the extent such provisions are not superceded by or 
inconsistent with subtitle C, the provisions of section 2705 (other 
than subsections (a)(1), (a)(2), and (c)) of the Public Health Service 
Act shall apply to a qualified health benefits plan, regardless of 
whether it is offered in the individual or group market, in the same 
manner as such provisions apply to health insurance coverage offered in 
the large group market.

SEC. 215. ENSURING ADEQUACY OF PROVIDER NETWORKS.

    (a) In General.--A qualified health benefits plan that uses a 
provider network for items and services shall meet such standards 
respecting provider networks as the Commissioner may establish to 
assure the adequacy of such networks in ensuring enrollee access to 
such items and services and transparency in the cost-sharing 
differentials among providers participating in the network and policies 
for accessing out-of-network providers.
    (b) Internet Access to Information.--A qualified health benefits 
plan that uses a provider network shall provide a current listing of 
all providers in its network on its Website and such data shall be 
available on the Health Insurance Exchange Website as a part of the 
basic information on that plan. The Commissioner shall also establish 
an on-line system whereby an individual may select by name any medical 
provider (as defined by the Commissioner) and be informed of the plan 
or plans with which that provider is contracting.
    (c) Provider Network Defined.--In this division, the term 
``provider network'' means the providers with respect to which covered 
benefits, treatments, and services are available under a health 
benefits plan.

SEC. 216. REQUIRING THE OPTION OF EXTENSION OF DEPENDENT COVERAGE FOR 
              UNINSURED YOUNG ADULTS.

    (a) In General.--A qualified health benefits plan shall make 
available, at the option of the principal enrollee under the plan, 
coverage for one or more qualified children (as defined in subsection 
(b)) of the enrollee.
    (b) Qualified Child Defined.--In this section, the term ``qualified 
child'' means, with respect to a principal enrollee in a qualified 
health benefits plan, an individual who (but for age) would be treated 
as a dependent child of the enrollee under such plan and who--
            (1) is under 27 years of age; and
            (2) is not enrolled in a health benefits plan other than 
        under this section.
    (c) Premiums.--Nothing in this section shall be construed as 
preventing a qualified health benefits plan from increasing the 
premiums otherwise required for coverage provided under this section 
consistent with standards established by the Commissioner based upon 
family size under section 213(a)(3).

SEC. 217. CONSISTENCY OF COSTS AND COVERAGE UNDER QUALIFIED HEALTH 
              BENEFITS PLANS DURING PLAN YEAR.

    In the case of health insurance coverage offered under a qualified 
health benefits plan, if the coverage decreases or the cost-sharing 
increases, the issuer of the coverage shall notify enrollees of the 
change at least 90 days before the change takes effect (or such shorter 
period of time in cases where the change is necessary to ensure the 
health and safety of enrollees).

    Subtitle C--Standards Guaranteeing Access to Essential Benefits

SEC. 221. COVERAGE OF ESSENTIAL BENEFITS PACKAGE.

    (a) In General.--A qualified health benefits plan shall provide 
coverage that at least meets the benefit standards adopted under 
section 224 for the essential benefits package described in section 222 
for the plan year involved.
    (b) Choice of Coverage.--
            (1) Non-exchange-participating health benefits plans.--In 
        the case of a qualified health benefits plan that is not an 
        Exchange-participating health benefits plan, such plan may 
        offer such coverage in addition to the essential benefits 
        package as the QHBP offering entity may specify.
            (2) Exchange-participating health benefits plans.--In the 
        case of an Exchange-participating health benefits plan, such 
        plan is required under section 203 to provide specified levels 
        of benefits and, in the case of a plan offering a premium-plus 
        level of benefits, provide additional benefits.
            (3) Continuation of offering of separate excepted benefits 
        coverage.--Nothing in this division shall be construed as 
        affecting the offering outside of the Health Insurance Exchange 
        and under State law of health benefits in the form of excepted 
        benefits (described in section 202(b)(1)(B)(ii)) if such 
        benefits are offered under a separate policy, contract, or 
        certificate of insurance.
    (c) Clinical Appropriateness.--Nothing in this Act shall be 
construed to prohibit a group health plan or health insurance issuer 
from using medical management practices so long as such management 
practices are based on valid medical evidence and are relevant to the 
patient whose medical treatment is under review.
    (d) Provision of Benefits.--Nothing in this division shall be 
construed as prohibiting a qualified health benefits plan from 
subcontracting with stand-alone health insurance issuers or insurers 
for the provision of dental, vision, mental health, and other benefits 
and services.

SEC. 222. ESSENTIAL BENEFITS PACKAGE DEFINED.

    (a) In General.--In this division, the term ``essential benefits 
package'' means health benefits coverage, consistent with standards 
adopted under section 224, to ensure the provision of quality health 
care and financial security, that--
            (1) provides payment for the items and services described 
        in subsection (b) in accordance with generally accepted 
        standards of medical or other appropriate clinical or 
        professional practice;
            (2) limits cost-sharing for such covered health care items 
        and services in accordance with such benefit standards, 
        consistent with subsection (c);
            (3) does not impose any annual or lifetime limit on the 
        coverage of covered health care items and services;
            (4) complies with section 215(a) (relating to network 
        adequacy); and
            (5) is equivalent in its scope of benefits, as certified by 
        Office of the Actuary of the Centers for Medicare & Medicaid 
        Services, to the average prevailing employer-sponsored coverage 
        in Y1.
 In order to carry out paragraph (5), the Secretary of Labor shall 
conduct a survey of employer-sponsored coverage to determine the 
benefits typically covered by employers, including multiemployer plans, 
and provide a report on such survey to the Health Benefits Advisory 
Committee and to the Secretary of Health and Human Services.
    (b) Minimum Services To Be Covered.--Subject to subsection (d), the 
items and services described in this subsection are the following:
            (1) Hospitalization.
            (2) Outpatient hospital and outpatient clinic services, 
        including emergency department services.
            (3) Professional services of physicians and other health 
        professionals.
            (4) Such services, equipment, and supplies incident to the 
        services of a physician's or a health professional's delivery 
        of care in institutional settings, physician offices, patients' 
        homes or place of residence, or other settings, as appropriate.
            (5) Prescription drugs.
            (6) Rehabilitative and habilitative services.
            (7) Mental health and substance use disorder services, 
        including behavioral health treatments.
            (8) Preventive services, including those services 
        recommended with a grade of A or B by the Task Force on 
        Clinical Preventive Services and those vaccines recommended for 
        use by the Director of the Centers for Disease Control and 
        Prevention.
            (9) Maternity care.
            (10) Well-baby and well-child care and oral health, vision, 
        and hearing services, equipment, and supplies for children 
        under 21 years of age.
            (11) Durable medical equipment, prosthetics, orthotics and 
        related supplies.
    (c) Requirements Relating to Cost-Sharing and Minimum Actuarial 
Value.--
            (1) No cost-sharing for preventive services.--There shall 
        be no cost-sharing under the essential benefits package for--
                    (A) preventive items and services recommended with 
                a grade of A or B by the Task Force on Clinical 
                Preventive Services and those vaccines recommended for 
                use by the Director of the Centers for Disease Control 
                and Prevention; or
                    (B) well-baby and well-child care.
            (2) Annual limitation.--
                    (A) Annual limitation.--The cost-sharing incurred 
                under the essential benefits package with respect to an 
                individual (or family) for a year does not exceed the 
                applicable level specified in subparagraph (B).
                    (B) Applicable level.--The applicable level 
                specified in this subparagraph for Y1 is not to exceed 
                $5,000 for an individual and not to exceed $10,000 for 
                a family. Such levels shall be increased (rounded to 
                the nearest $100) for each subsequent year by the 
                annual percentage increase in the enrollment-weighted 
                average of premium increases for basic plans applicable 
                to such year, except that Secretary shall adjust such 
                increase to ensure that the applicable level specified 
                in this subparagraph meets the minimum actuarial value 
                required under paragraph (3).
                    (C) Use of copayments.--In establishing cost-
                sharing levels for basic, enhanced, and premium plans 
                under this subsection, the Secretary shall, to the 
                maximum extent possible, use only copayments and not 
                coinsurance.
            (3) Minimum actuarial value.--
                    (A) In general.--The cost-sharing under the 
                essential benefits package shall be designed to provide 
                a level of coverage that is designed to provide 
                benefits that are actuarially equivalent to 
                approximately 70 percent of the full actuarial value of 
                the benefits provided under the reference benefits 
                package described in subparagraph (B).
                    (B) Reference benefits package described.--The 
                reference benefits package described in this 
                subparagraph is the essential benefits package if there 
                were no cost-sharing imposed.
    (d) Assessment and Counseling for Domestic Violence.--The Secretary 
shall support the need for an assessment and brief counseling for 
domestic violence as part of a behavioral health assessment or primary 
care visit and determine the appropriate coverage for such assessment 
and counseling.
    (e) Abortion Coverage Prohibited as Part of Minimum Benefits 
Package.--
            (1) Prohibition of required coverage.--The Health Benefits 
        Advisory Committee may not recommend under section 223(b), and 
        the Secretary may not adopt in standards under section 224(b), 
        the services described in paragraph (4)(A) or (4)(B) as part of 
        the essential benefits package and the Commissioner may not 
        require such services for qualified health benefits plans to 
        participate in the Health Insurance Exchange.
            (2) Voluntary choice of coverage by plan.--In the case of a 
        qualified health benefits plan, the plan is not required (or 
        prohibited) under this Act from providing coverage of services 
        described in paragraph (4)(A) or (4)(B) and the QHBP offering 
        entity shall determine whether such coverage is provided.
            (3) Coverage under public health insurance option.--The 
        public health insurance option shall provide coverage for 
        services described in paragraph (4)(B). Nothing in this Act 
        shall be construed as preventing the public health insurance 
        option from providing for or prohibiting coverage of services 
        described in paragraph (4)(A).
            (4) Abortion services.--
                    (A) Abortions for which public funding is 
                prohibited.--The services described in this 
                subparagraph are abortions for which the expenditure of 
                Federal funds appropriated for the Department of Health 
                and Human Services is not permitted, based on the law 
                as in effect as of the date that is 6 months before the 
                beginning of the plan year involved.
                    (B) Abortions for which public funding is 
                allowed.--The services described in this subparagraph 
                are abortions for which the expenditure of Federal 
                funds appropriated for the Department of Health and 
                Human Services is permitted, based on the law as in 
                effect as of the date that is 6 months before the 
                beginning of the plan year involved.
    (f) Report Regarding Inclusion of Oral Health Care in Essential 
Benefits Package.--Not later than 1 year after the date of the 
enactment of this Act, the Secretary of Health and Human Services shall 
submit to Congress a report containing the results of a study 
determining the need and cost of providing accessible and affordable 
oral health care to adults as part of the essential benefits package.

SEC. 223. HEALTH BENEFITS ADVISORY COMMITTEE.

    (a) Establishment.--
            (1) In general.--There is established a private-public 
        advisory committee which shall be a panel of medical and other 
        experts to be known as the Health Benefits Advisory Committee 
        to recommend covered benefits and essential, enhanced, and 
        premium plans.
            (2) Chair.--The Surgeon General shall be a member and the 
        chair of the Health Benefits Advisory Committee.
            (3) Membership.--The Health Benefits Advisory Committee 
        shall be composed of the following members, in addition to the 
        Surgeon General:
                    (A) Nine members who are not Federal employees or 
                officers and who are appointed by the President.
                    (B) Nine members who are not Federal employees or 
                officers and who are appointed by the Comptroller 
                General of the United States in a manner similar to the 
                manner in which the Comptroller General appoints 
                members to the Medicare Payment Advisory Commission 
                under section 1805(c) of the Social Security Act.
                    (C) Such even number of members (not to exceed 8) 
                who are Federal employees and officers, as the 
                President may appoint.
        Such initial appointments shall be made not later than 60 days 
        after the date of the enactment of this Act.
            (4) Terms.--Each member of the Health Benefits Advisory 
        Committee shall serve a 3-year term on the Committee, except 
        that the terms of the initial members shall be adjusted in 
        order to provide for a staggered term of appointment for all 
        such members.
            (5) Participation.--The membership of the Health Benefits 
        Advisory Committee shall at least reflect providers, patient 
        representatives, employers (including small employers), labor, 
        health insurance issuers, experts in health care financing and 
        delivery, experts in oral health care, experts in racial and 
        ethnic disparities, experts on health care needs and 
        disparities of individuals with disabilities, representatives 
        of relevant governmental agencies, and at least one practicing 
        physician or other health professional and an expert in child 
        and adolescent health and shall represent a balance among 
        various sectors of the health care system so that no single 
        sector unduly influences the recommendations of such Committee.
    (b) Duties.--
            (1) Recommendations on benefit standards.--The Health 
        Benefits Advisory Committee shall recommend to the Secretary of 
        Health and Human Services (in this subtitle referred to as the 
        ``Secretary'') benefit standards (as defined in paragraph (5)), 
        and periodic updates to such standards. In developing such 
        recommendations, the Committee shall take into account 
        innovation in health care and consider how such standards could 
        reduce health disparities.
            (2) Deadline.--The Health Benefits Advisory Committee shall 
        recommend initial benefit standards to the Secretary not later 
        than 1 year after the date of the enactment of this Act.
            (3) State input.--The Health Benefits Advisory Committee 
        shall examine the health coverage laws and benefits of each 
        State in developing recommendations under this subsection and 
        may incorporate such coverage and benefits as the Committee 
        determines to be appropriate and consistent with this Act. The 
        Health Benefits Advisory Committee shall also seek input from 
        the States and consider recommendations on how to ensure 
        quality of health coverage in all States.
            (4) Public input.--The Health Benefits Advisory Committee 
        shall allow for public input as a part of developing 
        recommendations under this subsection.
            (5) Benefit standards defined.--In this subtitle, the term 
        ``benefit standards'' means standards respecting--
                    (A) the essential benefits package described in 
                section 222, including categories of covered 
                treatments, items and services within benefit classes, 
                and cost-sharing consistent with subsection (d) of such 
                section; and
                    (B) the cost-sharing levels for enhanced plans and 
                premium plans (as provided under section 303(c)) 
                consistent with paragraph (5).
            (6) Levels of cost-sharing for enhanced and premium 
        plans.--
                    (A) Enhanced plan.--The level of cost-sharing for 
                enhanced plans shall be designed so that such plans 
                have benefits that are actuarially equivalent to 
                approximately 85 percent of the actuarial value of the 
                benefits provided under the reference benefits package 
                described in section 222(c)(3)(B).
                    (B) Premium plan.--The level of cost-sharing for 
                premium plans shall be designed so that such plans have 
                benefits that are actuarially equivalent to 
                approximately 95 percent of the actuarial value of the 
                benefits provided under the reference benefits package 
                described in section 222(c)(3)(B).
    (c) Operations.--
            (1) Per diem pay.--Each member of the Health Benefits 
        Advisory Committee shall receive travel expenses, including per 
        diem in accordance with applicable provisions under subchapter 
        I of chapter 57 of title 5, United States Code, and shall 
        otherwise serve without additional pay.
            (2) Members not treated as federal employees.--Members of 
        the Health Benefits Advisory Committee shall not be considered 
        employees of the Federal Government solely by reason of any 
        service on the Committee, except such members shall be 
        considered to be within the meaning of section 202(a) of title 
        18, United States Code, for the purposes of disclosure and 
        management of conflicts of interest.
            (3) Application of faca.--The Federal Advisory Committee 
        Act (5 U.S.C. App.), other than section 14, shall apply to the 
        Health Benefits Advisory Committee.
    (d) Publication.--The Secretary shall provide for publication in 
the Federal Register and the posting on the Internet Website of the 
Department of Health and Human Services of all recommendations made by 
the Health Benefits Advisory Committee under this section.

SEC. 224. PROCESS FOR ADOPTION OF RECOMMENDATIONS; ADOPTION OF BENEFIT 
              STANDARDS.

    (a) Process for Adoption of Recommendations.--
            (1) Review of recommended standards.--Not later than 45 
        days after the date of receipt of benefit standards recommended 
        under section 223 (including such standards as modified under 
        paragraph (2)(B)), the Secretary shall review such standards 
        and shall determine whether to propose adoption of such 
        standards as a package.
            (2) Determination to adopt standards.--If the Secretary 
        determines--
                    (A) to propose adoption of benefit standards so 
                recommended as a package, the Secretary shall, by 
                regulation under section 553 of title 5, United States 
                Code, propose adoption of such standards; or
                    (B) not to propose adoption of such standards as a 
                package, the Secretary shall notify the Health Benefits 
                Advisory Committee in writing of such determination and 
                the reasons for not proposing the adoption of such 
                recommendation and provide the Committee with a further 
                opportunity to modify its previous recommendations and 
                submit new recommendations to the Secretary on a timely 
                basis.
            (3) Contingency.--If, because of the application of 
        paragraph (2)(B), the Secretary would otherwise be unable to 
        propose initial adoption of such recommended standards by the 
        deadline specified in subsection (b)(1), the Secretary shall, 
        by regulation under section 553 of title 5, United States Code, 
        propose adoption of initial benefit standards by such deadline.
            (4) Publication.--The Secretary shall provide for 
        publication in the Federal Register of all determinations made 
        by the Secretary under this subsection.
    (b) Adoption of Standards.--
            (1) Initial standards.--Not later than 18 months after the 
        date of the enactment of this Act, the Secretary shall, through 
        the rulemaking process consistent with subsection (a), adopt an 
        initial set of benefit standards.
            (2) Periodic updating standards.--Under subsection (a), the 
        Secretary shall provide for the periodic updating of the 
        benefit standards previously adopted under this section.
            (3) Requirement.--The Secretary may not adopt any benefit 
        standards for an essential benefits package or for level of 
        cost-sharing that are inconsistent with the requirements for 
        such a package or level under sections 222 (including 
        subsection (d)) and 223(b)(5).

              Subtitle D--Additional Consumer Protections

SEC. 231. REQUIRING FAIR MARKETING PRACTICES BY HEALTH INSURERS.

    The Commissioner shall establish uniform marketing standards that 
all QHBP offering entities shall meet with respect to qualified health 
benefits plans that are health insurance coverage.

SEC. 232. REQUIRING FAIR GRIEVANCE AND APPEALS MECHANISMS.

    (a) In General.--A QHBP offering entity shall provide for timely 
grievance and appeals mechanisms with respect to qualified health 
benefits plans that the Commissioner shall establish consistent with 
this section. The Commissioner shall establish time limits for each of 
such mechanisms and implement them in a manner that is protective to 
the needs of patients.
    (b) Internal Claims and Appeals Process.--Under a qualified health 
benefits plan the QHBP offering entity shall provide an internal claims 
and appeals process that initially incorporates the claims and appeals 
procedures (including urgent claims) set forth at section 2560.503-1 of 
title 29, Code of Federal Regulations, as published on November 21, 
2000 (65 Fed. Reg. 70246) and shall update such process in accordance 
with any standards that the Commissioner may establish.
    (c) External Review Process.--
            (1) In general.--The Commissioner shall establish an 
        external review process (including procedures for expedited 
        reviews of urgent claims) that provides for an impartial, 
        independent, and de novo review of denied claims under this 
        division.
            (2) Requiring fair grievance and appeals mechanisms.--A 
        determination made, with respect to a qualified health benefits 
        plan offered by a QHBP offering entity, under the external 
        review process established under this subsection shall be 
        binding on the plan and the entity.
    (d) Time Limits.--The Commissioner shall establish time limits for 
each of these processes and implement them in a manner that is 
protective to the patient.
    (e) Construction.--Nothing in this section shall be construed as 
affecting the availability of judicial review under State law for 
adverse decisions under subsection (b) or (c), subject to section 251.

SEC. 233. REQUIRING INFORMATION TRANSPARENCY AND PLAN DISCLOSURE.

    (a) Accurate and Timely Disclosure.--
            (1) For exchange-participating health benefits plans.--A 
        QHBP offering entity offering an Exchange-participating health 
        benefits plan shall comply with standards established by the 
        Commissioner for the accurate and timely disclosure to the 
        Commissioner and the public of plan documents, plan terms and 
        conditions, claims payment policies and practices, periodic 
        financial disclosure, data on enrollment, data on 
        disenrollment, data on the number of claims denials, data on 
        rating practices, information on cost-sharing and payments with 
        respect to any out-of-network coverage, and other information 
        as determined appropriate by the Commissioner.
            (2) Employment-based health plans.--The Secretary of Labor 
        shall update and harmonize the Secretary's rules concerning the 
        accurate and timely disclosure to participants by group health 
        plans of plan disclosure, plan terms and conditions, and 
        periodic financial disclosure with the standards established by 
        the Commissioner under paragraph (1).
            (3) Use of plain language.--
                    (A) In general.--The disclosures under paragraphs 
                (1) and (2) shall be provided in plain language.
                    (B) Definition.--In this paragraph, the term 
                ``plain language'' means language that the intended 
                audience, including individuals with limited English 
                proficiency, can readily understand and use because 
                that language is concise, well-organized, and follows 
                other best practices of plain language writing.
                    (C) Guidance.--The Commissioner and the Secretary 
                of Labor shall jointly develop and issue guidance on 
                best practices of plain language writing.
            (4) Information on rights.--The information disclosed under 
        this subsection shall include information on enrollee and 
        participant rights under this division.
            (5) Cost-sharing transparency.--A qualified health benefits 
        plan shall allow individuals to learn the amount of cost-
        sharing (including deductibles, copayments, and coinsurance) 
        under the individual's plan or coverage that the individual 
        would be responsible for paying with respect to the furnishing 
        of a specific item or service by a participating provider in a 
        timely manner upon request. At a minimum, this information 
        shall be made available to such individual via an Internet 
        Website and other means for individuals without access to the 
        Internet.
    (b) Contracting Reimbursement.--A qualified health benefits plan 
shall comply with standards established by the Commissioner to ensure 
transparency to each health care provider relating to reimbursement 
arrangements between such plan and such provider.
    (c) Pharmacy Benefit Managers Transparency Requirements.--
            (1) In general.--If a QHBP offering entity contracts with a 
        pharmacy benefit manager or other entity (in this subsection 
        referred to as a ``PBM'') to manage prescription drug coverage 
        or otherwise control prescription drug costs under a qualified 
        health benefits plan, the PBM shall provide at least annually 
        to the Commissioner and to the QHBP offering entity offering 
        such plan the following information, in a form and manner to be 
        determined by the Commissioner:
                    (A) Information on the number and total cost of 
                prescriptions under the contract that are filled via 
                mail order and at retail pharmacies.
                    (B) An estimate of aggregate average payments under 
                the contract, per prescription (weighted by 
                prescription volume), made to mail order and retail 
                pharmacies, and the average amount, per prescription, 
                that the PBM was paid by the plan for prescriptions 
                filled at mail order and retail pharmacists.
                    (C) An estimate of the aggregate average payment 
                per prescription (weighted by prescription volume) 
                under the contract received from pharmaceutical 
                manufacturers, including all rebates, discounts, prices 
                concessions, or administrative, and other payments from 
                pharmaceutical manufacturers, and a description of the 
                types of payments, and the amount of these payments 
                that were shared with the plan, and a description of 
                the percentage of prescriptions for which the PBM 
                received such payments.
                    (D) Information on the overall percentage of 
                generic drugs dispensed under the contract at retail 
                and mail order pharmacies, and the percentage of cases 
                in which a generic drug is dispensed when available.
                    (E) Information on the percentage and number of 
                cases under the contract in which individuals were 
                switched because of PBM policies or at the direct or 
                indirect control of the PBM from a prescribed drug that 
                had a lower cost for the QHBP offering entity to a drug 
                that had a higher cost for the QHBP offering entity, 
                the rationale for these switches, and a description of 
                the PBM policies governing such switches.
            (2) Confidentiality of information.--Information disclosed 
        by a PBM to the Commissioner or a QHBP offering entity under 
        this subsection is confidential and shall not be disclosed by 
        the Commissioner or the QHBP offering entity in a form which 
        discloses the identity of a specific PBM or prices charged by 
        such PBM or a specific retailer, manufacturer, or wholesaler, 
        except only by the Commissioner--
                    (A) to permit State or Federal law enforcement 
                authorities to use the information provided for program 
                compliance purposes and for the purpose of combating 
                waste, fraud, and abuse;
                    (B) to permit the Comptroller General, the Medicare 
                Payment Advisory Commission, or the Secretary of Health 
                and Human Services to review the information provided; 
                and
                    (C) to permit the Director of the Congressional 
                Budget Office to review the information provided.
            (3) Annual public report.--On an annual basis, the 
        Commissioner shall prepare a public report providing 
        industrywide aggregate or average information to be used in 
        assessing the overall impact of PBMs on prescription drug 
        prices and spending. Such report shall not disclose the 
        identity of a specific PBM, or prices charged by such PBM, or a 
        specific retailer, manufacturer, or wholesaler, or any other 
        confidential or trade secret information.
            (4) Penalties.--The provisions of subsection (b)(3)(C) of 
        section 1927 shall apply to a PBM that fails to provide 
        information required under subsection (a) or that knowingly 
        provides false information in the same manner as such 
        provisions apply to a manufacturer with an agreement under such 
        section that fails to provide information under subsection 
        (b)(3)(A) of such section or knowingly provides false 
        information under such section, respectively.

SEC. 234. APPLICATION TO QUALIFIED HEALTH BENEFITS PLANS NOT OFFERED 
              THROUGH THE HEALTH INSURANCE EXCHANGE.

    The requirements of the previous provisions of this subtitle shall 
apply to qualified health benefits plans that are not being offered 
through the Health Insurance Exchange only to the extent specified by 
the Commissioner.

SEC. 235. TIMELY PAYMENT OF CLAIMS.

    A QHBP offering entity shall comply with the requirements of 
section 1857(f) of the Social Security Act with respect to a qualified 
health benefits plan it offers in the same manner as a Medicare 
Advantage organization is required to comply with such requirements 
with respect to a Medicare Advantage plan it offers under part C of 
Medicare.

SEC. 236. STANDARDIZED RULES FOR COORDINATION AND SUBROGATION OF 
              BENEFITS.

    The Commissioner shall establish standards for the coordination and 
subrogation of benefits and reimbursement of payments in cases of 
qualified health benefits plans involving individuals and multiple plan 
coverage.

SEC. 237. APPLICATION OF ADMINISTRATIVE SIMPLIFICATION.

    A QHBP offering entity is required to comply with administrative 
simplification provisions under part C of title XI of the Social 
Security Act with respect to qualified health benefits plans it offers.

SEC. 238. STATE PROHIBITIONS ON DISCRIMINATION AGAINST HEALTH CARE 
              PROVIDERS.

    This Act (and the amendments made by this Act) shall not be 
construed as superseding laws, as they now or hereinafter exist, of any 
State or jurisdiction designed to prohibit a qualified health benefits 
plan from discriminating with respect to participation, reimbursement, 
covered services, indemnification, or related requirements under such 
plan against a health care provider that is acting within the scope of 
that provider's license or certification under applicable State law.

SEC. 239. PROTECTION OF PHYSICIAN PRESCRIBER INFORMATION.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study on the use of physician prescriber information in sales 
and marketing practices of pharmaceutical manufacturers.
    (b) Report.--Based on the study conducted under subsection (a), the 
Secretary shall submit to Congress a report on actions needed to be 
taken by the Congress or the Secretary to protect providers from biased 
marketing and sales practices.

SEC. 240. DISSEMINATION OF ADVANCE CARE PLANNING INFORMATION.

    (a) In General.--The QHBP offering entity --
            (1) shall provide for the dissemination of information 
        related to end-of-life planning to individuals seeking 
        enrollment in Exchange-participating health benefits plans 
        offered through the Exchange;
            (2) shall present such individuals with--
                    (A) the option to establish advanced directives and 
                physician's orders for life sustaining treatment 
                according to the laws of the State in which the 
                individual resides; and
                    (B) information related to other planning tools; 
                and
            (3) shall not promote suicide, assisted suicide, 
        euthanasia, or mercy killing.
The information presented under paragraph (2) shall not presume the 
withdrawal of treatment and shall include end-of-life planning 
information that includes options to maintain all or most medical 
interventions.
    (b) Construction.-- Nothing in this section shall be construed--
            (1) to require an individual to complete an advanced 
        directive or a physician's order for life sustaining treatment 
        or other end-of-life planning document;
            (2) to require an individual to consent to restrictions on 
        the amount, duration, or scope of medical benefits otherwise 
        covered under a qualified health benefits plan; or
            (3) to promote suicide, assisted suicide, euthanasia, or 
        mercy killing.
    (c) Advanced Directive Defined.--In this section, the term 
``advanced directive'' includes a living will, a comfort care order, or 
a durable power of attorney for health care.
    (d) Prohibition on the Promotion of Assisted Suicide.--
            (1) In general.--Subject to paragraph (3), information 
        provided to meet the requirements of subsection (a)(2) shall 
        not include advanced directives or other planning tools that 
        list or describe as an option suicide, assisted suicide, 
        euthanasia, or mercy killing, regardless of legality.
            (2) Construction.--Nothing in paragraph (1) shall be 
        construed to apply to or affect any option to--
                    (A) withhold or withdraw of medical treatment or 
                medical care;
                    (B) withhold or withdraw of nutrition or hydration; 
                and
                    (C) provide palliative or hospice care or use an 
                item, good, benefit, or service furnished for the 
                purpose of alleviating pain or discomfort, even if such 
                use may increase the risk of death, so long as such 
                item, good, benefit, or service is not also furnished 
                for the purpose of causing, or the purpose of assisting 
                in causing, death, for any reason.
            (3) No preemption of state law.--Nothing in this section 
        shall be construed to preempt or otherwise have any effect on 
        State laws regarding advance care planning, palliative care, or 
        end-of-life decision-making.

                         Subtitle E--Governance

SEC. 241. HEALTH CHOICES ADMINISTRATION; HEALTH CHOICES COMMISSIONER.

    (a) In General.--There is hereby established, as an independent 
agency in the executive branch of the Government, a Health Choices 
Administration (in this division referred to as the 
``Administration'').
    (b) Commissioner.--
            (1) In general.--The Administration shall be headed by a 
        Health Choices Commissioner (in this division referred to as 
        the ``Commissioner'') who shall be appointed by the President, 
        by and with the advice and consent of the Senate.
            (2) Compensation; etc.--The provisions of paragraphs (2), 
        (5), and (7) of subsection (a) (relating to compensation, 
        terms, general powers, rulemaking, and delegation) of section 
        702 of the Social Security Act (42 U.S.C. 902) shall apply to 
        the Commissioner and the Administration in the same manner as 
        such provisions apply to the Commissioner of Social Security 
        and the Social Security Administration.
    (c) Inspector General.--For provision establishing an Office of the 
Inspector General for the Health Choices Administration, see section 
1647.

SEC. 242. DUTIES AND AUTHORITY OF COMMISSIONER.

    (a) Duties.--The Commissioner is responsible for carrying out the 
following functions under this division:
            (1) Qualified plan standards.--The establishment of 
        qualified health benefits plan standards under this title, 
        including the enforcement of such standards in coordination 
        with State insurance regulators and the Secretaries of Labor 
        and the Treasury.
            (2) Health insurance exchange.--The establishment and 
        operation of a Health Insurance Exchange under subtitle A of 
        title III.
            (3) Individual affordability credits.--The administration 
        of individual affordability credits under subtitle C of title 
        III, including determination of eligibility for such credits.
            (4) Additional functions.--Such additional functions as may 
        be specified in this division.
    (b) Promoting Accountability.--
            (1) In general.--The Commissioner shall undertake 
        activities in accordance with this subtitle to promote 
        accountability of QHBP offering entities in meeting Federal 
        health insurance requirements, regardless of whether such 
        accountability is with respect to qualified health benefits 
        plans offered through the Health Insurance Exchange or outside 
        of such Exchange.
            (2) Compliance examination and audits.--
                    (A) In general.--The Commissioner shall, in 
                coordination with States, conduct audits of qualified 
                health benefits plan compliance with Federal 
                requirements.   Such audits may include random 
                compliance audits and targeted audits in response to 
                complaints or other suspected noncompliance.
                    (B) Recoupment of costs in connection with 
                examination and audits.--The Commissioner is authorized 
                to recoup from qualified health benefits plans 
                reimbursement for the costs of such examinations and 
                audit of such QHBP offering entities.
    (c) Data Collection.--The Commissioner shall collect data for 
purposes of carrying out the Commissioner's duties, including for 
purposes of promoting quality and value, protecting consumers, and 
addressing disparities in health and health care and may share such 
data with the Secretary of Health and Human Services.
    (d) Sanctions Authority.--
            (1) In general.--In the case that the Commissioner 
        determines that a QHBP offering entity violates a requirement 
        of this title, the Commissioner may, in coordination with State 
        insurance regulators and the Secretary of Labor, provide, in 
        addition to any other remedies authorized by law, for any of 
        the remedies described in paragraph (2).
            (2) Remedies.--The remedies described in this paragraph, 
        with respect to a qualified health benefits plan offered by a 
        QHBP offering entity, are--
                    (A) civil money penalties of not more than the 
                amount that would be applicable under similar 
                circumstances for similar violations under section 
                1857(g) of the Social Security Act;
                    (B) suspension of enrollment of individuals under 
                such plan after the date the Commissioner notifies the 
                entity of a determination under paragraph (1) and until 
                the Commissioner is satisfied that the basis for such 
                determination has been corrected and is not likely to 
                recur;
                    (C) in the case of an Exchange-participating health 
                benefits plan, suspension of payment to the entity 
                under the Health Insurance Exchange for individuals 
                enrolled in such plan after the date the Commissioner 
                notifies the entity of a determination under paragraph 
                (1) and until the Secretary is satisfied that the basis 
                for such determination has been corrected and is not 
                likely to recur; or
                    (D) working with State insurance regulators to 
                terminate plans for repeated failure by the offering 
                entity to meet the requirements of this title.
    (e) Standard Definitions of Insurance and Medical Terms.--The 
Commissioner shall provide for the development of standards for the 
definitions of terms used in health insurance coverage, including 
insurance-related terms.
    (f) Efficiency in Administration.--The Commissioner shall issue 
regulations for the effective and efficient administration of the 
Health Insurance Exchange and affordability credits under subtitle C, 
including, with respect to the determination of eligibility for 
affordability credits, the use of personnel who are employed in 
accordance with the requirements of title 5, United States Code, to 
carry out the duties of the Commissioner or, in the case of sections 
308 and 341(b)(2), the use of State personnel who are employed in 
accordance with standards prescribed by the Office of Personnel 
Management pursuant to section 208 of the Intergovernmental Personnel 
Act of 1970 (42 U.S.C. 4728).

SEC. 243. CONSULTATION AND COORDINATION.

    (a) Consultation.--In carrying out the Commissioner's duties under 
this division, the Commissioner, as appropriate, shall consult at least 
with the following:
            (1) State attorneys general and State insurance regulators, 
        including concerning the standards for health insurance 
        coverage that is a qualified health benefits plan under this 
        title and enforcement of such standards.
            (2) The National Association of Insurance Commissioners, 
        including for purposes of using model guidelines established by 
        such association for purposes of subtitles B and D.
            (3) Appropriate State agencies, specifically concerning the 
        administration of individual affordability credits under 
        subtitle C of title III and the offering of Exchange-
        participating health benefits plans, to Medicaid eligible 
        individuals under subtitle A of such title.
            (4) The Federal Trade Commission, specifically concerning 
        the development and issuance of guidance, rules, or standards 
        regarding fair marketing practices under section 231 or 
        otherwise, or any consumer disclosure requirements under 
        section 233 or otherwise.
            (5) Other appropriate Federal agencies.
            (6) Indian tribes and tribal organizations.
    (b) Coordination.--
            (1) In general.--In carrying out the functions of the 
        Commissioner, including with respect to the enforcement of the 
        provisions of this division, the Commissioner shall work in 
        coordination with existing Federal and State entities to the 
        maximum extent feasible consistent with this division and in a 
        manner that prevents conflicts of interest in duties and 
        ensures effective enforcement.
            (2) Uniform standards.--The Commissioner, in coordination 
        with such entities, shall seek to achieve uniform standards 
        that adequately protect consumers in a manner that does not 
        unreasonably affect employers and insurers.

SEC. 244. HEALTH INSURANCE OMBUDSMAN.

    (a) In General.--The Commissioner shall appoint within the Health 
Choices Administration a Qualified Health Benefits Plan Ombudsman who 
shall have expertise and experience in the fields of health care and 
education of (and assistance to) individuals.
    (b) Duties.--The Qualified Health Benefits Plan Ombudsman shall, in 
a linguistically appropriate manner--
            (1) receive complaints, grievances, and requests for 
        information submitted by individuals through means such as the 
        mail, by telephone, electronically, and in person;
            (2) provide assistance with respect to complaints, 
        grievances, and requests referred to in paragraph (1), 
        including--
                    (A) helping individuals determine the relevant 
                information needed to seek an appeal of a decision or 
                determination;
                    (B) assistance to such individuals in choosing a 
                qualified health benefits plan in which to enroll;
                    (C) assistance to such individuals with any 
                problems arising from disenrollment from such a plan; 
                and
                    (D) assistance to such individuals in presenting 
                information under subtitle C (relating to affordability 
                credits); and
            (3) submit annual reports to Congress and the Commissioner 
        that describe the activities of the Ombudsman and that include 
        such recommendations for improvement in the administration of 
        this division as the Ombudsman determines appropriate. The 
        Ombudsman shall not serve as an advocate for any increases in 
        payments or new coverage of services, but may identify issues 
        and problems in payment or coverage policies.

       Subtitle F--Relation to Other Requirements; Miscellaneous

SEC. 251. RELATION TO OTHER REQUIREMENTS.

    (a) Coverage Not Offered Through Exchange.--
            (1) In general.--In the case of health insurance coverage 
        not offered through the Health Insurance Exchange (whether or 
        not offered in connection with an employment-based health 
        plan), and in the case of employment-based health plans, the 
        requirements of this title do not supercede any requirements 
        applicable under titles XXII and XXVII of the Public Health 
        Service Act, parts 6 and 7 of subtitle B of title I of the 
        Employee Retirement Income Security Act of 1974, or State law, 
        except insofar as such requirements prevent the application of 
        a requirement of this division, as determined by the 
        Commissioner.
            (2) Construction.--Nothing in paragraphs (1) or (2) shall 
        be construed as affecting the application of section 514 of the 
        Employee Retirement Income Security Act of 1974.
    (b) Coverage Offered Through Exchange.--
            (1) In general.--In the case of health insurance coverage 
        offered through the Health Insurance Exchange--
                    (A) the requirements of this title do not supercede 
                any requirements (including requirements relating to 
                genetic information nondiscrimination and mental health 
                parity) applicable under title XXVII of the Public 
                Health Service Act or under State law, except insofar 
                as such requirements prevent the application of a 
                requirement of this division, as determined by the 
                Commissioner; and
                    (B) individual rights and remedies under State laws 
                shall apply.
            (2) Construction.--In the case of coverage described in 
        paragraph (1), nothing in such paragraph shall be construed as 
        preventing the application of rights and remedies under State 
        laws to health insurance issuers generally with respect to any 
        requirement referred to in paragraph (1)(A). The previous 
        sentence shall not be construed as providing for the 
        applicability of rights or remedies under State laws with 
        respect to requirements applicable to employers or other plan 
        sponsors in connection with arrangements which are treated as 
        group health plans under section 802(a)(1) of the Employee 
        Retirement Income Security Act of 1974.

SEC. 252. PROHIBITING DISCRIMINATION IN HEALTH CARE.

    (a) In General.--Except as otherwise explicitly permitted by this 
Act and by subsequent regulations consistent with this Act, all health 
care and related services (including insurance coverage and public 
health activities) covered by this Act shall be provided without regard 
to personal characteristics extraneous to the provision of high quality 
health care or related services.
    (b) Implementation.--To implement the requirement set forth in 
subsection (a), the Secretary of Health and Human Services shall, not 
later than 18 months after the date of the enactment of this Act, 
promulgate such regulations as are necessary or appropriate to insure 
that all health care and related services (including insurance coverage 
and public health activities) covered by this Act are provided (whether 
directly or through contractual, licensing, or other arrangements) 
without regard to personal characteristics extraneous to the provision 
of high quality health care or related services.

SEC. 253. WHISTLEBLOWER PROTECTION.

    (a) Retaliation Prohibited.--No employer may discharge any employee 
or otherwise discriminate against any employee with respect to his 
compensation, terms, conditions, or other privileges of employment 
because the employee (or any person acting pursuant to a request of the 
employee)--
            (1) provided, caused to be provided, or is about to provide 
        or cause to be provided to the employer, the Federal 
        Government, or the attorney general of a State information 
        relating to any violation of, or any act or omission the 
        employee reasonably believes to be a violation of any provision 
        of this Act or any order, rule, or regulation promulgated under 
        this Act;
            (2) testified or is about to testify in a proceeding 
        concerning such violation;
            (3) assisted or participated or is about to assist or 
        participate in such a proceeding; or
            (4) objected to, or refused to participate in, any 
        activity, policy, practice, or assigned task that the employee 
        (or other such person) reasonably believed to be in violation 
        of any provision of this Act or any order, rule, or regulation 
        promulgated under this Act.
    (b) Enforcement Action.--An employee covered by this section who 
alleges discrimination by an employer in violation of subsection (a) 
may bring an action governed by the rules, procedures, legal burdens of 
proof, and remedies set forth in section 40(b) of the Consumer Product 
Safety Act (15 U.S.C. 2087(b)).
    (c) Employer Defined.--As used in this section, the term 
``employer'' means any person (including one or more individuals, 
partnerships, associations, corporations, trusts, professional 
membership organization including a certification, disciplinary, or 
other professional body, unincorporated organizations, nongovernmental 
organizations, or trustees) engaged in profit or nonprofit business or 
industry whose activities are governed by this Act, and any agent, 
contractor, subcontractor, grantee, or consultant of such person.
    (d) Rule of Construction.--The rule of construction set forth in 
section 20109(h) of title 49, United States Code, shall also apply to 
this section.

SEC. 254. CONSTRUCTION REGARDING COLLECTIVE BARGAINING.

    Nothing in this division shall be construed to alter or supersede 
any statutory or other obligation to engage in collective bargaining 
over the terms or conditions of employment related to health care. Any 
plan amendment made pursuant to a collective bargaining agreement 
relating to the plan which amends the plan solely to conform to any 
requirement added by this division shall not be treated as a 
termination of such collective bargaining agreement.

SEC. 255. SEVERABILITY.

    If any provision of this Act, or any application of such provision 
to any person or circumstance, is held to be unconstitutional, the 
remainder of the provisions of this Act and the application of the 
provision to any other person or circumstance shall not be affected.

SEC. 256. TREATMENT OF HAWAII PREPAID HEALTH CARE ACT.

    (a) In General.--Subject to this section--
            (1) nothing in this division (or an amendment made by this 
        division) shall be construed to modify or limit the application 
        of the exemption for the Hawaii Prepaid Health Care Act (Haw. 
        Rev. Stat. Sec. Sec.  393-1 et seq.) as provided for under 
        section 514(b)(5) of the Employee Retirement Income Security 
        Act of 1974 (29 U.S.C. 1144(b)(5)), and such exemption shall 
        also apply with respect to the provisions of this division; and
            (2) for purposes of this division (and the amendments made 
        by this division), coverage provided pursuant to the Hawaii 
        Prepaid Health Care Act shall be treated as a qualified health 
        benefits plan providing acceptable coverage so long as the 
        Secretary of Labor determines that such coverage for employees 
        (taking into account the benefits and the cost to employees for 
        such benefits) is substantially equivalent to or greater than 
        the coverage provided for employees pursuant to the essential 
        benefits package.
    (b) Coordination With State Law of Hawaii.--The Commissioner shall, 
based on ongoing consultation with the appropriate officials of the 
State of Hawaii, make adjustments to rules and regulations of the 
Commissioner under this division as may be necessary, as determined by 
the Commissioner, to most effectively coordinate the provisions of this 
division with the provisions of the Hawaii Prepaid Health Care Act, 
taking into account any changes made from time to time to the Hawaii 
Prepaid Health Care Act and related laws of such State.

SEC. 257. ACTIONS BY STATE ATTORNEYS GENERAL.

    Any State attorney general may bring a civil action in the name of 
such State as parens patriae on behalf of natural persons residing in 
such State, in any district court of the United States or State court 
having jurisdiction of the defendant to secure monetary or equitable 
relief for violation of any provisions of this title or regulations 
issued thereunder. Nothing in this section shall be construed as 
affecting the application of section 514 of the Employee Retirement 
Income Security Act of 1974.

SEC. 258. APPLICATION OF STATE AND FEDERAL LAWS REGARDING ABORTION.

    (a) No Preemption of State Laws Regarding Abortion.--Nothing in 
this Act shall be construed to preempt or otherwise have any effect on 
State laws regarding the prohibition of (or requirement of) coverage, 
funding, or procedural requirements on abortions, including parental 
notification or consent for the performance of an abortion on a minor.
    (b) No Effect on Federal Laws Regarding Abortion.--
            (1) In general.--Nothing in this Act shall be construed to 
        have any effect on Federal laws regarding--
                    (A) conscience protection;
                    (B) willingness or refusal to provide abortion; and
                    (C) discrimination on the basis of the willingness 
                or refusal to provide, pay for, cover, or refer for 
                abortion or to provide or participate in training to 
                provide abortion.
    (c) No Effect on Federal Civil Rights Law.--Nothing in this section 
shall alter the rights and obligations of employees and employers under 
title VII of the Civil Rights Act of 1964.

SEC. 259. NONDISCRIMINATION ON ABORTION AND RESPECT FOR RIGHTS OF 
              CONSCIENCE.

     (a) Nondiscrimination.--A Federal agency or program, and any State 
or local government that receives Federal financial assistance under 
this Act (or an amendment made by this Act), may not--
            (1) subject any individual or institutional health care 
        entity to discrimination; or
            (2) require any health plan created or regulated under this 
        Act (or an amendment made by this Act) to subject any 
        individual or institutional health care entity to 
        discrimination,
on the basis that the health care entity does not provide, pay for, 
provide coverage of, or refer for abortions.
    (b) Definition.--In this section, the term ``health care entity'' 
includes an individual physician or other health care professional, a 
hospital, a provider-sponsored organization, a health maintenance 
organization, a health insurance plan, or any other kind of health care 
facility, organization, or plan.
    (c) Administration.--The Office for Civil Rights of the Department 
of Health and Human Services is designated to receive complaints of 
discrimination based on this section, and coordinate the investigation 
of such complaints.

SEC. 260. AUTHORITY OF FEDERAL TRADE COMMISSION.

    Section 6 of the Federal Trade Commission Act (15 U.S.C. 46) is 
amended by striking ``and prepare reports'' and all that follows and 
inserting the following: ``and prepare reports, and to share 
information under clauses (f) and (k), relating to the business of 
insurance. Notwithstanding section 4, such authority shall include the 
authority to conduct studies and prepare reports, and to share 
information under clauses (f) and (k), relating to the business of 
insurance, without regard to whether the entity or entities that is the 
subject of such studies, reports, or information is a for-profit or 
not-for-profit entity.''.

SEC. 261. CONSTRUCTION REGARDING STANDARD OF CARE.

    (a) In General.--The development, recognition, or implementation of 
any guideline or other standard under a provision described in 
subsection (b) shall not be construed to establish the standard of care 
or duty of care owed by health care providers to their patients in any 
medical malpractice action or claim (as defined in section 431(7) of 
the Health Care Quality Improvement Act of 1986 (42 U.S.C. 11151(7)).
    (b) Provisions Described.--The provisions described in this 
subsection are the following:
            (1) Section 324 (relating to modernized payment initiatives 
        and delivery system reform under the public health option).
            (2) The amendments made by section 1151 (relating to 
        reducing potentially preventable hospital readmissions).
            (3) The amendments made by section 1751 (relating to health 
        care acquired conditions).
            (4) Section 3131 of the Public Health Service Act (relating 
        to the Task Force on Clinical Preventive Services), added by 
        section 2301.
            (5) Part D of title IX of the Public Health Service Act 
        (relating to implementation of best practices in the delivery 
        of health care), added by section 2401.

SEC. 262. RESTORING APPLICATION OF ANTITRUST LAWS TO HEALTH SECTOR 
              INSURERS.

    (a) Amendment to McCarran-Ferguson Act.--Section 3 of the Act of 
March 9, 1945 (15 U.S.C. 1013), commonly known as the McCarran-Ferguson 
Act, is amended by adding at the end the following:
    ``(c)(1) Except as provided in paragraph (2), nothing contained in 
this Act shall modify, impair, or supersede the operation of any of the 
antitrust laws with respect to price fixing, market allocation, or 
monopolization (or attempting to monopolize) by--
            ``(A) a person engaged in the business of health insurance, 
        in connection with providing health insurance; or
            ``(B) a person engaged in the business of medical 
        malpractice insurance, in connection with providing medical 
        malpractice insurance.
    ``(2) Paragraph (1) shall not apply to--
            ``(A) collecting, compiling, classifying, or disseminating 
        historical loss data;
            ``(B) determining a loss development factor applicable to 
        historical loss data;
            ``(C) performing actuarial services if doing so does not 
        involve a restraint of trade; or
            ``(D) information gathering and rate setting activities of 
        a State insurance commission or other State regulatory entity 
        with authority to set insurance rates.
    ``(3) For purposes of this subsection--
            ``(A) the term `antitrust laws' has the meaning given it in 
        subsection (a) of the first section of the Clayton Act, except 
        that such term includes section 5 of the Federal Trade 
        Commission Act to the extent that such section 5 applies to 
        unfair methods of competition;
            ``(B) the term `historical loss data' means information 
        respecting claims paid, or reserves held for claims reported, 
        by any person engaged in the business of insurance; and
            ``(C) the term `loss development factor' means an 
        adjustment to be made to the aggregate of losses incurred 
        during a prior period of time that have been paid, or for which 
        claims have been received and reserves are being held, in order 
        to estimate the aggregate of the losses incurred during such 
        period that will ultimately be paid.''.
    (b) Related Provision.--For purposes of section 5 of the Federal 
Trade Commission Act (15 U.S.C. 45) to the extent such section applies 
to unfair methods of competition, section 3(c) of the McCarran-Ferguson 
Act shall apply with respect to the business of health insurance, and 
with respect to the business of medical malpractice insurance, without 
regard to whether such business is carried on for profit, 
notwithstanding the definition of ``Corporation'' contained in section 
4 of the Federal Trade Commission Act.
    (c) Related Preservation of Antitrust Laws.--Except as provided in 
subsections (a) and (b), nothing in this Act, or in the amendments made 
by this Act, shall be construed to modify, impair, or supersede the 
operation of any of the antitrust laws. For purposes of the preceding 
sentence, the term ``antitrust laws'' has the meaning given it in 
subsection (a) of the first section of the Clayton Act, except that it 
includes section 5 of the Federal Trade Commission Act to the extent 
that such section 5 applies to unfair methods of competition.

SEC. 263. STUDY AND REPORT ON METHODS TO INCREASE EHR USE BY SMALL 
              HEALTH CARE PROVIDERS.

    (a) Study.--The Secretary of Health and Human Services shall 
conduct a study of potential methods to increase the use of qualified 
electronic health records (as defined in section 3000(13) of the Public 
Health Service Act) by small health care providers. Such study shall 
consider at least the following methods:
            (1) Providing for higher rates of reimbursement or other 
        incentives for such health care providers to use electronic 
        health records (taking into consideration initiatives by 
        private health insurance companies and incentives provided 
        under Medicare under title XVIII of the Social Security Act, 
        Medicaid under title XIX of such Act, and other programs).
            (2) Promoting low-cost electronic health record software 
        packages that are available for use by such health care 
        providers, including software packages that are available to 
        health care providers through the Veterans Administration and 
        other sources.
            (3) Training and education of such health care providers on 
        the use of electronic health records.
            (4) Providing assistance to such health care providers on 
        the implementation of electronic health records.
    (b) Report.--Not later than December 31, 2013, the Secretary of 
Health and Human Services shall submit to Congress a report containing 
the results of the study conducted under subsection (a), including 
recommendations for legislation or administrative action to increase 
the use of electronic health records by small health care providers 
that include the use of both public and private funding sources.

      TITLE III--HEALTH INSURANCE EXCHANGE AND RELATED PROVISIONS

                 Subtitle A--Health Insurance Exchange

SEC. 301. ESTABLISHMENT OF HEALTH INSURANCE EXCHANGE; OUTLINE OF 
              DUTIES; DEFINITIONS.

    (a) Establishment.--There is established within the Health Choices 
Administration and under the direction of the Commissioner a Health 
Insurance Exchange in order to facilitate access of individuals and 
employers, through a transparent process, to a variety of choices of 
affordable, quality health insurance coverage, including a public 
health insurance option.
    (b) Outline of Duties of Commissioner.--In accordance with this 
subtitle and in coordination with appropriate Federal and State 
officials as provided under section 243(b), the Commissioner shall--
            (1) under section 304 establish standards for, accept bids 
        from, and negotiate and enter into contracts with, QHBP 
        offering entities for the offering of health benefits plans 
        through the Health Insurance Exchange, with different levels of 
        benefits required under section 303, and including with respect 
        to oversight and enforcement;
            (2) under section 305 facilitate outreach and enrollment in 
        such plans of Exchange-eligible individuals and employers 
        described in section 302; and
            (3) conduct such activities related to the Health Insurance 
        Exchange as required, including establishment of a risk pooling 
        mechanism under section 306 and consumer protections under 
        subtitle D of title II.

SEC. 302. EXCHANGE-ELIGIBLE INDIVIDUALS AND EMPLOYERS.

    (a) Access to Coverage.--In accordance with this section, all 
individuals are eligible to obtain coverage through enrollment in an 
Exchange-participating health benefits plan offered through the Health 
Insurance Exchange unless such individuals are enrolled in another 
qualified health benefits plan or other acceptable coverage.
    (b) Definitions.--In this division:
            (1) Exchange-eligible individual.--The term ``Exchange-
        eligible individual'' means an individual who is eligible under 
        this section to be enrolled through the Health Insurance 
        Exchange in an Exchange-participating health benefits plan and, 
        with respect to family coverage, includes dependents of such 
        individual.
            (2) Exchange-eligible employer.--The term ``Exchange-
        eligible employer'' means an employer that is eligible under 
        this section to enroll through the Health Insurance Exchange 
        employees of the employer (and their dependents) in Exchange-
        eligible health benefits plans.
            (3) Employment-related definitions.--The terms 
        ``employer'', ``employee'', ``full-time employee'', and ``part-
        time employee'' have the meanings given such terms by the 
        Commissioner for purposes of this division.
    (c) Transition.--Individuals and employers shall only be eligible 
to enroll or participate in the Health Insurance Exchange in accordance 
with the following transition schedule:
            (1) First year.--In Y1 (as defined in section 100(c))--
                    (A) individuals described in subsection (d)(1), 
                including individuals described in subsection (d)(3); 
                and
                    (B) smallest employers described in subsection 
                (e)(1).
            (2) Second year.--In Y2--
                    (A) individuals and employers described in 
                paragraph (1); and
                    (B) smaller employers described in subsection 
                (e)(2).
            (3) Third and subsequent years.--In Y3--
                    (A) individuals and employers described in 
                paragraph (2);
                    (B) small employers described in subsection (e)(3); 
                and
                    (C) larger employers as permitted by the 
                Commissioner under subsection (e)(4).
    (d) Individuals.--
            (1) Individual described.--Subject to the succeeding 
        provisions of this subsection, an individual described in this 
        paragraph is an individual who--
                    (A) is not enrolled in coverage described in 
                subparagraph (C) or (D) of paragraph (2); and
                    (B) is not enrolled in coverage as a full-time 
                employee (or as a dependent of such an employee) under 
                a group health plan if the coverage and an employer 
                contribution under the plan meet the requirements of 
                section 412.
        For purposes of subparagraph (B), in the case of an individual 
        who is self-employed, who has at least 1 employee, and who 
        meets the requirements of section 412, such individual shall be 
        deemed a full-time employee described in such subparagraph.
            (2) Acceptable coverage.--For purposes of this division, 
        the term ``acceptable coverage'' means any of the following:
                    (A) Qualified health benefits plan coverage.--
                Coverage under a qualified health benefits plan.
                    (B) Grandfathered health insurance coverage; 
                coverage under current group health plan.--Coverage 
                under a grandfathered health insurance coverage (as 
                defined in subsection (a) of section 202) or under a 
                current group health plan (described in subsection (b) 
                of such section).
                    (C) Medicare.--Coverage under part A of title XVIII 
                of the Social Security Act.
                    (D) Medicaid.--Coverage for medical assistance 
                under title XIX of the Social Security Act, excluding 
                such coverage that is only available because of the 
                application of subsection (u), (z), or (aa) of section 
                1902 of such Act.
                    (E) Members of the armed forces and dependents 
                (including tricare).--Coverage under chapter 55 of 
                title 10, United States Code, including similar 
                coverage furnished under section 1781 of title 38 of 
                such Code.
                    (F) VA.--Coverage under the veteran's health care 
                program under chapter 17 of title 38, United States 
                Code.
                    (G) Other coverage.--Such other health benefits 
                coverage, such as a State health benefits risk pool, as 
                the Commissioner, in coordination with the Secretary of 
                the Treasury, recognizes for purposes of this 
                paragraph.
        The Commissioner shall make determinations under this paragraph 
        in coordination with the Secretary of the Treasury.
            (3) Continuing eligibility permitted.--
                    (A) In general.--Except as provided in subparagraph 
                (B), once an individual qualifies as an Exchange-
                eligible individual under this subsection (including as 
                an employee or dependent of an employee of an Exchange-
                eligible employer) and enrolls under an Exchange-
                participating health benefits plan through the Health 
                Insurance Exchange, the individual shall continue to be 
                treated as an Exchange-eligible individual until the 
                individual is no longer enrolled with an Exchange-
                participating health benefits plan.
                    (B) Exceptions.--
                            (i) In general.--Subparagraph (A) shall not 
                        apply to an individual once the individual 
                        becomes eligible for coverage--
                                    (I) under part A of the Medicare 
                                program;
                                    (II) under the Medicaid program as 
                                a Medicaid-eligible individual, except 
                                as permitted under clause (ii); or
                                    (III) in such other circumstances 
                                as the Commissioner may provide.
                            (ii) Transition period.--In the case 
                        described in clause (i)(II), the Commissioner 
                        shall permit the individual to continue 
                        treatment under subparagraph (A) until such 
                        limited time as the Commissioner determines it 
                        is administratively feasible, consistent with 
                        minimizing disruption in the individual's 
                        access to health care.
            (4) Transition for chip eligibles.--An individual who is 
        eligible for child health assistance under title XXI of the 
        Social Security Act for a period during Y1 shall not be an 
        Exchange-eligible individual during such period.
    (e) Employers.--
            (1) Smallest employer.--Subject to paragraph (5), smallest 
        employers described in this paragraph are employers with 25 or 
        fewer employees.
            (2) Smaller employers.--Subject to paragraph (5), smaller 
        employers described in this paragraph are employers that are 
        not smallest employers described in paragraph (1) and have 50 
        or fewer employees.
            (3) Small employers.--Subject to paragraph (5), small 
        employers described in this paragraph are employers that are 
        not described in paragraph (1) or (2) and have 100 or fewer 
        employees.
            (4) Larger employers.--
                    (A) In general.--Beginning with Y3, the 
                Commissioner may permit employers not described in 
                paragraph (1), (2), or (3) to be Exchange-eligible 
                employers.
                    (B) Phase-in.--In applying subparagraph (A), the 
                Commissioner may phase-in the application of such 
                subparagraph based on the number of full-time employees 
                of an employer and such other considerations as the 
                Commissioner deems appropriate.
            (5) Continuing eligibility.--Once an employer is permitted 
        to be an Exchange-eligible employer under this subsection and 
        enrolls employees through the Health Insurance Exchange, the 
        employer shall continue to be treated as an Exchange-eligible 
        employer for each subsequent plan year regardless of the number 
        of employees involved unless and until the employer meets the 
        requirement of section 411(a) through paragraph (1) of such 
        section by offering a group health plan and not through 
        offering an Exchange-participating health benefits plan.
            (6) Employer participation and contributions.--
                    (A) Satisfaction of employer responsibility.--For 
                any year in which an employer is an Exchange-eligible 
                employer, such employer may meet the requirements of 
                section 412 with respect to employees of such employer 
                by offering such employees the option of enrolling with 
                Exchange-participating health benefits plans through 
                the Health Insurance Exchange consistent with the 
                provisions of subtitle B of title IV.
                    (B) Employee choice.--Any employee offered 
                Exchange-participating health benefits plans by the 
                employer of such employee under subparagraph (A) may 
                choose coverage under any such plan. That choice 
                includes, with respect to family coverage, coverage of 
                the dependents of such employee.
            (7) Affiliated groups.--Any employer which is part of a 
        group of employers who are treated as a single employer under 
        subsection (b), (c), (m), or (o) of section 414 of the Internal 
        Revenue Code of 1986 shall be treated, for purposes of this 
        subtitle, as a single employer.
            (8) Treatment of multi-employer plans.--The plan sponsor of 
        a group health plan (as defined in section 773(a) of the 
        Employee Retirement Income Security Act of 1974) that is a 
        multi-employer plan (as defined in section 3(37) of such Act) 
        may obtain health insurance coverage with respect to 
        participants in the plan through the Exchange to the same 
        extent that an employer not described in paragraph (1) or (2) 
        is permitted by the Commissioner to obtain health insurance 
        coverage through the Exchange as an Exchange-eligible employer.
            (9) Other counting rules.--The Commissioner shall establish 
        rules relating to how employees are counted for purposes of 
        carrying out this subsection.
    (f) Special Situation Authority.--The Commissioner shall have the 
authority to establish such rules as may be necessary to deal with 
special situations with regard to uninsured individuals and employers 
participating as Exchange-eligible individuals and employers, such as 
transition periods for individuals and employers who gain, or lose, 
Exchange-eligible participation status, and to establish grace periods 
for premium payment.
    (g) Surveys of Individuals and Employers.--The Commissioner shall 
provide for periodic surveys of Exchange-eligible individuals and 
employers concerning satisfaction of such individuals and employers 
with the Health Insurance Exchange and Exchange-participating health 
benefits plans.
    (h) Exchange Access Study.--
            (1) In general.--The Commissioner shall conduct a study of 
        access to the Health Insurance Exchange for individuals and for 
        employers, including individuals and employers who are not 
        eligible and enrolled in Exchange-participating health benefits 
        plans. The goal of the study is to determine if there are 
        significant groups and types of individuals and employers who 
        are not Exchange-eligible individuals or employers, but who 
        would have improved benefits and affordability if made eligible 
        for coverage in the Exchange.
            (2) Items included in study.--Such study also shall 
        examine--
                    (A) the terms, conditions, and affordability of 
                group health coverage offered by employers and QHBP 
                offering entities outside of the Exchange compared to 
                Exchange-participating health benefits plans; and
                    (B) the affordability-test standard for access of 
                certain employed individuals to coverage in the Health 
                Insurance Exchange.
            (3) Report.--Not later than January 1 of Y3, in Y6, and 
        thereafter, the Commissioner shall submit to Congress a report 
        on the study conducted under this subsection and shall include 
        in such report recommendations regarding changes in standards 
        for Exchange eligibility for individuals and employers.

SEC. 303. BENEFITS PACKAGE LEVELS.

    (a) In General.--The Commissioner shall specify the benefits to be 
made available under Exchange-participating health benefits plans 
during each plan year, consistent with subtitle C of title II and this 
section.
    (b) Limitation on Health Benefits Plans Offered by Offering 
Entities.--The Commissioner may not enter into a contract with a QHBP 
offering entity under section 304(c) for the offering of an Exchange-
participating health benefits plan in a service area unless the 
following requirements are met:
            (1) Required offering of basic plan.--The entity offers 
        only one basic plan for such service area.
            (2) Optional offering of enhanced plan.--If and only if the 
        entity offers a basic plan for such service area, the entity 
        may offer one enhanced plan for such area.
            (3) Optional offering of premium plan.--If and only if the 
        entity offers an enhanced plan for such service area, the 
        entity may offer one premium plan for such area.
            (4) Optional offering of premium-plus plans.--If and only 
        if the entity offers a premium plan for such service area, the 
        entity may offer one or more premium-plus plans for such area.
All such plans may be offered under a single contract with the 
Commissioner.
    (c) Specification of Benefit Levels for Plans.--
            (1) In general.--The Commissioner shall establish the 
        following standards consistent with this subsection and title 
        II:
                    (A) Basic, enhanced, and premium plans.--Standards 
                for 3 levels of Exchange-participating health benefits 
                plans: basic, enhanced, and premium (in this division 
                referred to as a ``basic plan'', ``enhanced plan'', and 
                ``premium plan'', respectively).
                    (B) Premium-plus plan benefits.--Standards for 
                additional benefits that may be offered, consistent 
                with this subsection and subtitle C of title II, under 
                a premium plan (such a plan with additional benefits 
                referred to in this division as a ``premium-plus 
                plan'') .
            (2) Basic plan.--
                    (A) In general.--A basic plan shall offer the 
                essential benefits package required under title II for 
                a qualified health benefits plan with an actuarial 
                value of 70 percent of the full actuarial value of the 
                benefits provided under the reference benefits package.
                    (B) Tiered cost-sharing for affordable credit 
                eligible individuals.--In the case of an affordable 
                credit eligible individual (as defined in section 
                342(a)(1)) enrolled in an Exchange-participating health 
                benefits plan, the benefits under a basic plan are 
                modified to provide for the reduced cost-sharing for 
                the income tier applicable to the individual under 
                section 324(c).
            (3) Enhanced plan.--An enhanced plan shall offer, in 
        addition to the level of benefits under the basic plan, a lower 
        level of cost-sharing as provided under title II consistent 
        with section 223(b)(5)(A).
            (4) Premium plan.--A premium plan shall offer, in addition 
        to the level of benefits under the basic plan, a lower level of 
        cost-sharing as provided under title II consistent with section 
        223(b)(5)(B).
            (5) Premium-plus plan.--A premium-plus plan is a premium 
        plan that also provides additional benefits, such as adult oral 
        health and vision care, approved by the Commissioner. The 
        portion of the premium that is attributable to such additional 
        benefits shall be separately specified.
            (6) Range of permissible variation in cost-sharing.--The 
        Commissioner shall establish a permissible range of variation 
        of cost-sharing for each basic, enhanced, and premium plan, 
        except with respect to any benefit for which there is no cost-
        sharing permitted under the essential benefits package. Such 
        variation shall permit a variation of not more than plus (or 
        minus) 10 percent in cost-sharing with respect to each benefit 
        category specified under section 222. Nothing in this subtitle 
        shall be construed as prohibiting tiering in cost-sharing, 
        including through preferred and participating providers and 
        prescription drugs. In applying this paragraph, a health 
        benefits plan may increase the cost-sharing by 10 percent 
        within each category or tier, as applicable, and may decrease 
        or eliminate cost-sharing in any category or tier as compared 
        to the essential benefits package.
    (d) Treatment of State Benefit Mandates.--Insofar as a State 
requires a health insurance issuer offering health insurance coverage 
to include benefits beyond the essential benefits package, such 
requirement shall continue to apply to an Exchange-participating health 
benefits plan, if the State has entered into an arrangement 
satisfactory to the Commissioner to reimburse the Commissioner for the 
amount of any net increase in affordability premium credits under 
subtitle C as a result of an increase in premium in basic plans as a 
result of application of such requirement.
    (e) Rules Regarding Coverage of and Affordability Credits for 
Specified Services.--
            (1) Assured availability of varied coverage through the 
        health insurance exchange.--The Commissioner shall assure that, 
        of the Exchange participating health benefits plan offered in 
        each premium rating area of the Health Insurance Exchange--
                    (A) there is at least one such plan that provides 
                coverage of services described in subparagraphs (A) and 
                (B) of section 222(d)(4); and
                    (B) there is at least one such plan that does not 
                provide coverage of services described in section 
                222(d)(4)(A) which plan may also be one that does not 
                provide coverage of services described in section 
                222(d)(4)(B).
            (2) Segregation of funds.--If a qualified health benefits 
        plan provides coverage of services described in section 
        222(d)(4)(A), the plan shall provide assurances satisfactory to 
        the Commissioner that--
                    (A) any affordability credits provided under 
                subtitle C of title II are not used for purposes of 
                paying for such services; and
                    (B) only premium amounts attributable to the 
                actuarial value described in section 213(b) are used 
                for such purpose.

SEC. 304. CONTRACTS FOR THE OFFERING OF EXCHANGE-PARTICIPATING HEALTH 
              BENEFITS PLANS.

    (a) Contracting Duties.--In carrying out section 301(b)(1) and 
consistent with this subtitle:
            (1) Offering entity and plan standards.--The Commissioner 
        shall--
                    (A) establish standards necessary to implement the 
                requirements of this title and title II for--
                            (i) QHBP offering entities for the offering 
                        of an Exchange-participating health benefits 
                        plan; and
                            (ii) Exchange-participating health benefits 
                        plans; and
                    (B) certify QHBP offering entities and qualified 
                health benefits plans as meeting such standards and 
                requirements of this title and title II for purposes of 
                this subtitle.
            (2) Soliciting and negotiating bids; contracts.--
                    (A) Bid solicitation.--The Commissioner shall 
                solicit bids from QHBP offering entities for the 
                offering of Exchange-participating health benefits 
                plans. Such bids shall include justification for 
                proposed premiums.
                    (B) Bid review and negotiation.--The Commissioner 
                shall, based upon a review of such bids including the 
                premiums and their affordability, negotiate with such 
                entities for the offering of such plans.
                    (C) Denial of excessive premiums.--The Commissioner 
                shall deny excessive premiums and premium increases.
                    (D) Contracts.--The Commissioner shall enter into 
                contracts with such entities for the offering of such 
                plans through the Health Insurance Exchange under terms 
                (consistent with this title) negotiated between the 
                Commissioner and such entities.
            (3) Federal acquisition regulation.--In carrying out this 
        subtitle, the Commissioner may waive such provisions of the 
        Federal Acquisition Regulation that the Commissioner determines 
        to be inconsistent with the furtherance of this subtitle, other 
        than provisions relating to confidentiality of information. 
        Competitive procedures shall be used in awarding contracts 
        under this subtitle to the extent that such procedures are 
        consistent with this subtitle.
    (b) Standards for QHBP Offering Entities To Offer Exchange-
Participating Health Benefits Plans.--The standards established under 
subsection (a)(1)(A) shall require that, in order for a QHBP offering 
entity to offer an Exchange-participating health benefits plan, the 
entity must meet the following requirements:
            (1) Licensed.--The entity shall be licensed to offer health 
        insurance coverage under State law for each State in which it 
        is offering such coverage.
            (2) Data reporting.--The entity shall provide for the 
        reporting of such information as the Commissioner may specify, 
        including information necessary to administer the risk pooling 
        mechanism described in section 306(b) and information to 
        address disparities in health and health care.
            (3) Affordability.--The entity shall provide for affordable 
        premiums.
            (4) Implementing affordability credits.--The entity shall 
        provide for implementation of the affordability credits 
        provided for enrollees under subtitle C, including the 
        reduction in cost-sharing under section 344(c).
            (5) Enrollment.--The entity shall accept all enrollments 
        under this subtitle, subject to such exceptions (such as 
        capacity limitations) in accordance with the requirements under 
        title II for a qualified health benefits plan. The entity shall 
        notify the Commissioner if the entity projects or anticipates 
        reaching such a capacity limitation that would result in a 
        limitation in enrollment.
            (6) Risk pooling participation.--The entity shall 
        participate in such risk pooling mechanism as the Commissioner 
        establishes under section 306(b).
            (7) Essential community providers.--With respect to the 
        basic plan offered by the entity, the entity shall include 
        within the plan network those essential community providers, 
        where available, that serve predominantly low-income, 
        medically-underserved individuals, such as health care 
        providers defined in section 340B(a)(4) of the Public Health 
        Service Act and providers described in section 
        1927(c)(1)(D)(i)(IV) of the Social Security Act (as amended by 
        section 221 of Public Law 111-8). The Commissioner shall 
        specify the extent to which and manner in which the previous 
        sentence shall apply in the case of a basic plan with respect 
        to which the Commissioner determines provides substantially all 
        benefits through a health maintenance organization, as defined 
        in section 2791(b)(3) of the Public Health Service Act. This 
        paragraph shall not be construed to require a basic plan to 
        contract with a provider if such provider refuses to accept the 
        generally applicable payment rates of such plan.
            (8) Culturally and linguistically appropriate services and 
        communications.--The entity shall provide for culturally and 
        linguistically appropriate communication and health services.
            (9) Special rules with respect to indian enrollees and 
        indian health care providers.--
                    (A) Choice of providers.--The entity shall--
                            (i) demonstrate to the satisfaction of the 
                        Commissioner that it has contracted with a 
                        sufficient number of Indian health care 
                        providers to ensure timely access to covered 
                        services furnished by such providers to 
                        individual Indians through the entity's 
                        Exchange-participating health benefits plan; 
                        and
                            (ii) agree to pay Indian health care 
                        providers, whether such providers are 
                        participating or nonparticipating providers 
                        with respect to the entity, for covered 
                        services provided to those enrollees who are 
                        eligible to receive services from such 
                        providers at a rate that is not less than the 
                        level and amount of payment which the entity 
                        would make for the services of a participating 
                        provider which is not an Indian health care 
                        provider.
                    (B) Special rule relating to indian health care 
                providers.--Provision of services by an Indian health 
                care provider exclusively to Indians and their 
                dependents shall not constitute discrimination under 
                this Act.
            (10) Program integrity standards.--The entity shall 
        establish and operate a program to protect and promote the 
        integrity of Exchange-participating health benefits plans it 
        offers, in accordance with standards and functions established 
        by the Commissioner.
            (11) Additional requirements.--The entity shall comply with 
        other applicable requirements of this title, as specified by 
        the Commissioner, which shall include standards regarding 
        billing and collection practices for premiums and related grace 
        periods and which may include standards to ensure that the 
        entity does not use coercive practices to force providers not 
        to contract with other entities offering coverage through the 
        Health Insurance Exchange.
    (c) Contracts.--
            (1) Bid application.--To be eligible to enter into a 
        contract under this section, a QHBP offering entity shall 
        submit to the Commissioner a bid at such time, in such manner, 
        and containing such information as the Commissioner may 
        require.
            (2) Term.--Each contract with a QHBP offering entity under 
        this section shall be for a term of not less than one year, but 
        may be made automatically renewable from term to term in the 
        absence of notice of termination by either party.
            (3) Enforcement of network adequacy.--In the case of a 
        health benefits plan of a QHBP offering entity that uses a 
        provider network, the contract under this section with the 
        entity shall provide that if--
                    (A) the Commissioner determines that such provider 
                network does not meet such standards as the 
                Commissioner shall establish under section 215; and
                    (B) an individual enrolled in such plan receives an 
                item or service from a provider that is not within such 
                network;
        then any cost-sharing for such item or service shall be equal 
        to the amount of such cost-sharing that would be imposed if 
        such item or service was furnished by a provider within such 
        network.
            (4) Oversight and enforcement responsibilities.--The 
        Commissioner shall establish processes, in coordination with 
        State insurance regulators, to oversee, monitor, and enforce 
        applicable requirements of this title with respect to QHBP 
        offering entities offering Exchange-participating health 
        benefits plans, including the marketing of such plans. Such 
        processes shall include the following:
                    (A) Grievance and complaint mechanisms.--The 
                Commissioner shall establish, in coordination with 
                State insurance regulators, a process under which 
                Exchange-eligible individuals and employers may file 
                complaints concerning violations of such standards.
                    (B) Enforcement.--In carrying out authorities under 
                this division relating to the Health Insurance 
                Exchange, the Commissioner may impose one or more of 
                the intermediate sanctions described in section 242(d).
                    (C) Termination.--
                            (i) In general.--The Commissioner may 
                        terminate a contract with a QHBP offering 
                        entity under this section for the offering of 
                        an Exchange-participating health benefits plan 
                        if such entity fails to comply with the 
                        applicable requirements of this title. Any 
                        determination by the Commissioner to terminate 
                        a contract shall be made in accordance with 
                        formal investigation and compliance procedures 
                        established by the Commissioner under which--
                                    (I) the Commissioner provides the 
                                entity with the reasonable opportunity 
                                to develop and implement a corrective 
                                action plan to correct the deficiencies 
                                that were the basis of the 
                                Commissioner's determination; and
                                    (II) the Commissioner provides the 
                                entity with reasonable notice and 
                                opportunity for hearing (including the 
                                right to appeal an initial decision) 
                                before terminating the contract.
                            (ii) Exception for imminent and serious 
                        risk to health.--Clause (i) shall not apply if 
                        the Commissioner determines that a delay in 
                        termination, resulting from compliance with the 
                        procedures specified in such clause prior to 
                        termination, would pose an imminent and serious 
                        risk to the health of individuals enrolled 
                        under the qualified health benefits plan of the 
                        QHBP offering entity.
                    (D) Construction.--Nothing in this subsection shall 
                be construed as preventing the application of other 
                sanctions under subtitle E of title II with respect to 
                an entity for a violation of such a requirement.
            (5) Special rule related to cost-sharing and indian health 
        care providers.--The contract under this section with a QHBP 
        offering entity for a health benefits plan shall provide that 
        if an individual who is an Indian is enrolled in such a plan 
        and such individual receives a covered item or service from an 
        Indian health care provider (regardless of whether such 
        provider is in the plan's provider network), the cost-sharing 
        for such item or service shall be equal to the amount of cost-
        sharing that would be imposed if such item or service--
                    (A) had been furnished by another provider in the 
                plan's provider network; or
                    (B) in the case that the plan has no such network, 
                was furnished by a non-Indian provider.
            (6) National plan.--Nothing in this section shall be 
        construed as preventing the Commissioner from entering into a 
        contract under this subsection with a QHBP offering entity for 
        the offering of a health benefits plan with the same benefits 
        in every State so long as such entity is licensed to offer such 
        plan in each State and the benefits meet the applicable 
        requirements in each such State.
    (d) No Discrimination on the Basis of Provision of Abortion.--No 
Exchange participating health benefits plan may discriminate against 
any individual health care provider or health care facility because of 
its willingness or unwillingness to provide, pay for, provide coverage 
of, or refer for abortions.

SEC. 305. OUTREACH AND ENROLLMENT OF EXCHANGE-ELIGIBLE INDIVIDUALS AND 
              EMPLOYERS IN EXCHANGE-PARTICIPATING HEALTH BENEFITS PLAN.

    (a) In General.--
            (1) Outreach.--The Commissioner shall conduct outreach 
        activities consistent with subsection (c), including through 
        use of appropriate entities as described in paragraph (3) of 
        such subsection, to inform and educate individuals and 
        employers about the Health Insurance Exchange and Exchange-
        participating health benefits plan options. Such outreach shall 
        include outreach specific to vulnerable populations, such as 
        children, individuals with disabilities, individuals with 
        mental illness, and individuals with other cognitive 
        impairments.
            (2) Eligibility.--The Commissioner shall make timely 
        determinations of whether individuals and employers are 
        Exchange-eligible individuals and employers (as defined in 
        section 302).
            (3) Enrollment.--The Commissioner shall establish and carry 
        out an enrollment process for Exchange-eligible individuals and 
        employers, including at community locations, in accordance with 
        subsection (b).
    (b) Enrollment Process.--
            (1) In general.--The Commissioner shall establish a process 
        consistent with this title for enrollments in Exchange-
        participating health benefits plans. Such process shall provide 
        for enrollment through means such as the mail, by telephone, 
        electronically, and in person.
            (2) Enrollment periods.--
                    (A) Open enrollment period.--The Commissioner shall 
                establish an annual open enrollment period during which 
                an Exchange-eligible individual or employer may elect 
                to enroll in an Exchange-participating health benefits 
                plan for the following plan year and an enrollment 
                period for affordability credits under subtitle C. Such 
                periods shall be during September through November of 
                each year, or such other time that would maximize 
                timeliness of income verification for purposes of such 
                subtitle. The open enrollment period shall not be less 
                than 30 days.
                    (B) Special enrollment.--The Commissioner shall 
                also provide for special enrollment periods to take 
                into account special circumstances of individuals and 
                employers, such as an individual who--
                            (i) loses acceptable coverage;
                            (ii) experiences a change in marital or 
                        other dependent status;
                            (iii) moves outside the service area of the 
                        Exchange-participating health benefits plan in 
                        which the individual is enrolled; or
                            (iv) experiences a significant change in 
                        income.
                    (C) Enrollment information.--The Commissioner shall 
                provide for the broad dissemination of information to 
                prospective enrollees on the enrollment process, 
                including before each open enrollment period. In 
                carrying out the previous sentence, the Commissioner 
                may work with other appropriate entities to facilitate 
                such provision of information.
            (3) Automatic enrollment for non-medicaid eligible 
        individuals.--
                    (A) In general.--The Commissioner shall provide for 
                a process under which individuals who are Exchange-
                eligible individuals described in subparagraph (B) are 
                automatically enrolled under an appropriate Exchange-
                participating health benefits plan. Such process may 
                involve a random assignment or some other form of 
                assignment that takes into account the health care 
                providers used by the individual involved or such other 
                relevant factors as the Commissioner may specify.
                    (B) Subsidized individuals described.--An 
                individual described in this subparagraph is an 
                Exchange-eligible individual who is either of the 
                following:
                            (i) Affordability credit eligible 
                        individuals.--The individual--
                                    (I) has applied for, and been 
                                determined eligible for, affordability 
                                credits under subtitle C;
                                    (II) has not opted out from 
                                receiving such affordability credit; 
                                and
                                    (III) does not otherwise enroll in 
                                another Exchange-participating health 
                                benefits plan.
                            (ii) Individuals enrolled in a terminated 
                        plan.--The individual who is enrolled in an 
                        Exchange-participating health benefits plan 
                        that is terminated (during or at the end of a 
                        plan year) and who does not otherwise enroll in 
                        another Exchange-participating health benefits 
                        plan.
            (4) Direct payment of premiums to plans.--Under the 
        enrollment process, individuals enrolled in an Exchange-
        participating health benefits plan shall pay such plans 
        directly, and not through the Commissioner or the Health 
        Insurance Exchange.
    (c) Coverage Information and Assistance.--
            (1) Coverage information.--The Commissioner shall provide 
        for the broad dissemination of information on Exchange-
        participating health benefits plans offered under this title. 
        Such information shall be provided in a comparative manner, and 
        shall include information on benefits, premiums, cost-sharing, 
        quality, provider networks, and consumer satisfaction.
            (2) Consumer assistance with choice.--To provide assistance 
        to Exchange-eligible individuals and employers, the 
        Commissioner shall--
                    (A) provide for the operation of a toll-free 
                telephone hotline to respond to requests for assistance 
                and maintain an Internet Web site through which 
                individuals may obtain information on coverage under 
                Exchange-participating health benefits plans and file 
                complaints;
                    (B) develop and disseminate information to 
                Exchange-eligible enrollees on their rights and 
                responsibilities;
                    (C) assist Exchange-eligible individuals in 
                selecting Exchange-participating health benefits plans 
                and obtaining benefits through such plans; and
                    (D) ensure that the Internet Web site described in 
                subparagraph (A) and the information described in 
                subparagraph (B) is developed using plain language (as 
                defined in section 233(a)(2)).
            (3) Use of other entities.--In carrying out this 
        subsection, the Commissioner may work with other appropriate 
        entities to facilitate the dissemination of information under 
        this subsection and to provide assistance as described in 
        paragraph (2).
    (d) Coverage for Certain Newborns Under Medicaid.--
            (1) In general.--In the case of a child born in the United 
        States who at the time of birth is not otherwise covered under 
        acceptable coverage, for the period of time beginning on the 
        date of birth and ending on the date the child otherwise is 
        covered under acceptable coverage (or, if earlier, the end of 
        the month in which the 60-day period, beginning on the date of 
        birth, ends), the child shall be deemed--
                    (A) to be a Medicaid eligible individual for 
                purposes of this division and Medicaid; and
                    (B) to be automatically enrolled in Medicaid as a 
                traditional Medicaid eligible individual (as defined in 
                section 1943(c) of the Social Security Act).
            (2) Extended treatment as medicaid eligible individual.--In 
        the case of a child described in paragraph (1) who at the end 
        of the period referred to in such paragraph is not otherwise 
        covered under acceptable coverage, the child shall be deemed 
        (until such time as the child obtains such coverage or the 
        State otherwise makes a determination of the child's 
        eligibility for medical assistance under its Medicaid plan 
        pursuant to section 1943(b)(1) of the Social Security Act) to 
        be a Medicaid eligible individual described in section 
        1902(l)(1)(B) of such Act.
    (e) Medicaid Coverage for Medicaid Eligible Individuals.--
            (1) Medicaid enrollment obligation.--An individual may 
        apply, in the manner described in section 341(b)(1), for a 
        determination of whether the individual is a Medicaid-eligible 
        individual. If the individual is determined to be so eligible, 
        the Commissioner, through the Medicaid memorandum of 
        understanding under paragraph (2), shall provide for the 
        enrollment of the individual under the State Medicaid plan in 
        accordance with such memorandum of understanding. In the case 
        of such an enrollment, the State shall provide for the same 
        periodic redetermination of eligibility under Medicaid as would 
        otherwise apply if the individual had directly applied for 
        medical assistance to the State Medicaid agency.
            (2) Coordinated enrollment with state through memorandum of 
        understanding.--The Commissioner, in consultation with the 
        Secretary of Health and Human Services, shall enter into a 
        memorandum of understanding with each State with respect to 
        coordinating enrollment of individuals in Exchange-
        participating health benefits plans and under the State's 
        Medicaid program consistent with this section and to otherwise 
        coordinate the implementation of the provisions of this 
        division with respect to the Medicaid program. Such memorandum 
        shall permit the exchange of information consistent with the 
        limitations described in section 1902(a)(7) of the Social 
        Security Act. Nothing in this section shall be construed as 
        permitting such memorandum to modify or vitiate any requirement 
        of a State Medicaid plan.
    (f) Effective Culturally and Linguistically Appropriate 
Communication.--In carrying out this section, the Commissioner shall 
establish effective methods for communicating in plain language and a 
culturally and linguistically appropriate manner.
    (g) Role for Enrollment Agents and Brokers.--Nothing in this 
division shall be construed to affect the role of enrollment agents and 
brokers under State law, including with regard to the enrollment of 
individuals and employers in qualified health benefits plans including 
the public health insurance option.
    (h) Assistance for Small Employers.--
            (1) In general.--The Commissioner, in consultation with the 
        Small Business Administration, shall establish and carry out a 
        program to provide to small employers counseling and technical 
        assistance with respect to the provision of health insurance to 
        employees of such employers through the Health Insurance 
        Exchange.
            (2) Duties.--The program established under paragraph (1) 
        shall include the following services:
                    (A) Educational activities to increase awareness of 
                the Health Insurance Exchange and available small 
                employer health plan options.
                    (B) Distribution of information to small employers 
                with respect to the enrollment and selection process 
                for health plans available under the Health Insurance 
                Exchange, including standardized comparative 
                information on the health plans available under the 
                Health Insurance Exchange.
                    (C) Distribution of information to small employers 
                with respect to available affordability credits or 
                other financial assistance.
                    (D) Referrals to appropriate entities of complaints 
                and questions relating to the Health Insurance 
                Exchange.
                    (E) Enrollment and plan selection assistance for 
                employers with respect to the Health Insurance 
                Exchange.
                    (F) Responses to questions relating to the Health 
                Insurance Exchange and the program established under 
                paragraph (1).
            (3) Authority to provide services directly or by 
        contract.--The Commissioner may provide services under 
        paragraph (2) directly or by contract with nonprofit entities 
        that the Commissioner determines capable of carrying out such 
        services.
            (4) Small employer defined.--In this subsection, the term 
        ``small employer'' means an employer with less than 100 
        employees.
    (i) Participation of Small Employer Benefit Arrangements.--
            (1) In general.--The Commissioner may enter into contracts 
        with small employer benefit arrangements to provide consumer 
        information, outreach, and assistance in the enrollment of 
        small employers (and their employees) who are members of such 
        an arrangement under Exchange participating health benefits 
        plans.
            (2) Small employer benefit arrangement defined.--In this 
        subsection, the term ``small employer benefit arrangement'' 
        means a not-for-profit agricultural or other cooperative that--
                    (A) consists solely of its members and is operated 
                for the primary purpose of providing affordable 
                employee benefits to its members;
                    (B) only has as members small employers in the same 
                industry or line of business;
                    (C) has no member that has more than a 5 percent 
                voting interest in the cooperative; and
                    (D) is governed by a board of directors elected by 
                its members.

SEC. 306. OTHER FUNCTIONS.

    (a) Coordination of Affordability Credits.--The Commissioner shall 
coordinate the distribution of affordability premium and cost-sharing 
credits under subtitle C to QHBP offering entities offering Exchange-
participating health benefits plans.
    (b) Coordination of Risk Pooling.--The Commissioner shall establish 
a mechanism whereby there is an adjustment made of the premium amounts 
payable among QHBP offering entities offering Exchange-participating 
health benefits plans of premiums collected for such plans that takes 
into account (in a manner specified by the Commissioner) the 
differences in the risk characteristics of individuals and employees 
enrolled under the different Exchange-participating health benefits 
plans offered by such entities so as to minimize the impact of adverse 
selection of enrollees among the plans offered by such entities. For 
purposes of the previous sentence, the Commissioner may utilize data 
regarding enrollee demographics, inpatient and outpatient diagnoses (in 
a similar manner as such data are used under parts C and D of title 
XVIII of the Social Security Act), and such other information as the 
Secretary determines may be necessary, such as the actual medical costs 
of enrollees during the previous year.

SEC. 307. HEALTH INSURANCE EXCHANGE TRUST FUND.

    (a) Establishment of Health Insurance Exchange Trust Fund.--There 
is created within the Treasury of the United States a trust fund to be 
known as the ``Health Insurance Exchange Trust Fund'' (in this section 
referred to as the ``Trust Fund''), consisting of such amounts as may 
be appropriated or credited to the Trust Fund under this section or any 
other provision of law.
    (b) Payments From Trust Fund.--The Commissioner shall pay from time 
to time from the Trust Fund such amounts as the Commissioner determines 
are necessary to make payments to operate the Health Insurance 
Exchange, including payments under subtitle C (relating to 
affordability credits).
    (c) Transfers to Trust Fund.--
            (1) Dedicated payments.--There are hereby appropriated to 
        the Trust Fund amounts equivalent to the following:
                    (A) Taxes on individuals not obtaining acceptable 
                coverage.--The amounts received in the Treasury under 
                section 59B of the Internal Revenue Code of 1986 
                (relating to requirement of health insurance coverage 
                for individuals).
                    (B) Employment taxes on employers not providing 
                acceptable coverage.--The amounts received in the 
                Treasury under sections 3111(c) and 3221(c) of the 
                Internal Revenue Code of 1986 (relating to employers 
                electing to not provide health benefits).
                    (C) Excise tax on failures to meet certain health 
                coverage requirements.--The amounts received in the 
                Treasury under section 4980H(b) (relating to excise tax 
                with respect to failure to meet health coverage 
                participation requirements).
            (2) Appropriations to cover government contributions.--
        There are hereby appropriated, out of any moneys in the 
        Treasury not otherwise appropriated, to the Trust Fund, an 
        amount equivalent to the amount of payments made from the Trust 
        Fund under subsection (b) plus such amounts as are necessary 
        reduced by the amounts deposited under paragraph (1).
    (d) Application of Certain Rules.--Rules similar to the rules of 
subchapter B of chapter 98 of the Internal Revenue Code of 1986 shall 
apply with respect to the Trust Fund.

SEC. 308. OPTIONAL OPERATION OF STATE-BASED HEALTH INSURANCE EXCHANGES.

    (a) In General.--If--
            (1) a State (or group of States, subject to the approval of 
        the Commissioner) applies to the Commissioner for approval of a 
        State-based Health Insurance Exchange to operate in the State 
        (or group of States); and
            (2) the Commissioner approves such State-based Health 
        Insurance Exchange,
then, subject to subsections (c) and (d), the State-based Health 
Insurance Exchange shall operate, instead of the Health Insurance 
Exchange, with respect to such State (or group of States). The 
Commissioner shall approve a State-based Health Insurance Exchange if 
it meets the requirements for approval under subsection (b).
    (b) Requirements for Approval.--
            (1) In general.--The Commissioner may not approve a State-
        based Health Insurance Exchange under this section unless the 
        following requirements are met:
                    (A) The State-based Health Insurance Exchange must 
                demonstrate the capacity to and provide assurances 
                satisfactory to the Commissioner that the State-based 
                Health Insurance Exchange will carry out the functions 
                specified for the Health Insurance Exchange in the 
                State (or States) involved, including--
                            (i) negotiating and contracting with QHBP 
                        offering entities for the offering of Exchange-
                        participating health benefits plans, which 
                        satisfy the standards and requirements of this 
                        title and title II;
                            (ii) enrolling Exchange-eligible 
                        individuals and employers in such State in such 
                        plans;
                            (iii) the establishment of sufficient local 
                        offices to meet the needs of Exchange-eligible 
                        individuals and employers;
                            (iv) administering affordability credits 
                        under subtitle B using the same methodologies 
                        (and at least the same income verification 
                        methods) as would otherwise apply under such 
                        subtitle and at a cost to the Federal 
                        Government which does exceed the cost to the 
                        Federal Government if this section did not 
                        apply; and
                            (v) enforcement activities consistent with 
                        Federal requirements.
                    (B) There is no more than one Health Insurance 
                Exchange operating with respect to any one State.
                    (C) The State provides assurances satisfactory to 
                the Commissioner that approval of such an Exchange will 
                not result in any net increase in expenditures to the 
                Federal Government.
                    (D) The State provides for reporting of such 
                information as the Commissioner determines and 
                assurances satisfactory to the Commissioner that it 
                will vigorously enforce violations of applicable 
                requirements.
                    (E) Such other requirements as the Commissioner may 
                specify.
            (2) Presumption for certain state-operated exchanges.--
                    (A) In general.--In the case of a State operating 
                an Exchange prior to January 1, 2010, that seeks to 
                operate the State-based Health Insurance Exchange under 
                this section, the Commissioner shall presume that such 
                Exchange meets the standards under this section unless 
                the Commissioner determines, after completion of the 
                process established under subparagraph (B), that the 
                Exchange does not comply with such standards.
                    (B) Process.--The Commissioner shall establish a 
                process to work with a State described in subparagraph 
                (A) to provide assistance necessary to assure that the 
                State's Exchange comes into compliance with the 
                standards for approval under this section.
    (c) Ceasing Operation.--
            (1) In general.--A State-based Health Insurance Exchange 
        may, at the option of each State involved, and only after 
        providing timely and reasonable notice to the Commissioner, 
        cease operation as such an Exchange, in which case the Health 
        Insurance Exchange shall operate, instead of such State-based 
        Health Insurance Exchange, with respect to such State (or 
        States).
            (2) Termination; health insurance exchange resumption of 
        functions.--The Commissioner may terminate the approval (for 
        some or all functions) of a State-based Health Insurance 
        Exchange under this section if the Commissioner determines that 
        such Exchange no longer meets the requirements of subsection 
        (b) or is no longer capable of carrying out such functions in 
        accordance with the requirements of this subtitle. In lieu of 
        terminating such approval, the Commissioner may temporarily 
        assume some or all functions of the State-based Health 
        Insurance Exchange until such time as the Commissioner 
        determines the State-based Health Insurance Exchange meets such 
        requirements of subsection (b) and is capable of carrying out 
        such functions in accordance with the requirements of this 
        subtitle.
            (3) Effectiveness.--The ceasing or termination of a State-
        based Health Insurance Exchange under this subsection shall be 
        effective in such time and manner as the Commissioner shall 
        specify.
    (d) Retention of Authority.--
            (1) Authority retained.--Enforcement authorities of the 
        Commissioner shall be retained by the Commissioner.
            (2) Discretion to retain additional authority.--The 
        Commissioner may specify functions of the Health Insurance 
        Exchange that--
                    (A) may not be performed by a State-based Health 
                Insurance Exchange under this section; or
                    (B) may be performed by the Commissioner and by 
                such a State-based Health Insurance Exchange.
    (e) References.--In the case of a State-based Health Insurance 
Exchange, except as the Commissioner may otherwise specify under 
subsection (d), any references in this subtitle to the Health Insurance 
Exchange or to the Commissioner in the area in which the State-based 
Health Insurance Exchange operates shall be deemed a reference to the 
State-based Health Insurance Exchange and the head of such Exchange, 
respectively.
    (f) Funding.--In the case of a State-based Health Insurance 
Exchange, there shall be assistance provided for the operation of such 
Exchange in the form of a matching grant with a State share of 
expenditures required.

SEC. 309. INTERSTATE HEALTH INSURANCE COMPACTS.

    (a) In General.--Effective January 1, 2015, 2 or more States may 
form Health Care Choice Compacts (in this section referred to as 
``compacts'') to facilitate the purchase of individual health insurance 
coverage across State lines.
    (b) Model Guidelines.--The Secretary of Health and Human Services 
(in this section referred to as the ``Secretary'') shall request the 
National Association of Insurance Commissioners (in this section 
referred to as ``NAIC'') to develop model guidelines for the creation 
of compacts. In developing such guidelines, the NAIC shall consult with 
consumers, health insurance issuers, the Secretary, and other 
interested parties. Such guidelines shall--
            (1) provide for the sale of health insurance coverage to 
        residents of all compacting States subject to the laws and 
        regulations of a primary State designated by the health 
        insurance issuer;
            (2) require health insurance issuers issuing health 
        insurance coverage in secondary States to maintain licensure in 
        every such State;
            (3) preserve the authority of the State of an individual's 
        residence to address--
                    (A) market conduct;
                    (B) unfair trade practices;
                    (C) network adequacy;
                    (D) consumer protection standards;
                    (E) grievance and appeals;
                    (F) fair claims payment requirements; and
                    (G) prompt payment of claims;
            (4) permit State insurance commissioners and other State 
        agencies in secondary States access to the records of a health 
        insurance issuer to the same extent as if the policy were 
        written in that State; and
            (5) provide for clear and conspicuous disclosure to 
        consumers that the policy may not be subject to all the laws 
        and regulations of the State in which the purchaser resides.
    (c) Required Consideration.--If model guidelines developed under 
subsection (b) are submitted to the Secretary by January 1, 2013, the 
Secretary shall issue them as regulations. If the NAIC fails to submit 
such model guidelines by such date, the Secretary shall, no later than 
October 1, 2013, develop and promulgate the regulations implementing 
model guidelines described in subsection (b).
    (d) No Requirement to Compact.--Nothing in this section shall be 
construed to require a State to join a compact.
    (e) State Authority.--A State may not enter into a compact under 
this subsection unless the State enacts a law after the date of 
enactment of this Act that specifically authorizes the State to enter 
into such compact.
    (f) Consumer Protections.--If a State enters into a compact it must 
retain responsibility for the consumer protections of its residents and 
its residents retain the right to bring a claim in a State court in the 
State in which the resident resides.
    (g) Assistance to Compacting States.--
            (1) In general.--Beginning January 1, 2015, the Secretary 
        shall make awards, from amounts appropriated under paragraph 
        (5), to States in the amount specified in paragraph (2) for the 
        uses described in paragraph (3).
            (2) Amount specified.--
                    (A) In general.--For each fiscal year, the 
                Secretary shall determine the total amount that the 
                Secretary will make available for grants under this 
                subsection.
                    (B) State amount.--For each State that is awarded a 
                grant under paragraph (1), the amount of such grants 
                shall be based on a formula established by the 
                Secretary, not to exceed $1 million per State, under 
                which States shall receive an award in the amount that 
                is based on the following two components:
                            (i) A minimum amount for each State.
                            (ii) An additional amount based on 
                        population of the State.
            (3) Use of funds.--A State shall use amounts awarded under 
        this subsection for activities (including planning activities) 
        related regulating health insurance coverage sold in secondary 
        States.
            (4) Renewability of grant.--The Secretary may renew a grant 
        award under paragraph (1) if the State receiving the grant 
        continues to be a member of a compact.
            (5) Authorization of appropriations.--There are authorized 
        to be appropriated such sums as may be necessary to carry out 
        this subsection in each of fiscal years 2015 through 2020.

SEC. 310. HEALTH INSURANCE COOPERATIVES.

    (a) Establishment.--Not later than 6 months after the date of the 
enactment of this Act, the Commissioner, in consultation with the 
Secretary of the Treasury, shall establish a Consumer Operated and 
Oriented Plan program (in this section referred to as the ``CO-OP 
program'') under which the Commissioner may make grants and loans for 
the establishment and initial operation of not-for-profit, member-run 
health insurance cooperatives (in this section individually referred to 
as a ``cooperative'') that provide insurance through the Health 
Insurance Exchange or a State-based Health Insurance Exchange under 
section 308. Nothing in this section shall be construed as requiring a 
State to establish such a cooperative.
    (b) Start-up and Solvency Grants and Loans.--
            (1) In general.--Not later than 36 months after the date of 
        the enactment of this Act, the Commissioner, acting through the 
        CO-OP program, may make--
                    (A) loans (of such period and with such terms as 
                the Secretary may specify) to cooperatives to assist 
                such cooperatives with start-up costs; and
                    (B) grants to cooperatives to assist such 
                cooperatives in meeting State solvency requirements in 
                the States in which such cooperative offers or issues 
                insurance coverage.
            (2)  Conditions.--A grant or loan may not be awarded under 
        this subsection with respect to a cooperative unless the 
        following conditions are met:
                    (A) The cooperative is structured as a not-for-
                profit, member organization under the law of each State 
                in which such cooperative offers, intends to offer, or 
                issues insurance coverage, with the membership of the 
                cooperative being made up entirely of beneficiaries of 
                the insurance coverage offered by such cooperative.
                    (B) The cooperative did not offer insurance on or 
                before July 16, 2009, and the cooperative is not an 
                affiliate or successor to an insurance company offering 
                insurance on or before such date.
                    (C) The governing documents of the cooperative 
                incorporate ethical and conflict of interest standards 
                designed to protect against insurance industry 
                involvement and interference in the governance of the 
                cooperative.
                    (D) The cooperative is not sponsored by a State 
                government.
                    (E) Substantially all of the activities of the 
                cooperative consist of the issuance of qualified health 
                benefits plans through the Health Insurance Exchange or 
                a State-based health insurance exchange.
                    (F) The cooperative is licensed to offer insurance 
                in each State in which it offers insurance.
                    (G) The governance of the cooperative must be 
                subject to a majority vote of its members.
                    (H) As provided in guidance issued by the Secretary 
                of Health and Human Services, the cooperative operates 
                with a strong consumer focus, including timeliness, 
                responsiveness, and accountability to members.
                    (I) Any profits made by the cooperative are used to 
                lower premiums, improve benefits, or to otherwise 
                improve the quality of health care delivered to 
                members.
            (3) Priority.--The Commissioner, in making grants and loans 
        under this subsection, shall give priority to cooperatives 
        that--
                    (A) operate on a statewide basis;
                    (B) use an integrated delivery system; or
                    (C) have a significant level of financial support 
                from nongovernmental sources.
            (4) Rules of construction.--Nothing in this section shall 
        be construed to prevent a cooperative established in one State 
        from integrating with a cooperative established in another 
        State the administration, issuance of coverage, or other 
        activities related to acting as a QHBP offering entity. Nothing 
        in this section shall be construed as preventing State 
        governments from taking actions to permit such integration.
            (5) Amortization of grants and loans.--The Secretary shall 
        provide for the repayment of grants or loans provided under 
        this subsection to the Treasury in an amortized manner over a 
        10-year period.
            (6) Repayment for violations of terms of program.--If a 
        cooperative violates the terms of the CO-OP program and fails 
        to correct the violation within a reasonable period of time, as 
        determined by the Commissioner, the cooperative shall repay the 
        total amount of any loan or grant received by such cooperative 
        under this section, plus interest (at a rate determined by the 
        Secretary).
            (7) Authorization of appropriations.--There is authorized 
        to be appropriated $5,000,000,000 for the period of fiscal 
        years 2010 through 2014 to provide for grants and loans under 
        this subsection.
    (c) Definitions.--For purposes of this section:
            (1) State.--The term ``State'' means each of the 50 States 
        and the District of Columbia.
            (2) Member.--The term ``member'', with respect to a 
        cooperative, means an individual who, after the cooperative 
        offers health insurance coverage, is enrolled in such coverage.

SEC. 311. RETENTION OF DOD AND VA AUTHORITY.

     Nothing in this subtitle shall be construed as affecting any 
authority under title 38, United States Code, or chapter 55 of title 
10, United States Code.

               Subtitle B--Public Health Insurance Option

SEC. 321. ESTABLISHMENT AND ADMINISTRATION OF A PUBLIC HEALTH INSURANCE 
              OPTION AS AN EXCHANGE-QUALIFIED HEALTH BENEFITS PLAN.

    (a) Establishment.--For years beginning with Y1, the Secretary of 
Health and Human Services (in this subtitle referred to as the 
``Secretary'') shall provide for the offering of an Exchange-
participating health benefits plan (in this division referred to as the 
``public health insurance option'') that ensures choice, competition, 
and stability of affordable, high quality coverage throughout the 
United States in accordance with this subtitle. In designing the 
option, the Secretary's primary responsibility is to create a low-cost 
plan without compromising quality or access to care.
    (b) Offering as an Exchange-participating Health Benefits Plan.--
            (1) Exclusive to the exchange.--The public health insurance 
        option shall only be made available through the Health 
        Insurance Exchange.
            (2) Ensuring a level playing field.--Consistent with this 
        subtitle, the public health insurance option shall comply with 
        requirements that are applicable under this title to an 
        Exchange-participating health benefits plan, including 
        requirements related to benefits, benefit levels, provider 
        networks, notices, consumer protections, and cost-sharing.
            (3) Provision of benefit levels.--The public health 
        insurance option--
                    (A) shall offer basic, enhanced, and premium plans; 
                and
                    (B) may offer premium-plus plans.
    (c) Administrative Contracting.--The Secretary may enter into 
contracts for the purpose of performing administrative functions 
(including functions described in subsection (a)(4) of section 1874A of 
the Social Security Act) with respect to the public health insurance 
option in the same manner as the Secretary may enter into contracts 
under subsection (a)(1) of such section. The Secretary has the same 
authority with respect to the public health insurance option as the 
Secretary has under subsections (a)(1) and (b) of section 1874A of the 
Social Security Act with respect to title XVIII of such Act. Contracts 
under this subsection shall not involve the transfer of insurance risk 
to such entity.
    (d) Ombudsman.--The Secretary shall establish an office of the 
ombudsman for the public health insurance option which shall have 
duties with respect to the public health insurance option similar to 
the duties of the Medicare Beneficiary Ombudsman under section 
1808(c)(2) of the Social Security Act.
    (e) Data Collection.--The Secretary shall collect such data as may 
be required to establish premiums and payment rates for the public 
health insurance option and for other purposes under this subtitle, 
including to improve quality and to reduce racial, ethnic, and other 
disparities in health and health care. Nothing in this subtitle may be 
construed as authorizing the Secretary (or any employee or contractor) 
to create or maintain lists of non-medical personal property.
    (f) Treatment of Public Health Insurance Option.--With respect to 
the public health insurance option, the Secretary shall be treated as a 
QHBP offering entity offering an Exchange-participating health benefits 
plan.
    (g) Access to Federal Courts.--The provisions of Medicare (and 
related provisions of title II of the Social Security Act) relating to 
access of Medicare beneficiaries to Federal courts for the enforcement 
of rights under Medicare, including with respect to amounts in 
controversy, shall apply to the public health insurance option and 
individuals enrolled under such option under this title in the same 
manner as such provisions apply to Medicare and Medicare beneficiaries.

SEC. 322. PREMIUMS AND FINANCING.

    (a) Establishment of Premiums.--
            (1) In general.--The Secretary shall establish 
        geographically adjusted premium rates for the public health 
        insurance option--
                    (A) in a manner that complies with the premium 
                rules established by the Commissioner under section 213 
                for Exchange-participating health benefits plans; and
                    (B) at a level sufficient to fully finance the 
                costs of--
                            (i) health benefits provided by the public 
                        health insurance option; and
                            (ii) administrative costs related to 
                        operating the public health insurance option.
            (2) Contingency margin.--In establishing premium rates 
        under paragraph (1), the Secretary shall include an appropriate 
        amount for a contingency margin (which shall be not less than 
        90 days of estimated claims). Before setting such appropriate 
        amount for years starting with Y3, the Secretary shall solicit 
        a recommendation on such amount from the American Academy of 
        Actuaries.
    (b) Account.--
            (1) Establishment.--There is established in the Treasury of 
        the United States an Account for the receipts and disbursements 
        attributable to the operation of the public health insurance 
        option, including the start-up funding under paragraph (2). 
        Section 1854(g) of the Social Security Act shall apply to 
        receipts described in the previous sentence in the same manner 
        as such section applies to payments or premiums described in 
        such section.
            (2) Start-up funding.--
                    (A) In general.--In order to provide for the 
                establishment of the public health insurance option, 
                there is hereby appropriated to the Secretary, out of 
                any funds in the Treasury not otherwise appropriated, 
                $2,000,000,000. In order to provide for initial claims 
                reserves before the collection of premiums, there are 
                hereby appropriated to the Secretary, out of any funds 
                in the Treasury not otherwise appropriated, such sums 
                as necessary to cover 90 days worth of claims reserves 
                based on projected enrollment.
                    (B) Amortization of start-up funding.--The 
                Secretary shall provide for the repayment of the 
                startup funding provided under subparagraph (A) to the 
                Treasury in an amortized manner over the 10-year period 
                beginning with Y1.
                    (C) Limitation on funding.--Nothing in this section 
                shall be construed as authorizing any additional 
                appropriations to the Account, other than such amounts 
                as are otherwise provided with respect to other 
                Exchange-participating health benefits plans.
            (3) No bailouts.--In no case shall the public health 
        insurance option receive any Federal funds for purposes of 
        insolvency in any manner similar to the manner in which 
        entities receive Federal funding under the Troubled Assets 
        Relief Program of the Secretary of the Treasury.

SEC. 323. PAYMENT RATES FOR ITEMS AND SERVICES.

    (a) Negotiation of Payment Rates.--
            (1) In general.--The Secretary shall negotiate payment for 
        the public health insurance option for health care providers 
        and items and services, including prescription drugs, 
        consistent with this section and section 324.
            (2) Manner of negotiation.--The Secretary shall negotiate 
        such rates in a manner that results in payment rates that are 
        not lower, in the aggregate, than rates under title XVIII of 
        the Social Security Act, and not higher, in the aggregate, than 
        the average rates paid by other QHBP offering entities for 
        services and health care providers.
            (3) Innovative payment methods.--Nothing in this subsection 
        shall be construed as preventing the use of innovative payment 
        methods such as those described in section 324 in connection 
        with the negotiation of payment rates under this subsection.
    (b) Establishment of a Provider Network.--
            (1) In general.--Health care providers (including 
        physicians and hospitals) participating in Medicare are 
        participating providers in the public health insurance option 
        unless they opt out in a process established by the Secretary 
        consistent with this subsection.
            (2) Requirements for opt-out process.--Under the process 
        established under paragraph (1)--
                    (A) providers described in such paragraph shall be 
                provided at least a 1-year period prior to the first 
                day of Y1 to opt out of participating in the public 
                health insurance option;
                    (B) no provider shall be subject to a penalty for 
                not participating in the public health insurance 
                option;
                    (C) the Secretary shall include information on how 
                providers participating in Medicare who chose to opt 
                out of participating in the public health insurance 
                option may opt back in; and
                    (D) there shall be an annual enrollment period in 
                which providers may decide whether to participate in 
                the public health insurance option.
            (3) Rulemaking.--Not later than 18 months before the first 
        day of Y1, the Secretary shall promulgate rules (pursuant to 
        notice and comment) for the process described in paragraph (1).
    (c) Limitations on Review.--There shall be no administrative or 
judicial review of a payment rate or methodology established under this 
section or under section 324.

SEC. 324. MODERNIZED PAYMENT INITIATIVES AND DELIVERY SYSTEM REFORM.

    (a) In General.--For plan years beginning with Y1, the Secretary 
may utilize innovative payment mechanisms and policies to determine 
payments for items and services under the public health insurance 
option. The payment mechanisms and policies under this section may 
include patient-centered medical home and other care management 
payments, accountable care organizations, value-based purchasing, 
bundling of services, differential payment rates, performance or 
utilization based payments, partial capitation, and direct contracting 
with providers.
    (b) Requirements for Innovative Payments.--The Secretary shall 
design and implement the payment mechanisms and policies under this 
section in a manner that--
            (1) seeks to--
                    (A) improve health outcomes;
                    (B) reduce health disparities (including racial, 
                ethnic, and other disparities);
                    (C) provide efficient and affordable care;
                    (D) address geographic variation in the provision 
                of health services; or
                    (E) prevent or manage chronic illness; and
            (2) promotes care that is integrated, patient-centered, 
        quality, and efficient.
    (c) Encouraging the Use of High Value Services.--To the extent 
allowed by the benefit standards applied to all Exchange-participating 
health benefits plans, the public health insurance option may modify 
cost-sharing and payment rates to encourage the use of services that 
promote health and value.
    (d) Promotion of Delivery System Reform.--The Secretary shall 
monitor and evaluate the progress of payment and delivery system 
reforms under this Act and shall seek to implement such reforms subject 
to the following:
            (1) To the extent that the Secretary finds a payment and 
        delivery system reform successful in improving quality and 
        reducing costs, the Secretary shall implement such reform on as 
        large a geographic scale as practical and economical.
            (2) The Secretary may delay the implementation of such a 
        reform in geographic areas in which such implementation would 
        place the public health insurance option at a competitive 
        disadvantage.
            (3) The Secretary may prioritize implementation of such a 
        reform in high cost geographic areas or otherwise in order to 
        reduce total program costs or to promote high value care.
    (e) Non-uniformity Permitted.--Nothing in this subtitle shall 
prevent the Secretary from varying payments based on different payment 
structure models (such as accountable care organizations and medical 
homes) under the public health insurance option for different 
geographic areas.

SEC. 325. PROVIDER PARTICIPATION.

    (a) In General.--The Secretary shall establish conditions of 
participation for health care providers under the public health 
insurance option.
    (b) Licensure or Certification.--
            (1) In general.--Except as provided in paragraph (2), the 
        Secretary shall not allow a health care provider to participate 
        in the public health insurance option unless such provider is 
        appropriately licensed, certified, or otherwise permitted to 
        practice under State law.
            (2) Special rule for ihs facilities and providers.--The 
        requirements under paragraph (1) shall not apply to--
                    (A) a facility that is operated by the Indian 
                Health Service;
                    (B) a facility operated by an Indian Tribe or 
                tribal organization under the Indian Self-Determination 
                Act (Public Law 93-638);
                    (C) a health care professional employed by the 
                Indian Health Service; or
                    (D) a health care professional--
                            (i) who is employed to provide health care 
                        services in a facility operated by an Indian 
                        Tribe or tribal organization under the Indian 
                        Self-Determination Act; and
                            (ii) who is licensed or certified in any 
                        State.
    (c) Payment Terms for Providers.--
            (1) Physicians.--The Secretary shall provide for the annual 
        participation of physicians under the public health insurance 
        option, for which payment may be made for services furnished 
        during the year, in one of 2 classes:
                    (A) Preferred physicians.--Those physicians who 
                agree to accept the payment under section 323 (without 
                regard to cost-sharing) as the payment in full.
                    (B) Participating, non-preferred physicians.--Those 
                physicians who agree not to impose charges (in relation 
                to the payment described in section 323 for such 
                physicians) that exceed the sum of the in-network cost-
                sharing plus 15 percent of the total payment for each 
                item and service. The Secretary shall reduce the 
                payment described in section 323 for such physicians.
            (2) Other providers.--The Secretary shall provide for the 
        participation (on an annual or other basis specified by the 
        Secretary) of health care providers (other than physicians) 
        under the public health insurance option under which payment 
        shall only be available if the provider agrees to accept the 
        payment under section 323 (without regard to cost-sharing) as 
        the payment in full.
    (d) Exclusion of Certain Providers.--The Secretary shall exclude 
from participation under the public health insurance option a health 
care provider that is excluded from participation in a Federal health 
care program (as defined in section 1128B(f) of the Social Security 
Act).

SEC. 326. APPLICATION OF FRAUD AND ABUSE PROVISIONS.

    Provisions of civil law identified by the Secretary by regulation, 
in consultation with the Inspector General of the Department of Health 
and Human Services, that impose sanctions with respect to waste, fraud, 
and abuse under Medicare, such as sections 3729 through 3733 of title 
31, United States Code (commonly known as the False Claims Act), shall 
also apply to the public health insurance option.

SEC. 327. APPLICATION OF HIPAA INSURANCE REQUIREMENTS.

    The requirements of sections 2701 through 2792 of the Public Health 
Service Act shall apply to the public health insurance option in the 
same manner as they apply to health insurance coverage offered by a 
health insurance issuer in the individual market.

SEC. 328. APPLICATION OF HEALTH INFORMATION PRIVACY, SECURITY, AND 
              ELECTRONIC TRANSACTION REQUIREMENTS.

    Part C of title XI of the Social Security Act, relating to 
standards for protections against the wrongful disclosure of 
individually identifiable health information, health information 
security, and the electronic exchange of health care information, shall 
apply to the public health insurance option in the same manner as such 
part applies to other health plans (as defined in section 1171(5) of 
such Act).

SEC. 329. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION IS VOLUNTARY.

    Nothing in this division shall be construed as requiring anyone to 
enroll in the public health insurance option. Enrollment in such option 
is voluntary.

SEC. 330. ENROLLMENT IN PUBLIC HEALTH INSURANCE OPTION BY MEMBERS OF 
              CONGRESS.

    Notwithstanding any other provision of this Act, Members of 
Congress may enroll in the public health insurance option.

SEC. 331. REIMBURSEMENT OF SECRETARY OF VETERANS AFFAIRS.

    The Secretary of Health and Human Services shall seek to enter into 
a memorandum of understanding with the Secretary of Veterans Affairs 
regarding the recovery of costs related to non-service-connected care 
or services provided by the Secretary of Veterans Affairs to an 
individual covered under the public health insurance option in a manner 
consistent with recovery of costs related to non-service-connected care 
from private health insurance plans.

              Subtitle C--Individual Affordability Credits

SEC. 341. AVAILABILITY THROUGH HEALTH INSURANCE EXCHANGE.

    (a) In General.--Subject to the succeeding provisions of this 
subtitle, in the case of an affordable credit eligible individual 
enrolled in an Exchange-participating health benefits plan--
            (1) the individual shall be eligible for, in accordance 
        with this subtitle, affordability credits consisting of--
                    (A) an affordability premium credit under section 
                343 to be applied against the premium for the Exchange-
                participating health benefits plan in which the 
                individual is enrolled; and
                    (B) an affordability cost-sharing credit under 
                section 344 to be applied as a reduction of the cost-
                sharing otherwise applicable to such plan; and
            (2) the Commissioner shall pay the QHBP offering entity 
        that offers such plan from the Health Insurance Exchange Trust 
        Fund the aggregate amount of affordability credits for all 
        affordable credit eligible individuals enrolled in such plan.
    (b) Application.--
            (1) In general.--An Exchange eligible individual may apply 
        to the Commissioner through the Health Insurance Exchange or 
        through another entity under an arrangement made with the 
        Commissioner, in a form and manner specified by the 
        Commissioner. The Commissioner through the Health Insurance 
        Exchange or through another public entity under an arrangement 
        made with the Commissioner shall make a determination as to 
        eligibility of an individual for affordability credits under 
        this subtitle. The Commissioner shall establish a process 
        whereby, on the basis of information otherwise available, 
        individuals may be deemed to be affordable credit eligible 
        individuals. In carrying this subtitle, the Commissioner shall 
        establish effective methods that ensure that individuals with 
        limited English proficiency are able to apply for affordability 
        credits.
            (2) Use of state medicaid agencies.--If the Commissioner 
        determines that a State Medicaid agency has the capacity to 
        make a determination of eligibility for affordability credits 
        under this subtitle and under the same standards as used by the 
        Commissioner, under the Medicaid memorandum of understanding 
        under section 305(e)(2)--
                    (A) the State Medicaid agency is authorized to 
                conduct such determinations for any Exchange-eligible 
                individual who requests such a determination; and
                    (B) the Commissioner shall reimburse the State 
                Medicaid agency for the costs of conducting such 
                determinations.
            (3) Medicaid screen and enroll obligation.--In the case of 
        an application made under paragraph (1), there shall be a 
        determination of whether the individual is a Medicaid-eligible 
        individual. If the individual is determined to be so eligible, 
        the Commissioner, through the Medicaid memorandum of 
        understanding under section 305(e)(2), shall provide for the 
        enrollment of the individual under the State Medicaid plan in 
        accordance with such Medicaid memorandum of understanding. In 
        the case of such an enrollment, the State shall provide for the 
        same periodic redetermination of eligibility under Medicaid as 
        would otherwise apply if the individual had directly applied 
        for medical assistance to the State Medicaid agency.
            (4) Application and verification of requirement of 
        citizenship or lawful presence in the united states.--
                    (A) Requirement.--No individual shall be an 
                affordable credit eligible individual (as defined in 
                section 342(a)(1)) unless the individual is a citizen 
                or national of the United States or is lawfully present 
                in a State in the United States (other than as a 
                nonimmigrant described in a subparagraph (excluding 
                subparagraphs (K), (T), (U), and (V)) of section 
                101(a)(15) of the Immigration and Nationality Act).
                    (B) Declaration of citizenship or lawful 
                immigration status.--No individual shall be an 
                affordable credit eligible individual unless there has 
                been a declaration made, in a form and manner specified 
                by the Health Choices Commissioner similar to the 
                manner required under section 1137(d)(1) of the Social 
                Security Act and under penalty of perjury, that the 
                individual--
                            (i) is a citizen or national of the United 
                        States; or
                            (ii) is not such a citizen or national but 
                        is lawfully present in a State in the United 
                        States (other than as a nonimmigrant described 
                        in a subparagraph (excluding subparagraphs (K), 
                        (T), (U), and (V)) of section 101(a)(15) of the 
                        Immigration and Nationality Act).
                Such declaration shall be verified in accordance with 
                subparagraph (C) or (D), as the case may be.
                    (C) Verification process for citizens.--
                            (i) In general.--In the case of an 
                        individual making the declaration described in 
                        subparagraph (B)(i), subject to clause (ii), 
                        section 1902(ee) of the Social Security Act 
                        shall apply to such declaration in the same 
                        manner as such section applies to a declaration 
                        described in paragraph (1) of such section.
                            (ii) Special rules.--In applying section 
                        1902(ee) of such Act under clause (i)--
                                    (I) any reference in such section 
                                to a State is deemed a reference to the 
                                Commissioner (or other public entity 
                                making the eligibility determination);
                                    (II) any reference to medical 
                                assistance or enrollment under a State 
                                plan is deemed a reference to provision 
                                of affordability credits under this 
                                subtitle;
                                    (III) a reference to a newly 
                                enrolled individual under paragraph 
                                (2)(A) of such section is deemed a 
                                reference to an individual newly in 
                                receipt of an affordability credit 
                                under this subtitle;
                                    (IV) approval by the Secretary 
                                shall not be required in applying 
                                paragraph (2)(B)(ii) of such section;
                                    (V) paragraph (3) of such section 
                                shall not apply; and
                                    (VI) before the end of Y2, the 
                                Health Choices Commissioner, in 
                                consultation with the Commissioner of 
                                Social Security, may extend the periods 
                                specified in paragraph (1)(B)(ii) of 
                                such section.
                    (D) Verification process for noncitizens.--
                            (i) In general.--In the case of an 
                        individual making the declaration described in 
                        subparagraph (B)(ii), subject to clause (ii), 
                        the verification procedures of paragraphs (2) 
                        through (5) of section 1137(d) of the Social 
                        Security Act shall apply to such declaration in 
                        the same manner as such procedures apply to a 
                        declaration described in paragraph (1) of such 
                        section.
                            (ii) Special rules.--In applying such 
                        paragraphs of section 1137(d) of such Act under 
                        clause (i)--
                                    (I) any reference in such 
                                paragraphs to a State is deemed a 
                                reference to the Health Choices 
                                Commissioner; and
                                    (II) any reference to benefits 
                                under a program is deemed a reference 
                                to affordability credits under this 
                                subtitle.
                            (iii) Application to state-based 
                        exchanges.--In the case of the application of 
                        the verification process under this 
                        subparagraph to a State-based Health Insurance 
                        Exchange approved under section 308, section 
                        1137(e) of such Act shall apply to the Health 
                        Choices Commissioner in relation to the State.
                    (E) Annual reports.--The Health Choices 
                Commissioner shall report to Congress annually on the 
                number of applicants for affordability credits under 
                this subtitle, their citizenship or immigration status, 
                and the disposition of their applications. Such report 
                shall be made publicly available and shall include 
                information on--
                            (i) the number of applicants whose 
                        declaration of citizenship or immigration 
                        status, name, or social security account number 
                        was not consistent with records maintained by 
                        the Commissioner of Social Security or the 
                        Department of Homeland Security and, of such 
                        applicants, the number who contested the 
                        inconsistency and sought to document their 
                        citizenship or immigration status, name, or 
                        social security account number or to correct 
                        the information maintained in such records and, 
                        of those, the results of such contestations; 
                        and
                            (ii) the administrative costs of conducting 
                        the status verification under this paragraph.
                    (F) GAO report.--Not later than the end of Y2, the 
                Comptroller General of the United States shall submit 
                to the Committee on Ways and Means, the Committee on 
                Energy and Commerce, the Committee on Education and 
                Labor, and the Committee on the Judiciary of the House 
                of Representatives and the Committee on Finance, the 
                Committee on Health, Education, Labor, and Pensions, 
                and the Committee on the Judiciary of the Senate a 
                report examining the effectiveness of the citizenship 
                and immigration verification systems applied under this 
                paragraph. Such report shall include an analysis of the 
                following:
                            (i) The causes of erroneous determinations 
                        under such systems.
                            (ii) The effectiveness of the processes 
                        used in remedying such erroneous 
                        determinations.
                            (iii) The impact of such systems on 
                        individuals, health care providers, and Federal 
                        and State agencies, including the effect of 
                        erroneous determinations under such systems.
                            (iv) The effectiveness of such systems in 
                        preventing ineligible individuals from 
                        receiving for affordability credits.
                            (v) The characteristics of applicants 
                        described in subparagraph (E)(i).
                    (G) Prohibition of database.--Nothing in this 
                paragraph or the amendments made by paragraph (6) shall 
                be construed as authorizing the Health Choices 
                Commissioner or the Commissioner of Social Security to 
                establish a database of information on citizenship or 
                immigration status.
                    (H) Initial funding.--
                            (i) In general.--Out of any funds in the 
                        Treasury not otherwise appropriated, there is 
                        appropriated to the Commissioner of Social 
                        Security $30,000,000, to be available without 
                        fiscal year limit to carry out this paragraph 
                        and section 205(v) of the Social Security Act.
                            (ii) Funding limitation.--In no case shall 
                        funds from the Social Security Administration's 
                        Limitation on Administrative Expenses be used 
                        to carry out activities related to this 
                        paragraph or section 205(v) of the Social 
                        Security Act.
            (5) Agreement with social security commissioner.--
                    (A) In general.--The Health Choices Commissioner 
                shall enter into and maintain an agreement described in 
                section 205(v)(2) of the Social Security Act with the 
                Commissioner of Social Security.
                    (B) Funding.--The agreement entered into under 
                subparagraph (A) shall, for each fiscal year (beginning 
                with fiscal year 2013)--
                            (i) provide funds to the Commissioner of 
                        Social Security for the full costs of the 
                        responsibilities of the Commissioner of Social 
                        Security under paragraph (4), including--
                                    (I) acquiring, installing, and 
                                maintaining technological equipment and 
                                systems necessary for the fulfillment 
                                of the responsibilities of the 
                                Commissioner of Social Security under 
                                paragraph (4), but only that portion of 
                                such costs that are attributable to 
                                such responsibilities; and
                                    (II) responding to individuals who 
                                contest with the Commissioner of Social 
                                Security a reported inconsistency with 
                                records maintained by the Commissioner 
                                of Social Security or the Department of 
                                Homeland Security relating to 
                                citizenship or immigration status, 
                                name, or social security account number 
                                under paragraph (4);
                            (ii) based on an estimating methodology 
                        agreed to by the Commissioner of Social 
                        Security and the Health Choices Commissioner, 
                        provide such funds, within 10 calendar days of 
                        the beginning of the fiscal year for the first 
                        quarter and in advance for all subsequent 
                        quarters in that fiscal year; and
                            (iii) provide for an annual accounting and 
                        reconciliation of the actual costs incurred and 
                        the funds provided under the agreement.
                    (C) Review of accounting.--The annual accounting 
                and reconciliation conducted pursuant to subparagraph 
                (B)(iii) shall be reviewed by the Inspectors General of 
                the Social Security Administration and the Health 
                Choices Administration, including an analysis of 
                consistency with the requirements of paragraph (4).
                    (D) Contingency.--In any case in which agreement 
                with respect to the provisions required under 
                subparagraph (B) for any fiscal year has not been 
                reached as of the first day of such fiscal year, the 
                latest agreement with respect to such provisions shall 
                be deemed in effect on an interim basis for such fiscal 
                year until such time as an agreement relating to such 
                provisions is subsequently reached. In any case in 
                which an interim agreement applies for any fiscal year 
                under this subparagraph, the Commissioner of Social 
                Security shall, not later than the first day of such 
                fiscal year, notify the appropriate Committees of the 
                Congress of the failure to reach the agreement with 
                respect to such provisions for such fiscal year. Until 
                such time as the agreement with respect to such 
                provisions has been reached for such fiscal year, the 
                Commissioner of Social Security shall, not later than 
                the end of each 90-day period after October 1 of such 
                fiscal year, notify such Committees of the status of 
                negotiations between such Commissioner and the Health 
                Choices Commissioner in order to reach such an 
                agreement.
                    (E) Application to public entities administering 
                affordability credits.--If the Health Choices 
                Commissioner provides for the conduct of verifications 
                under paragraph (4) through a public entity, the Health 
                Choices Commissioner shall require the public entity to 
                enter into an agreement with the Commissioner of Social 
                Security which provides the same terms as the agreement 
                described in this paragraph (and section 205(v) of the 
                Social Security Act) between the Health Choices 
                Commissioner and the Commissioner of Social Security, 
                except that the Health Choices Commissioner shall be 
                responsible for providing funds for the Commissioner of 
                Social Security in accordance with subparagraphs (B) 
                through (D).
            (6) Amendments to social security act.--
                    (A) Coordination of information between social 
                security administration and health choices 
                administration.--
                            (i) In general.--Section 205 of the Social 
                        Security Act (42 U.S.C. 405) is amended by 
                        adding at the end the following new subsection:

    ``Coordination of Information With Health Choices Administration

    ``(v)(1) The Health Choices Commissioner may collect and use the 
names and social security account numbers of individuals as required to 
provide for verification of citizenship under subsection (b)(4)(C) of 
section 341 of the Affordable Health Care for America Act in connection 
with determinations of eligibility for affordability credits under such 
section.
    ``(2)(A) The Commissioner of Social Security shall enter into and 
maintain an agreement with the Health Choices Commissioner for the 
purpose of establishing, in compliance with the requirements of section 
1902(ee) as applied pursuant to section 341(b)(4)(C) of the Affordable 
Health Care for America Act, a program for verifying information 
required to be collected by the Health Choices Commissioner under such 
section 341(b)(4)(C).
    ``(B) The agreement entered into pursuant to subparagraph (A) shall 
include such safeguards as are necessary to ensure the maintenance of 
confidentiality of any information disclosed for purposes of verifying 
information described in subparagraph (A) and to provide procedures for 
permitting the Health Choices Commissioner to use the information for 
purposes of maintaining the records of the Health Choices 
Administration.
    ``(C) The agreement entered into pursuant to subparagraph (A) shall 
provide that information provided by the Commissioner of Social 
Security to the Health Choices Commissioner pursuant to the agreement 
shall be provided at such time, at such place, and in such manner as 
the Commissioner of Social Security determines appropriate.
    ``(D) Information provided by the Commissioner of Social Security 
to the Health Choices Commissioner pursuant to an agreement entered 
into pursuant to subparagraph (A) shall be considered as strictly 
confidential and shall be used only for the purposes described in this 
paragraph and for carrying out such agreement. Any officer or employee 
or former officer or employee of the Health Choices Commissioner, or 
any officer or employee or former officer or employee of a contractor 
of the Health Choices Commissioner, who, without the written authority 
of the Commissioner of Social Security, publishes or communicates any 
information in such individual's possession by reason of such 
employment or position as such an officer shall be guilty of a felony 
and, upon conviction thereof, shall be fined or imprisoned, or both, as 
described in section 208.
    ``(3) The agreement entered into under paragraph (2) shall provide 
for funding to the Commissioner of Social Security consistent with 
section 341(b)(5) of Affordable Health Care for America Act.
    ``(4) This subsection shall apply in the case of a public entity 
that conducts verifications under section 341(b)(4) of the Affordable 
Health Care for America Act and the obligations of this subsection 
shall apply to such an entity in the same manner as such obligations 
apply to the Health Choices Commissioner when such Commissioner is 
conducting such verifications.''.
                            (ii) Conforming amendment.--Section 
                        205(c)(2)(C) of such Act (42 U.S.C. 
                        405(c)(2)(C)) is amended by adding at the end 
                        the following new clause:
    ``(x) For purposes of the administration of the verification 
procedures described in section 341(b)(4) of the Affordable Health Care 
for America Act, the Health Choices Commissioner may collect and use 
social security account numbers as provided for in section 
205(v)(1).''.
                    (B) Improving the integrity of data and 
                effectiveness of save.--Section 1137(d) of the Social 
                Security Act (42 U.S.C. 1320b-7(d)) is amended by 
                adding at the end the following new paragraphs:
    ``(6)(A) With respect to the use by any agency of the system 
described in subsection (b) by programs specified in subsection (b) or 
any other use of such system, the U.S. Citizenship and Immigration 
Services and any other agency charged with the management of the system 
shall establish appropriate safeguards necessary to protect and improve 
the integrity and accuracy of data relating to individuals by--
            ``(i) establishing a process though which such individuals 
        are provided access to, and the ability to amend, correct, and 
        update, their own personally identifiable information contained 
        within the system;
            ``(ii) providing a written response, without undue delay, 
        to any individual who has made such a request to amend, 
        correct, or update such individual's own personally 
        identifiable information contained within the system; and
            ``(iii) developing a written notice for user agencies to 
        provide to individuals who are denied a benefit due to a 
        determination of ineligibility based on a final verification 
        determination under the system.
    ``(B) The notice described in subparagraph (A)(ii) shall include--
            ``(i) information about the reason for such notice;
            ``(ii) a description of the right of the recipient of the 
        notice under subparagraph (A)(i) to contest such notice;
            ``(iii) a description of the right of the recipient under 
        subparagraph (A)(i) to access and attempt to amend, correct, 
        and update the recipient's own personally identifiable 
        information contained within records of the system described in 
        paragraph (3); and
            ``(iv) instructions on how to contest such notice and 
        attempt to correct records of such system relating to the 
        recipient, including contact information for relevant 
        agencies.''.
                    (C) Streamlining administration of verification 
                process for united states citizens.--Section 
                1902(ee)(2) of the Social Security Act (42 U.S.C. 
                1396a(ee)(2)) is amended by adding at the end the 
                following:
    ``(D) In carrying out the verification procedures under this 
subsection with respect to a State, if the Commissioner of Social 
Security determines that the records maintained by such Commissioner 
are not consistent with an individual's allegation of United States 
citizenship, pursuant to procedures which shall be established by the 
State in coordination with the Commissioner of Social Security, the 
Secretary of Homeland Security, and the Secretary of Health and Human 
Services--
            ``(i) the Commissioner of Social Security shall inform the 
        State of the inconsistency;
            ``(ii) upon being so informed of the inconsistency, the 
        State shall submit the information on the individual to the 
        Secretary of Homeland Security for a determination of whether 
        the records of the Department of Homeland Security indicate 
        that the individual is a citizen;
            ``(iii) upon making such determination, the Department of 
        Homeland Security shall inform the State of such determination; 
        and
            ``(iv) information provided by the Commissioner of Social 
        Security shall be considered as strictly confidential and shall 
        only be used by the State and the Secretary of Homeland 
        Security for the purposes of such verification procedures.
    ``(E) Verification of status eligibility pursuant to the procedures 
established under this subsection shall be deemed a verification of 
status eligibility for purposes of this title, title XXI, and 
affordability credits under section 341(b)(4) of the Affordable Health 
Care for America Act, regardless of the program in which the individual 
is applying for benefits.''.
    (c) Use of Affordability Credits.--
            (1) In general.--In Y1 and Y2 an affordable credit eligible 
        individual may use an affordability credit only with respect to 
        a basic plan.
            (2) Flexibility in plan enrollment authorized.--Beginning 
        with Y3, the Commissioner shall establish a process to allow an 
        affordability premium credit under section 343, but not the 
        affordability cost-sharing credit under section 344, to be used 
        for enrollees in enhanced or premium plans. In the case of an 
        affordable credit eligible individual who enrolls in an 
        enhanced or premium plan, the individual shall be responsible 
        for any difference between the premium for such plan and the 
        affordability credit amount otherwise applicable if the 
        individual had enrolled in a basic plan.
            (3) Prohibition of use of public funds for abortion 
        coverage.--An affordability credit may not be used for payment 
        for services described in section 222(d)(4)(A).
    (d) Access to Data.--In carrying out this subtitle, the 
Commissioner shall request from the Secretary of the Treasury 
consistent with section 6103 of the Internal Revenue Code of 1986 such 
information as may be required to carry out this subtitle.
    (e) No Cash Rebates.--In no case shall an affordable credit 
eligible individual receive any cash payment as a result of the 
application of this subtitle.

SEC. 342. AFFORDABLE CREDIT ELIGIBLE INDIVIDUAL.

    (a) Definition.--
            (1) In general.--For purposes of this division, the term 
        ``affordable credit eligible individual'' means, subject to 
        subsection (b) and section 346, an individual who is lawfully 
        present in a State in the United States (other than as a 
        nonimmigrant described in a subparagraph (excluding 
        subparagraphs (K), (T), (U), and (V)) of section 101(a)(15) of 
        the Immigration and Nationality Act)--
                    (A) who is enrolled under an Exchange-participating 
                health benefits plan and is not enrolled under such 
                plan as an employee (or dependent of an employee) 
                through an employer qualified health benefits plan that 
                meets the requirements of section 412;
                    (B) with modified adjusted gross income below 400 
                percent of the Federal poverty level for a family of 
                the size involved;
                    (C) who is not a Medicaid eligible individual, 
                other than an individual during a transition period 
                under section 302(d)(3)(B)(ii); and
                    (D) subject to paragraph (3), who is not enrolled 
                in acceptable coverage (other than an Exchange-
                participating health benefits plan).
            (2) Treatment of family.--Except as the Commissioner may 
        otherwise provide, members of the same family who are 
        affordable credit eligible individuals shall be treated as a 
        single affordable credit individual eligible for the applicable 
        credit for such a family under this subtitle.
            (3) Special rule for indians.--Subparagraph (D) of 
        paragraph (1) shall not apply to an individual who has coverage 
        that is treated as acceptable coverage for purposes of section 
        59B(d)(2) of the Internal Revenue Code of 1986 but is not 
        treated as acceptable coverage for purposes of this division.
    (b) Limitations on Employee and Dependent Disqualification.--
            (1) In general.--Subject to paragraph (2), the term 
        ``affordable credit eligible individual'' does not include a 
        full-time employee of an employer if the employer offers the 
        employee coverage (for the employee and dependents) as a full-
        time employee under a group health plan if the coverage and 
        employer contribution under the plan meet the requirements of 
        section 412.
            (2) Exceptions.--
                    (A) For certain family circumstances.--The 
                Commissioner shall establish such exceptions and 
                special rules in the case described in paragraph (1) as 
                may be appropriate in the case of a divorced or 
                separated individual or such a dependent of an employee 
                who would otherwise be an affordable credit eligible 
                individual.
                    (B) For unaffordable employer coverage.--Beginning 
                in Y2, in the case of full-time employees for which the 
                cost of the employee premium for coverage under a group 
                health plan would exceed 12 percent of current modified 
                adjusted gross income (determined by the Commissioner 
                on the basis of verifiable documentation), paragraph 
                (1) shall not apply.
    (c) Income Defined.--
            (1) In general.--In this title, the term ``income'' means 
        modified adjusted gross income (as defined in section 59B of 
        the Internal Revenue Code of 1986).
            (2) Study of income disregards.--The Commissioner shall 
        conduct a study that examines the application of income 
        disregards for purposes of this subtitle. Not later than the 
        first day of Y2, the Commissioner shall submit to Congress a 
        report on such study and shall include such recommendations as 
        the Commissioner determines appropriate.
    (d) Clarification of Treatment of Affordability Credits.--
Affordability credits under this subtitle shall not be treated, for 
purposes of title IV of the Personal Responsibility and Work 
Opportunity Reconciliation Act of 1996, to be a benefit provided under 
section 403 of such title.

SEC. 343. AFFORDABILITY PREMIUM CREDIT.

    (a) In General.--The affordability premium credit under this 
section for an affordable credit eligible individual enrolled in an 
Exchange-participating health benefits plan is in an amount equal to 
the amount (if any) by which the reference premium amount specified in 
subsection (c), exceeds the affordable premium amount specified in 
subsection (b) for the individual, except that in no case shall the 
affordable premium credit exceed the premium for the plan.
    (b) Affordable Premium Amount.--
            (1) In general.--The affordable premium amount specified in 
        this subsection for an individual for the annual premium in a 
        plan year shall be equal to the product of--
                    (A) the premium percentage limit specified in 
                paragraph (2) for the individual based upon the 
                individual's modified adjusted gross income for the 
                plan year; and
                    (B) the individual's modified adjusted gross income 
                for such plan year.
            (2) Premium percentage limits based on table.--The 
        Commissioner shall establish premium percentage limits so that 
        for individuals whose modified adjusted gross income is within 
        an income tier specified in the table in subsection (d) such 
        percentage limits shall increase, on a sliding scale in a 
        linear manner, from the initial premium percentage to the final 
        premium percentage specified in such table for such income 
        tier.
    (c) Reference Premium Amount.--The reference premium amount 
specified in this subsection for a plan year for an individual in a 
premium rating area is equal to the average premium for the 3 basic 
plans in the area for the plan year with the lowest premium levels. In 
computing such amount the Commissioner may exclude plans with extremely 
limited enrollments.
    (d) Table of Premium Percentage Limits, Actuarial Value 
Percentages, and Out-of-pocket Limits for Y1 Based on Income Tier.--
            (1) In general.--For purposes of this subtitle, subject to 
        paragraph (3) and section 346, the table specified in this 
        subsection is as follows:

 
    In the case of modified
     adjusted gross income                                                                           The out-of-
  (expressed as a percent of     The initial premium     The final premium     The actuarial value      pocket
   FPL) within the following       percentage is--        percentage is--        percentage is--      limit for
         income tier:                                                                                  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
 

            (2) Special rules.--For purposes of applying the table 
        under paragraph (1):
                    (A) For lowest level of income.--In the case of an 
                individual with income that does not exceed 133 percent 
                of FPL, the individual shall be considered to have 
                income that is 133 percent of FPL.
                    (B) Application of higher actuarial value 
                percentage at tier transition points.--If two actuarial 
                value percentages may be determined with respect to an 
                individual, the actuarial value percentage shall be the 
                higher of such percentages.
            (3) Indexing.--For years after Y1, the Commissioner shall 
        adjust the initial and final premium percentages to maintain 
        the ratio of governmental to enrollee shares of premiums over 
        time, for each income tier identified in the table in paragraph 
        (1).

SEC. 344. AFFORDABILITY COST-SHARING CREDIT.

    (a) In General.--The affordability cost-sharing credit under this 
section for an affordable credit eligible individual enrolled in an 
Exchange-participating health benefits plan is in the form of the cost-
sharing reduction described in subsection (b) provided under this 
section for the income tier in which the individual is classified based 
on the individual's modified adjusted gross income.
    (b) Cost-sharing Reductions.--The Commissioner shall specify a 
reduction in cost-sharing amounts and the annual limitation on cost-
sharing specified in section 222(c)(2)(B) under a basic plan for each 
income tier specified in the table under section 343(d), with respect 
to a year, in a manner so that, as estimated by the Commissioner--
            (1) the actuarial value of the coverage with such reduced 
        cost-sharing amounts (and the reduced annual cost-sharing 
        limit) is equal to the actuarial value percentage (specified in 
        the table under section 343(d) for the income tier involved) of 
        the full actuarial value if there were no cost-sharing imposed 
        under the plan; and
            (2) the annual limitation on cost-sharing specified in 
        section 222(c)(2)(B) is reduced to a level that does not exceed 
        the maximum out-of-pocket limit specified in subsection (c).
    (c) Maximum Out-of-pocket Limit.--
            (1) In general.--Subject to paragraph (2), the maximum out-
        of-pocket limit specified in this subsection for an individual 
        within an income tier--
                    (A) for individual coverage--
                            (i) for Y1 is the out-of-pocket limit for 
                        Y1 specified in subsection (c) in the table 
                        under section 343(d) for the income tier 
                        involved; or
                            (ii) for a subsequent year is such out-of-
                        pocket limit for the previous year under this 
                        subparagraph increased (rounded to the nearest 
                        $10) for each subsequent year by the percentage 
                        increase in the enrollment-weighted average of 
                        premium increases for basic plans applicable to 
                        such year; or
                    (B) for family coverage is twice the maximum out-
                of-pocket limit under subparagraph (A) for the year 
                involved.
            (2) Adjustment.--The Commissioner shall adjust the maximum 
        out-of-pocket limits under paragraph (1) to ensure that such 
        limits meet the actuarial value percentage specified in the 
        table under section 343(d) for the income tier involved.
    (d) Determination and Payment of Cost-sharing Affordability 
Credit.--In the case of an affordable credit eligible individual in a 
tier enrolled in an Exchange-participating health benefits plan offered 
by a QHBP offering entity, the Commissioner shall provide for payment 
to the offering entity of an amount equivalent to the increased 
actuarial value of the benefits under the plan provided under section 
303(c)(2)(B) resulting from the reduction in cost-sharing described in 
subsections (b) and (c).

SEC. 345. INCOME DETERMINATIONS.

    (a) In General.--In applying this subtitle for an affordability 
credit for an individual for a plan year, the individual's income shall 
be the income (as defined in section 342(c)) for the individual for the 
most recent taxable year (as determined in accordance with rules of the 
Commissioner). The Federal poverty level applied shall be such level in 
effect as of the date of the application.
    (b) Program Integrity; Income Verification Procedures.--
            (1) Program integrity.--The Commissioner shall take such 
        steps as may be appropriate to ensure the accuracy of 
        determinations and redeterminations under this subtitle.
            (2) Income verification.--
                    (A) In general.--Upon an initial application of an 
                individual for an affordability credit under this 
                subtitle (or in applying section 342(b)) or upon an 
                application for a change in the affordability credit 
                based upon a significant change in modified adjusted 
                gross income described in subsection (c)(1)--
                            (i) the Commissioner shall request from the 
                        Secretary of the Treasury the disclosure to the 
                        Commissioner of such information as may be 
                        permitted to verify the information contained 
                        in such application; and
                            (ii) the Commissioner shall use the 
                        information so disclosed to verify such 
                        information.
                    (B) Alternative procedures.--The Commissioner shall 
                establish procedures for the verification of income for 
                purposes of this subtitle if no income tax return is 
                available for the most recent completed tax year.
    (c) Special Rules.--
            (1) Changes in income as a percent of fpl.--In the case 
        that an individual's income (expressed as a percentage of the 
        Federal poverty level for a family of the size involved) for a 
        plan year is expected (in a manner specified by the 
        Commissioner) to be significantly different from the income (as 
        so expressed) used under subsection (a), the Commissioner shall 
        establish rules requiring an individual to report, consistent 
        with the mechanism established under paragraph (2), significant 
        changes in such income (including a significant change in 
        family composition) to the Commissioner and requiring the 
        substitution of such income for the income otherwise 
        applicable.
            (2) Reporting of significant changes in income.--The 
        Commissioner shall establish rules under which an individual 
        determined to be an affordable credit eligible individual would 
        be required to inform the Commissioner when there is a 
        significant change in the modified adjusted gross income of the 
        individual (expressed as a percentage of the FPL for a family 
        of the size involved) and of the information regarding such 
        change. Such mechanism shall provide for guidelines that 
        specify the circumstances that qualify as a significant change, 
        the verifiable information required to document such a change, 
        and the process for submission of such information. If the 
        Commissioner receives new information from an individual 
        regarding the modified adjusted gross income of the individual, 
        the Commissioner shall provide for a redetermination of the 
        individual's eligibility to be an affordable credit eligible 
        individual.
            (3) Transition for chip.--In the case of a child described 
        in section 302(d)(2), the Commissioner shall establish rules 
        under which the modified adjusted gross income of the child is 
        deemed to be no greater than the family income of the child as 
        most recently determined before Y1 by the State under title XXI 
        of the Social Security Act.
            (4) Study of geographic variation in application of fpl.--
                    (A) In general.--The Secretary of Health and Human 
                Services shall conduct a study to examine the 
                feasibility and implication of adjusting the 
                application of the Federal poverty level under this 
                subtitle for different geographic areas so as to 
                reflect the variations in cost-of-living among 
                different areas within the United States. If the 
                Secretary determines that an adjustment is feasible, 
                the study should include a methodology to make such an 
                adjustment. Not later than the first day of Y1, the 
                Secretary shall submit to Congress a report on such 
                study and shall include such recommendations as the 
                Secretary determines appropriate.
                    (B) Inclusion of territories.--
                            (i) In general.--The Secretary shall ensure 
                        that the study under subparagraph (A) covers 
                        the territories of the United States and that 
                        special attention is paid to the disparity that 
                        exists among poverty levels and the cost of 
                        living in such territories and to the impact of 
                        such disparity on efforts to expand health 
                        coverage and ensure health care.
                            (ii) Territories defined.--In this 
                        subparagraph, the term ``territories of the 
                        United States'' includes the Commonwealth of 
                        Puerto Rico, the United States Virgin Islands, 
                        Guam, the Northern Mariana Islands, and any 
                        other territory or possession of the United 
                        States.
    (d) Penalties for Misrepresentation.--In the case of an individual 
who intentionally misrepresents modified adjusted gross income or the 
individual fails (without regard to intent) to disclose to the 
Commissioner a significant change in modified adjusted gross income 
under subsection (c) in a manner that results in the individual 
becoming an affordable credit eligible individual when the individual 
is not or in the amount of the affordability credit exceeding the 
correct amount--
            (1) the individual is liable for repayment of the amount of 
        the improper affordability credit; and
            (2) in the case of such an intentional misrepresentation or 
        other egregious circumstances specified by the Commissioner, 
        the Commissioner may impose an additional penalty.

SEC. 346. SPECIAL RULES FOR APPLICATION TO TERRITORIES.

    (a) One-time Election for Treatment and Application of Funding.--
            (1) In general.--A territory may elect, in a form and 
        manner specified by the Commissioner in consultation with the 
        Secretary of Health and Human Services and the Secretary of the 
        Treasury and not later than October 1, 2012, either--
                    (A) to be treated as a State for purposes of 
                applying this title and title II; or
                    (B) not to be so treated but instead, to have the 
                dollar limitation otherwise applicable to the territory 
                under subsections (f) and (g) of section 1108 of the 
                Social Security Act (42 U.S.C. 1308) for a fiscal year 
                increased by a dollar amount equivalent to the cap 
                amount determined under subsection (c)(2) for the 
                territory as applied by the Secretary for the fiscal 
                year involved.
            (2) Conditions for acceptance.--The Commissioner has the 
        nonreviewable authority to accept or reject an election 
        described in paragraph (1)(A). Any such acceptance is--
                    (A) contingent upon entering into an agreement 
                described in subsection (b) between the Commissioner 
                and the territory and subsection (c); and
                    (B) subject to the approval of the Secretary of 
                Health and Human Services and the Secretary of the 
                Treasury and subject to such other terms and conditions 
                as the Commissioner, in consultation with such 
                Secretaries, may specify.
            (3) Default rule.--A territory failing to make such an 
        election (or having an election under paragraph (1)(A) not 
        accepted under paragraph (2)) shall be treated as having made 
        the election described in paragraph (1)(B).
    (b) Agreement for Substitution of Percentages for Affordability 
Credits.--
            (1) Negotiation.--In the case of a territory making an 
        election under subsection (a)(1)(A) (in this section referred 
        to as an ``electing territory'') , the Commissioner, in 
        consultation with the Secretaries of Health and Human Services 
        and the Treasury, shall enter into negotiations with the 
        government of such territory so that, before Y1, there is an 
        agreement reached between the parties on the percentages that 
        shall be applied under paragraph (2) for that territory. The 
        Commissioner shall not enter into such an agreement unless--
                    (A) payments made under this subtitle with respect 
                to residents of the territory are consistent with the 
                cap established under subsection (c) for such territory 
                and with subsection (d); and
                    (B) the requirements of paragraphs (3) and (4) are 
                met.
            (2) Application of substitute percentages and dollar 
        amounts.--In the case of an electing territory, there shall be 
        substituted in section 342(a)(1)(B) and in the table in section 
        341(d)(1) for 400 percent, 133 percent, and other percentages 
        and dollar amounts specified in such table, such respective 
        percentages and dollar amounts as are established under the 
        agreement under paragraph (1) consistent with the following:
                    (A) No income gap between medicaid and 
                affordability credits.--The substituted percentages 
                shall be specified in a manner so as to prevent any gap 
                in coverage for individuals between income level at 
                which medical assistance is available through Medicaid 
                and the income level at which affordability credits are 
                available.
                    (B) Adjustment for out-of-pocket responsibility for 
                premiums and cost-sharing in relation to income.--The 
                substituted percentages of FPL for income tiers under 
                such table shall be specified in a manner so that--
                            (i) affordable credit eligible individuals 
                        residing in the territory bear the same out-of-
                        pocket responsibility for premiums and cost-
                        sharing in relation to average income for 
                        residents in that territory, as
                            (ii) the out-of-pocket responsibility for 
                        premiums and cost-sharing for affordable credit 
                        eligible individuals residing in the 50 States 
                        or the District of Columbia in relation to 
                        average income for such residents.
            (3) Special rules with respect to application of tax and 
        penalty provisions.--The electing territory shall enact one or 
        more laws under which provisions similar to the following 
        provisions apply with respect to such territory:
                    (A) Section 59B of the Internal Revenue Code of 
                1986, except that any resident of the territory who is 
                not an affordable credit eligible individual but who 
                would be an affordable credit eligible individual if 
                such resident were a resident of one of the 50 States 
                (and any qualifying child residing with such 
                individual) may be treated as covered by acceptable 
                coverage.
                    (B) Section 4980H of the Internal Revenue Code of 
                1986 and section 502(c)(11) of the Employee Retirement 
                Income Security Act of 1974.
                    (C) Section 3121(c) of the Internal Revenue Code of 
                1986.
            (4) Implementation of insurance reform and consumer 
        protection requirements.--The electing territory shall enact 
        and implement such laws and regulations as may be required to 
        apply the requirements of title II with respect to health 
        insurance coverage offered in the territory.
    (c) Cap on Additional Expenditures.--
            (1) In general.--In entering into an agreement with an 
        electing territory under subsection (b), the Commissioner shall 
        ensure that the aggregate expenditures under this subtitle with 
        respect to residents of such territory during the period 
        beginning with Y1 and ending with 2019 will not exceed the cap 
        amount specified in paragraph (2) for such territory. The 
        Commissioner shall adjust from time to time the percentages 
        applicable under such agreement as needed in order to carry out 
        the previous sentence.
            (2) Cap amount.--
                    (A) In general.--The cap amount specified in this 
                paragraph--
                            (i) for Puerto Rico is $3,700,000,000 
                        increased by the amount (if any) elected under 
                        subparagraph (C); or
                            (ii) for another territory is the portion 
                        of $300,000,000 negotiated for such territory 
                        under subparagraph (B).
                    (B) Negotiation for certain territories.--The 
                Commissioner in consultation with the Secretary of 
                Health and Human Services shall negotiate with the 
                governments of the territories (other than Puerto Rico) 
                to allocate the amount specified in subparagraph 
                (A)(ii) among such territories.
                    (C) Optional supplementation for puerto rico.--
                            (i) In general.--Puerto Rico may elect, in 
                        a form and manner specified by the Secretary of 
                        Health and Human Services in consultation with 
                        the Commissioner to increase the dollar amount 
                        specified in subparagraph (A)(i) by up to 
                        $1,000,000,000.
                            (ii) Offset in medicaid cap.--If Puerto 
                        Rico makes the election described in clause 
                        (i), the Secretary shall decrease the dollar 
                        limitation otherwise applicable to Puerto Rico 
                        under subsections (f) and (g) of section 1108 
                        of the Social Security Act (42 U.S.C. 1308) for 
                        a fiscal year by the additional aggregate 
                        payments the Secretary estimates will be 
                        payable under this section for the fiscal year 
                        because of such election.
    (d) Limitation on Funding.--In no case shall this section 
(including the agreement under subsection (b)) permit--
            (1) the obligation of funds for expenditures under this 
        subtitle for periods beginning on or after January 1, 2020; or
            (2) any increase in the dollar limitation described in 
        subsection (a)(1)(B) for any portion of any fiscal year 
        occurring on or after such date.

SEC. 347. NO FEDERAL PAYMENT FOR UNDOCUMENTED ALIENS.

    Nothing in this subtitle shall allow Federal payments for 
affordability credits on behalf of individuals who are not lawfully 
present in the United States.

                    TITLE IV--SHARED RESPONSIBILITY

                 Subtitle A--Individual Responsibility

SEC. 401. INDIVIDUAL RESPONSIBILITY.

    For an individual's responsibility to obtain acceptable coverage, 
see section 59B of the Internal Revenue Code of 1986 (as added by 
section 501 of this Act).

                  Subtitle B--Employer Responsibility

           PART 1--HEALTH COVERAGE PARTICIPATION REQUIREMENTS

SEC. 411. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

    An employer meets the requirements of this section if such employer 
does all of the following:
            (1) Offer of coverage.--The employer offers each employee 
        individual and family coverage under a qualified health 
        benefits plan (or under a current employment-based health plan 
        (within the meaning of section 202(b))) in accordance with 
        section 412.
            (2) Contribution towards coverage.--If an employee accepts 
        such offer of coverage, the employer makes timely contributions 
        towards such coverage in accordance with section 412.
            (3) Contribution in lieu of coverage.--Beginning with Y2, 
        if an employee declines such offer but otherwise obtains 
        coverage in an Exchange-participating health benefits plan 
        (other than by reason of being covered by family coverage as a 
        spouse or dependent of the primary insured), the employer shall 
        make a timely contribution to the Health Insurance Exchange 
        with respect to each such employee in accordance with section 
        413.

SEC. 412. EMPLOYER RESPONSIBILITY TO CONTRIBUTE TOWARD EMPLOYEE AND 
              DEPENDENT COVERAGE.

    (a) In General.--An employer meets the requirements of this section 
with respect to an employee if the following requirements are met:
            (1) Offering of coverage.--The employer offers the coverage 
        described in section 411(1). In the case of an Exchange-
        eligible employer, the employer may offer such coverage either 
        through an Exchange-participating health benefits plan or other 
        than through such a plan.
            (2) Employer required contribution.--The employer timely 
        pays to the issuer of such coverage an amount not less than the 
        employer required contribution specified in subsection (b) for 
        such coverage.
            (3) Provision of information.--The employer provides the 
        Health Choices Commissioner, the Secretary of Labor, the 
        Secretary of Health and Human Services, and the Secretary of 
        the Treasury, as applicable, with such information as the 
        Commissioner may require to ascertain compliance with the 
        requirements of this section, including the following:
                    (A) The name, date, and employer identification 
                number of the employer.
                    (B) A certification as to whether the employer 
                offers to its full-time employees (and their 
                dependents) the opportunity to enroll in a qualified 
                health benefits plan or a current employment-based 
                health plan (within the meaning of section 202(b)).
                    (C) If the employer certifies that the employer did 
                offer to its full-time employees (and their dependents) 
                the opportunity to so enroll--
                            (i) the months during the calendar year for 
                        which such coverage was available; and
                            (ii) the monthly premium for the lowest 
                        cost option in each of the enrollment 
                        categories under each such plan offered to 
                        employees.
                    (D) The name, address, and TIN of each full-time 
                employee during the calendar year and the months (if 
                any) during which such employee (and any dependents) 
                were covered under any such plans.
            (4) Autoenrollment of employees.--The employer provides for 
        autoenrollment of the employee in accordance with subsection 
        (c).
This subsection shall supersede any law of a State which would prevent 
automatic payroll deduction of employee contributions to an employment-
based health plan.
    (b) Reduction of Employee Premiums Through Minimum Employer 
Contribution.--
            (1) Full-time employees.--The minimum employer contribution 
        described in this subsection for coverage of a full-time 
        employee (and, if any, the employee's spouse and qualifying 
        children (as defined in section 152(c) of the Internal Revenue 
        Code of 1986)) under a qualified health benefits plan (or 
        current employment-based health plan) is equal to--
                    (A) in case of individual coverage, not less than 
                72.5 percent of the applicable premium (as defined in 
                section 4980B(f)(4) of such Code, subject to paragraph 
                (2)) of the lowest cost plan offered by the employer 
                that is a qualified health benefits plan (or is such 
                current employment-based health plan); and
                    (B) in the case of family coverage which includes 
                coverage of such spouse and children, not less 65 
                percent of such applicable premium of such lowest cost 
                plan.
            (2) Applicable premium for exchange coverage.--In this 
        subtitle, the amount of the applicable premium of the lowest 
        cost plan with respect to coverage of an employee under an 
        Exchange-participating health benefits plan is the reference 
        premium amount under section 343(c) for individual coverage 
        (or, if elected, family coverage) for the premium rating area 
        in which the individual or family resides.
            (3) Minimum employer contribution for employees other than 
        full-time employees.--In the case of coverage for an employee 
        who is not a full-time employee, the amount of the minimum 
        employer contribution under this subsection shall be a 
        proportion (as determined in accordance with rules of the 
        Health Choices Commissioner, the Secretary of Labor, the 
        Secretary of Health and Human Services, and the Secretary of 
        the Treasury, as applicable) of the minimum employer 
        contribution under this subsection with respect to a full-time 
        employee that reflects the proportion of--
                    (A) the average weekly hours of employment of the 
                employee by the employer, to
                    (B) the minimum weekly hours specified by the 
                Commissioner for an employee to be a full-time 
                employee.
            (4) Salary reductions not treated as employer 
        contributions.--For purposes of this section, any contribution 
        on behalf of an employee with respect to which there is a 
        corresponding reduction in the compensation of the employee 
        shall not be treated as an amount paid by the employer.
    (c) Automatic Enrollment for Employer Sponsored Health Benefits.--
            (1) In general.--The requirement of this subsection with 
        respect to an employer and an employee is that the employer 
        automatically enroll such employee into the employment-based 
        health benefits plan for individual coverage under the plan 
        option with the lowest applicable employee premium.
            (2) Opt-out.--In no case may an employer automatically 
        enroll an employee in a plan under paragraph (1) if such 
        employee makes an affirmative election to opt out of such plan 
        or to elect coverage under an employment-based health benefits 
        plan offered by such employer. An employer shall provide an 
        employee with a 30-day period to make such an affirmative 
        election before the employer may automatically enroll the 
        employee in such a plan.
            (3) Notice requirements.--
                    (A) In general.--Each employer described in 
                paragraph (1) who automatically enrolls an employee 
                into a plan as described in such paragraph shall 
                provide the employees, within a reasonable period 
                before the beginning of each plan year (or, in the case 
                of new employees, within a reasonable period before the 
                end of the enrollment period for such a new employee), 
                written notice of the employees' rights and obligations 
                relating to the automatic enrollment requirement under 
                such paragraph. Such notice must be comprehensive and 
                understood by the average employee to whom the 
                automatic enrollment requirement applies.
                    (B) Inclusion of specific information.--The written 
                notice under subparagraph (A) must explain an 
                employee's right to opt out of being automatically 
                enrolled in a plan and in the case that more than one 
                level of benefits or employee premium level is offered 
                by the employer involved, the notice must explain which 
                level of benefits and employee premium level the 
                employee will be automatically enrolled in the absence 
                of an affirmative election by the employee.

SEC. 413. EMPLOYER CONTRIBUTIONS IN LIEU OF COVERAGE.

    (a) In General.--A contribution is made in accordance with this 
section with respect to an employee if such contribution is equal to an 
amount equal to 8 percent of the average wages paid by the employer 
during the period of enrollment (determined by taking into account all 
employees of the employer and in such manner as the Commissioner 
provides, including rules providing for the appropriate aggregation of 
related employers) but not to exceed the minimum employer contribution 
described in section 412(b)(1)(A). Any such contribution--
            (1) shall be paid to the Health Choices Commissioner for 
        deposit into the Health Insurance Exchange Trust Fund; and
            (2) shall not be applied against the premium of the 
        employee under the Exchange-participating health benefits plan 
        in which the employee is enrolled.
    (b) Special Rules for Small Employers.--
            (1) In general.--In the case of any employer who is a small 
        employer for any calendar year, subsection (a) shall be applied 
        by substituting the applicable percentage determined in 
        accordance with the following table for ``8 percent'':

If the annual payroll of such employer   The applicable percentage is:
 for the preceding calendar year:
  Does not exceed $500,000.............  0 percent
  Exceeds $500,000, but does not exceed  2 percent
   $585,000.
  Exceeds $585,000, but does not exceed  4 percent
   $670,000.
  Exceeds $670,000, but does not exceed  6 percent
   $750,000.
 

            (2) Small employer.--For purposes of this subsection, the 
        term ``small employer'' means any employer for any calendar 
        year if the annual payroll of such employer for the preceding 
        calendar year does not exceed $750,000.
            (3) Annual payroll.--For purposes of this paragraph, the 
        term ``annual payroll'' means, with respect to any employer for 
        any calendar year, the aggregate wages paid by the employer 
        during such calendar year.
            (4) Aggregation rules.--Related employers and predecessors 
        shall be treated as a single employer for purposes of this 
        subsection.

SEC. 414. AUTHORITY RELATED TO IMPROPER STEERING.

    The Health Choices Commissioner (in coordination with the Secretary 
of Labor, the Secretary of Health and Human Services, and the Secretary 
of the Treasury) shall have authority to set standards for determining 
whether employers or insurers are undertaking any actions to affect the 
risk pool within the Health Insurance Exchange by inducing individuals 
to decline coverage under a qualified health benefits plan (or current 
employment-based health plan (within the meaning of section 202(b)) 
offered by the employer and instead to enroll in an Exchange-
participating health benefits plan. An employer violating such 
standards shall be treated as not meeting the requirements of this 
section.

SEC. 415. IMPACT STUDY ON EMPLOYER RESPONSIBILITY REQUIREMENTS.

    (a) In General.--The Secretary of Labor shall conduct a study to 
examine the effect of the exemptions under section 512(a) and coverage 
thresholds under this division (in this section referred to 
collectively as "employer responsibility requirements)on employment-
based health plan sponsorship, generally and within specific 
industries, and the effect of such requirements and thresholds on 
employers, employment-based health plans, and employees in each 
industry.
    (b) Annual Report.--The Secretary of Labor annually shall submit to 
Congress a report on findings on how employer responsibility 
requirements have impacted and are likely to impact employers, plans, 
and employees during the previous year and projected trends.
    (c) Legislative Recommendations.--No later than January 1, 2012 and 
on an annual basis thereafter, the Secretary of Labor shall submit 
legislative recommendations to Congress to modify the employer 
responsibility requirements if the Secretary determines that the 
requirements are detrimentally affecting or will detrimentally affect 
employer plan sponsorship or otherwise creating inequities among 
employers, health plans, and employees. The Secretary may also submit 
such recommendations as the Secretary determines necessary to improve 
and strengthen employment-based health plan sponsorship, employer 
responsibility, and related proposals that would enhance the delivery 
of health care benefits between employers and employees.

SEC. 416. STUDY ON EMPLOYER HARDSHIP EXEMPTION.

    (a) In General.--The Secretary of Labor together with the Secretary 
of Treasury, the Secretary of Health and Human Services, and the 
Commissioner, shall conduct a study to examine the impact of the 
employer responsibility requirements described in section 415(a) and 
make a recommendation to Congress about whether an employer hardship 
exemption would be appropriate.
    (b) Items Included in Study.--Within such study the Secretaries and 
Commissioner shall examine cases where such employer responsibility 
requirements may pose a particular hardship, and specifically look at 
employers by industry, profit margin, length of time in business, and 
size. In this examination, the economic conditions shall be considered, 
including the rate of increase in business costs, the availability of 
short-term credit lines, and abilities to restructure debt. In 
addition, the study shall examine the impact an employer hardship 
waiver could have on employees.
    (c) Report.--Not later than January 1, 2012, the Secretaries and 
Commissioner shall report to Congress on their findings and make a 
recommendation regarding the need or lack of need for a partial or 
complete employer hardship waiver. The Secretaries and Commissioner may 
also submit recommendations about the criteria Congress should include 
when developing eligibility requirements for the employer hardship 
waiver and what safeguards are necessary to protect the employees of 
that employer.

   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.

    (a) In General.--Subtitle B of title I of the Employee Retirement 
Income Security Act of 1974 is amended by adding at the end the 
following new part:

     ``PART 8--NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS

``SEC. 801. ELECTION OF EMPLOYER TO BE SUBJECT TO NATIONAL HEALTH 
              COVERAGE PARTICIPATION REQUIREMENTS.

    ``(a) In General.--An employer may make an election with the 
Secretary to be subject to the health coverage participation 
requirements.
    ``(b) Time and Manner.--An election under subsection (a) may be 
made at such time and in such form and manner as the Secretary may 
prescribe.

``SEC. 802. TREATMENT OF COVERAGE RESULTING FROM ELECTION.

    ``(a) In General.--If an employer makes an election to the 
Secretary under section 801--
            ``(1) such election shall be treated as the establishment 
        and maintenance of a group health plan (as defined in section 
        733(a)) for purposes of this title, subject to section 251 of 
        the ; and
            ``(2) the health coverage participation requirements shall 
        be deemed to be included as terms and conditions of such plan.
    ``(b) Periodic Investigations To Discover Noncompliance.--The 
Secretary shall regularly audit a representative sampling of employers 
and group health plans and conduct investigations and other activities 
under section 504 with respect to such sampling of plans so as to 
discover noncompliance with the health coverage participation 
requirements in connection with such plans. The Secretary shall 
communicate findings of noncompliance made by the Secretary under this 
subsection to the Secretary of the Treasury and the Health Choices 
Commissioner. The Secretary shall take such timely enforcement action 
as appropriate to achieve compliance.
    ``(c) Recordkeeping.--To facilitate the audits described in 
subsection (b), the Secretary shall promulgate recordkeeping 
requirements for employers to account for both employees of the 
employer and individuals whom the employer has not treated as employees 
of the employer but with whom the employer, in the course of its trade 
or business, has engaged for the performance of labor or services. The 
scope and content of such recordkeeping requirements shall be 
determined by the Secretary and shall be designed to ensure that 
employees who are not properly treated as such may be identified and 
properly treated.

``SEC. 803. HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

    ``For purposes of this part, the term `health coverage 
participation requirements' means the requirements of part 1 of 
subtitle B of title IV of division A of (as in effect on the date of 
the enactment of such Act).

``SEC. 804. RULES FOR APPLYING REQUIREMENTS.

    ``(a) Affiliated Groups.--In the case of any employer which is part 
of a group of employers who are treated as a single employer under 
subsection (b), (c), (m), or (o) of section 414 of the Internal Revenue 
Code of 1986, the election under section 801 shall be made by such 
employer as the Secretary may provide. Any such election, once made, 
shall apply to all members of such group.
    ``(b) Separate Elections.--Under regulations prescribed by the 
Secretary, separate elections may be made under section 801 with 
respect to--
            ``(1) separate lines of business, and
            ``(2) full-time employees and employees who are not full-
        time employees.

``SEC. 805. TERMINATION OF ELECTION IN CASES OF SUBSTANTIAL 
              NONCOMPLIANCE.

    ``The Secretary may terminate the election of any employer under 
section 801 if the Secretary (in coordination with the Health Choices 
Commissioner) determines that such employer is in substantial 
noncompliance with the health coverage participation requirements and 
shall refer any such determination to the Secretary of the Treasury as 
appropriate.

``SEC. 806. REGULATIONS.

    ``The Secretary may promulgate such regulations as may be necessary 
or appropriate to carry out the provisions of this part, in accordance 
with section 424(a) of the . The Secretary may promulgate any interim 
final rules as the Secretary determines are appropriate to carry out 
this part.''.
    (b) Enforcement of Health Coverage Participation Requirements.--
Section 502 of such Act (29 U.S.C. 1132) is amended--
            (1) in subsection (a)(6), by striking ``paragraph'' and all 
        that follows through ``subsection (c)'' and inserting 
        ``paragraph (2), (4), (5), (6), (7), (8), (9), (10), or (11) of 
        subsection (c)''; and
            (2) in subsection (c), by redesignating the second 
        paragraph (10) as paragraph (12) and by inserting after the 
        first paragraph (10) the following new paragraph:
            ``(11) Health coverage participation requirements.--
                    ``(A) Civil penalties.--In the case of any employer 
                who fails (during any period with respect to which an 
                election under section 801(a) is in effect) to satisfy 
                the health coverage participation requirements with 
                respect to any employee, the Secretary may assess a 
                civil penalty against the employer of $100 for each day 
                in the period beginning on the date such failure first 
                occurs and ending on the date such failure is 
                corrected.
                    ``(B) Health coverage participation requirements.--
                For purposes of this paragraph, the term `health 
                coverage participation requirements' has the meaning 
                provided in section 803.
                    ``(C) Limitations on amount of penalty.--
                            ``(i) Penalty not to apply where failure 
                        not discovered exercising reasonable 
                        diligence.--No penalty shall be assessed under 
                        subparagraph (A) with respect to any failure 
                        during any period for which it is established 
                        to the satisfaction of the Secretary that the 
                        employer did not know, or exercising reasonable 
                        diligence would not have known, that such 
                        failure existed.
                            ``(ii) Penalty not to apply to failures 
                        corrected within 30 days.--No penalty shall be 
                        assessed under subparagraph (A) with respect to 
                        any failure if--
                                    ``(I) such failure was due to 
                                reasonable cause and not to willful 
                                neglect, and
                                    ``(II) such failure is corrected 
                                during the 30-day period beginning on 
                                the 1st date that the employer knew, or 
                                exercising reasonable diligence would 
                                have known, that such failure existed.
                            ``(iii) Overall limitation for 
                        unintentional failures.--In the case of 
                        failures which are due to reasonable cause and 
                        not to willful neglect, the penalty assessed 
                        under subparagraph (A) for failures during any 
                        1-year period shall not exceed the amount equal 
                        to the lesser of--
                                    ``(I) 10 percent of the aggregate 
                                amount paid or incurred by the employer 
                                (or predecessor employer) during the 
                                preceding 1-year period for group 
                                health plans, or
                                    ``(II) $500,000.
                    ``(D) Advance notification of failure prior to 
                assessment.--Before a reasonable time prior to the 
                assessment of any penalty under this paragraph with 
                respect to any failure by an employer, the Secretary 
                shall inform the employer in writing of such failure 
                and shall provide the employer information regarding 
                efforts and procedures which may be undertaken by the 
                employer to correct such failure.
                    ``(E) Coordination with excise tax.--Under 
                regulations prescribed in accordance with section 424 
                of the , the Secretary and the Secretary of the 
                Treasury shall coordinate the assessment of penalties 
                under this section in connection with failures to 
                satisfy health coverage participation requirements with 
                the imposition of excise taxes on such failures under 
                section 4980H(b) of the Internal Revenue Code of 1986 
                so as to avoid duplication of penalties with respect to 
                such failures.
                    ``(F) Deposit of penalty collected.--Any amount of 
                penalty collected under this paragraph shall be 
                deposited as miscellaneous receipts in the Treasury of 
                the United States.''.
    (c) Clerical Amendments.--The table of contents in section 1 of 
such Act is amended by inserting after the 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.''.
    (d) Effective Date.--The amendments made by this section shall 
apply to periods beginning after December 31, 2012.

SEC. 422. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS 
              UNDER THE INTERNAL REVENUE CODE OF 1986.

    (a) Failure To Elect, or Substantially Comply With, Health Coverage 
Participation Requirements.--For employment tax on employers who fail 
to elect, or substantially comply with, the health coverage 
participation requirements described in part 1, see section 3111(c) of 
the Internal Revenue Code of 1986 (as added by section 512 of this 
Act).
    (b) Other Failures.--For excise tax on other failures of electing 
employers to comply with such requirements, see section 4980H of the 
Internal Revenue Code of 1986 (as added by section 511 of this Act).

SEC. 423. SATISFACTION OF HEALTH COVERAGE PARTICIPATION REQUIREMENTS 
              UNDER THE PUBLIC HEALTH SERVICE ACT.

    (a) In General.--Part C of title XXVII of the Public Health Service 
Act is amended by adding at the end the following new section:

``SEC. 2793. NATIONAL HEALTH COVERAGE PARTICIPATION REQUIREMENTS.

    ``(a) Election of Employer To Be Subject to National Health 
Coverage Participation Requirements.--
            ``(1) In general.--An employer may make an election with 
        the Secretary to be subject to the health coverage 
        participation requirements.
            ``(2) Time and manner.--An election under paragraph (1) may 
        be made at such time and in such form and manner as the 
        Secretary may prescribe.
    ``(b) Treatment of Coverage Resulting From Election.--
            ``(1) In general.--If an employer makes an election to the 
        Secretary under subsection (a)--
                    ``(A) such election shall be treated as the 
                establishment and maintenance of a group health plan 
                for purposes of this title, subject to section 251 of 
                the Affordable Health Care for America Act; and
                    ``(B) the health coverage participation 
                requirements shall be deemed to be included as terms 
                and conditions of such plan.
            ``(2) Periodic investigations to determine compliance with 
        health coverage participation requirements.--The Secretary 
        shall regularly audit a representative sampling of employers 
        and conduct investigations and other activities with respect to 
        such sampling of employers so as to discover noncompliance with 
        the health coverage participation requirements in connection 
        with such employers (during any period with respect to which an 
        election under subsection (a) is in effect). The Secretary 
        shall communicate findings of noncompliance made by the 
        Secretary under this subsection to the Secretary of the 
        Treasury and the Health Choices Commissioner. The Secretary 
        shall take such timely enforcement action as appropriate to 
        achieve compliance.
            ``(3) Recordkeeping.--To facilitate the audits described in 
        subsection (b), the Secretary shall promulgate recordkeeping 
        requirements for employers to account for both employees of the 
        employer and individuals whom the employer has not treated as 
        employees of the employer but with whom the employer, in the 
        course of its trade or business, has engaged for the 
        performance of labor or services. The scope and content of such 
        recordkeeping requirements shall be determined by the Secretary 
        and shall be designed to ensure that employees who are not 
        properly treated as such may be identified and properly 
        treated.
    ``(c) Health Coverage Participation Requirements.--For purposes of 
this section, the term `health coverage participation requirements' 
means the requirements of part 1 of subtitle B of title IV of division 
A of the (as in effect on the date of the enactment of this section).
    ``(d) Separate Elections.--Under regulations prescribed by the 
Secretary, separate elections may be made under subsection (a) with 
respect to full-time employees and employees who are not full-time 
employees.
    ``(e) Termination of Election in Cases of Substantial 
Noncompliance.--The Secretary may terminate the election of any 
employer under subsection (a) if the Secretary (in coordination with 
the Health Choices Commissioner) determines that such employer is in 
substantial noncompliance with the health coverage participation 
requirements and shall refer any such determination to the Secretary of 
the Treasury as appropriate.
    ``(f) Enforcement of Health Coverage Participation Requirements.--
            ``(1) Civil penalties.--In the case of any employer who 
        fails (during any period with respect to which the election 
        under subsection (a) is in effect) to satisfy the health 
        coverage participation requirements with respect to any 
        employee, the Secretary may assess a civil penalty against the 
        employer of $100 for each day in the period beginning on the 
        date such failure first occurs and ending on the date such 
        failure is corrected.
            ``(2) Limitations on amount of penalty.--
                    ``(A) Penalty not to apply where failure not 
                discovered exercising reasonable diligence.--No penalty 
                shall be assessed under paragraph (1) with respect to 
                any failure during any period for which it is 
                established to the satisfaction of the Secretary that 
                the employer did not know, or exercising reasonable 
                diligence would not have known, that such failure 
                existed.
                    ``(B) Penalty not to apply to failures corrected 
                within 30 days.--No penalty shall be assessed under 
                paragraph (1) with respect to any failure if--
                            ``(i) such failure was due to reasonable 
                        cause and not to willful neglect, and
                            ``(ii) such failure is corrected during the 
                        30-day period beginning on the 1st date that 
                        the employer knew, or exercising reasonable 
                        diligence would have known, that such failure 
                        existed.
                    ``(C) Overall limitation for unintentional 
                failures.--In the case of failures which are due to 
                reasonable cause and not to willful neglect, the 
                penalty assessed under paragraph (1) for failures 
                during any 1-year period shall not exceed the amount 
                equal to the lesser of--
                            ``(i) 10 percent of the aggregate amount 
                        paid or incurred by the employer (or 
                        predecessor employer) during the preceding 
                        taxable year for group health plans, or
                            ``(ii) $500,000.
            ``(3) Advance notification of failure prior to 
        assessment.--Before a reasonable time prior to the assessment 
        of any penalty under paragraph (1) with respect to any failure 
        by an employer, the Secretary shall inform the employer in 
        writing of such failure and shall provide the employer 
        information regarding efforts and procedures which may be 
        undertaken by the employer to correct such failure.
            ``(4) Actions to enforce assessments.--The Secretary may 
        bring a civil action in any District Court of the United States 
        to collect any civil penalty under this subsection.
            ``(5) Coordination with excise tax.--Under regulations 
        prescribed in accordance with section 424 of the , the 
        Secretary and the Secretary of the Treasury shall coordinate 
        the assessment of penalties under paragraph (1) in connection 
        with failures to satisfy health coverage participation 
        requirements with the imposition of excise taxes on such 
        failures under section 4980H(b) of the Internal Revenue Code of 
        1986 so as to avoid duplication of penalties with respect to 
        such failures.
            ``(6) Deposit of penalty collected.--Any amount of penalty 
        collected under this subsection shall be deposited as 
        miscellaneous receipts in the Treasury of the United States.
    ``(g) Regulations.--The Secretary may promulgate such regulations 
as may be necessary or appropriate to carry out the provisions of this 
section, in accordance with section 424(a) of the . The Secretary may 
promulgate any interim final rules as the Secretary determines are 
appropriate to carry out this section.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to periods beginning after December 31, 2012.

SEC. 424. ADDITIONAL RULES RELATING TO HEALTH COVERAGE PARTICIPATION 
              REQUIREMENTS.

    (a) Assuring Coordination.--The officers consisting of the 
Secretary of Labor, the Secretary of the Treasury, the Secretary of 
Health and Human Services, and the Health Choices Commissioner shall 
ensure, through the execution of an interagency memorandum of 
understanding among such officers, that--
            (1) regulations, rulings, and interpretations issued by 
        such officers relating to the same matter over which two or 
        more of such officers have responsibility under subpart B of 
        part 8 of subtitle B of title I of the Employee Retirement 
        Income Security Act of 1974, section 4980H of the Internal 
        Revenue Code of 1986, and section 2793 of the Public Health 
        Service Act are administered so as to have the same effect at 
        all times; and
            (2) coordination of policies relating to enforcing the same 
        requirements through such officers in order to have a 
        coordinated enforcement strategy that avoids duplication of 
        enforcement efforts and assigns priorities in enforcement.
    (b) Multiemployer Plans.--In the case of a group health plan that 
is a multiemployer plan (as defined in section 3(37) of the Employee 
Retirement Income Security Act of 1974), the regulations prescribed in 
accordance with subsection (a) by the officers referred to in 
subsection (a) shall provide for the application of the health coverage 
participation requirements to the plan sponsor and contributing 
employers of such plan. For purposes of this division, contributions 
made pursuant to a collective bargaining agreement or other agreement 
to such a group health plan shall be treated as amounts paid by the 
employer.

          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.

    (a) In General.--Subchapter A of chapter 1 of the Internal Revenue 
Code of 1986 is amended by adding at the end the following new part:

                 ``PART VIII--HEALTH CARE RELATED TAXES

    ``subpart a. tax on individuals without acceptable health care 
                               coverage.

``Subpart A--Tax on Individuals Without Acceptable Health Care Coverage

``Sec. 59B. Tax on individuals without acceptable health care coverage.

``SEC. 59B. TAX ON INDIVIDUALS WITHOUT ACCEPTABLE HEALTH CARE COVERAGE.

    ``(a) Tax Imposed.--In the case of any individual who does not meet 
the requirements of subsection (d) at any time during the taxable year, 
there is hereby imposed a tax equal to 2.5 percent of the excess of--
            ``(1) the taxpayer's modified adjusted gross income for the 
        taxable year, over
            ``(2) the amount of gross income specified in section 
        6012(a)(1) with respect to the taxpayer.
    ``(b) Limitations.--
            ``(1) Tax limited to average premium.--
                    ``(A) In general.--The tax imposed under subsection 
                (a) with respect to any taxpayer for any taxable year 
                shall not exceed the applicable national average 
                premium for such taxable year.
                    ``(B) Applicable national average premium.--
                            ``(i) In general.--For purposes of 
                        subparagraph (A), the `applicable national 
                        average premium' means, with respect to any 
                        taxable year, the average premium (as 
                        determined by the Secretary, in coordination 
                        with the Health Choices Commissioner) for self-
                        only coverage under a basic plan which is 
                        offered in a Health Insurance Exchange for the 
                        calendar year in which such taxable year 
                        begins.
                            ``(ii) Failure to provide coverage for more 
                        than one individual.--In the case of any 
                        taxpayer who fails to meet the requirements of 
                        subsection (d) with respect to more than one 
                        individual during the taxable year, clause (i) 
                        shall be applied by substituting `family 
                        coverage' for `self-only coverage'.
            ``(2) Proration for part year failures.--The tax imposed 
        under subsection (a) with respect to any taxpayer for any 
        taxable year shall not exceed the amount which bears the same 
        ratio to the amount of tax so imposed (determined without 
        regard to this paragraph and after application of paragraph 
        (1)) as--
                    ``(A) the aggregate periods during such taxable 
                year for which such individual failed to meet the 
                requirements of subsection (d), bears to
                    ``(B) the entire taxable year.
    ``(c) Exceptions.--
            ``(1) Dependents.--Subsection (a) shall not apply to any 
        individual for any taxable year if a deduction is allowable 
        under section 151 with respect to such individual to another 
        taxpayer for any taxable year beginning in the same calendar 
        year as such taxable year.
            ``(2) Nonresident aliens.--Subsection (a) shall not apply 
        to any individual who is a nonresident alien.
            ``(3) Individuals residing outside united states.--Any 
        qualified individual (as defined in section 911(d)) (and any 
        qualifying child residing with such individual) shall be 
        treated for purposes of this section as covered by acceptable 
        coverage during the period described in subparagraph (A) or (B) 
        of section 911(d)(1), whichever is applicable.
            ``(4) Individuals residing in possessions of the united 
        states.--Any individual who is a bona fide resident of any 
        possession of the United States (as determined under section 
        937(a)) for any taxable year (and any qualifying child residing 
        with such individual) shall be treated for purposes of this 
        section as covered by acceptable coverage during such taxable 
        year.
            ``(5) Religious conscience exemption.--
                    ``(A) In general.--Subsection (a) shall not apply 
                to any individual (and any qualifying child residing 
                with such individual) for any period if such individual 
                has in effect an exemption which certifies that such 
                individual is a member of a recognized religious sect 
                or division thereof described in section 1402(g)(1) and 
                an adherent of established tenets or teachings of such 
                sect or division as described in such section.
                    ``(B) Exemption.--An application for the exemption 
                described in subparagraph (A) shall be filed with the 
                Secretary at such time and in such form and manner as 
                the Secretary may prescribe. The Secretary may treat an 
                application for exemption under section 1402(g)(1) as 
                an application for exemption under this section, or may 
                otherwise coordinate applications under such sections, 
                as the Secretary determines appropriate. Any such 
                exemption granted by the Secretary shall be effective 
                for such period as the Secretary determines 
                appropriate.
    ``(d) Acceptable Coverage Requirement.--
            ``(1) In general.--The requirements of this subsection are 
        met with respect to any individual for any period if such 
        individual (and each qualifying child of such individual) is 
        covered by acceptable coverage at all times during such period.
            ``(2) Acceptable coverage.--For purposes of this section, 
        the term `acceptable coverage' means any of the following:
                    ``(A) Qualified health benefits plan coverage.--
                Coverage under a qualified health benefits plan (as 
                defined in section 100(c) of the ).
                    ``(B) Grandfathered health insurance coverage; 
                coverage under grandfathered employment-based health 
                plan.--Coverage under a grandfathered health insurance 
                coverage (as defined in subsection (a) of section 202 
                of the ) or under a current employment-based health 
                plan (within the meaning of subsection (b) of such 
                section).
                    ``(C) Medicare.--Coverage under part A of title 
                XVIII of the Social Security Act.
                    ``(D) Medicaid.--Coverage for medical assistance 
                under title XIX of the Social Security Act.
                    ``(E) Members of the armed forces and dependents 
                (including tricare).--Coverage under chapter 55 of 
                title 10, United States Code, including similar 
                coverage furnished under section 1781 of title 38 of 
                such Code.
                    ``(F) VA.--Coverage under the veteran's health care 
                program under chapter 17 of title 38, United States 
                Code.
                    ``(G) Members of indian tribes.--Health care 
                services made available through the Indian Health 
                Service, a tribal organization (as defined in section 4 
                of the Indian Health Care Improvement Act), or an urban 
                Indian organization (as defined in such section) to 
                members of an Indian tribe (as defined in such 
                section).
                    ``(H) Other coverage.--Such other health benefits 
                coverage as the Secretary, in coordination with the 
                Health Choices Commissioner, recognizes for purposes of 
                this subsection.
    ``(e) Other Definitions and Special Rules.--
            ``(1) Qualifying child.--For purposes of this section, the 
        term `qualifying child' has the meaning given such term by 
        section 152(c). With respect to any period during which health 
        coverage for a child must be provided by an individual pursuant 
        to a child support order, such child shall be treated as a 
        qualifying child of such individual (and not as a qualifying 
        child of any other individual).
            ``(2) Basic plan.--For purposes of this section, the term 
        `basic plan' has the meaning given such term under section 
        100(c) of the .
            ``(3) Health insurance exchange.--For purposes of this 
        section, the term `Health Insurance Exchange' has the meaning 
        given such term under section 100(c) of the , including any 
        State-based health insurance exchange approved for operation 
        under section 308 of such Act.
            ``(4) Family coverage.--For purposes of this section, the 
        term `family coverage' means any coverage other than self-only 
        coverage.
            ``(5) Modified adjusted gross income.--For purposes of this 
        section, the term `modified adjusted gross income' means 
        adjusted gross income increased by--
                    ``(A) any amount excluded from gross income under 
                section 911, and
                    ``(B) any amount of interest received or accrued by 
                the taxpayer during the taxable year which is exempt 
                from tax.
            ``(6) Not treated as tax imposed by this chapter for 
        certain purposes.--The tax imposed under this section shall not 
        be treated as tax imposed by this chapter for purposes of 
        determining the amount of any credit under this chapter or for 
        purposes of section 55.
    ``(f) Regulations.--The Secretary shall prescribe such regulations 
or other guidance as may be necessary or appropriate to carry out the 
purposes of this section, including regulations or other guidance 
(developed in coordination with the Health Choices Commissioner) which 
provide--
            ``(1) exemption from the tax imposed under subsection (a) 
        in cases of de minimis lapses of acceptable coverage, and
            ``(2) a waiver of the application of subsection (a) in 
        cases of hardship, including a process for applying for such a 
        waiver.''.
    (b) Information Reporting.--
            (1) In general.--Subpart B of part III of subchapter A of 
        chapter 61 of such Code is amended by inserting after section 
        6050W the following new section:

``SEC. 6050X. RETURNS RELATING TO HEALTH INSURANCE COVERAGE.

    ``(a) Requirement of Reporting.--Every person who provides 
acceptable coverage (as defined in section 59B(d)) to any individual 
during any calendar year shall, at such time as the Secretary may 
prescribe, make the return described in subsection (b) with respect to 
such individual.
    ``(b) Form and Manner of Returns.--A return is described in this 
subsection if such return--
            ``(1) is in such form as the Secretary may prescribe, and
            ``(2) contains--
                    ``(A) the name, address, and TIN of the primary 
                insured and the name of each other individual obtaining 
                coverage under the policy,
                    ``(B) the period for which each such individual was 
                provided with the coverage referred to in subsection 
                (a), and
                    ``(C) such other information as the Secretary may 
                require.
    ``(c) Statements to Be Furnished to Individuals With Respect to 
Whom Information Is Required.--Every person required to make a return 
under subsection (a) shall furnish to each primary insured whose name 
is required to be set forth in such return a written statement 
showing--
            ``(1) the name and address of the person required to make 
        such return and the phone number of the information contact for 
        such person, and
            ``(2) the information required to be shown on the return 
        with respect to such individual.
The written statement required under the preceding sentence shall be 
furnished on or before January 31 of the year following the calendar 
year for which the return under subsection (a) is required to be made.
    ``(d) Coverage Provided by Governmental Units.--In the case of 
coverage provided by any governmental unit or any agency or 
instrumentality thereof, the officer or employee who enters into the 
agreement to provide such coverage (or the person appropriately 
designated for purposes of this section) shall make the returns and 
statements required by this section.''.
            (2) Penalty for failure to file.--
                    (A) Return.--Subparagraph (B) of section 6724(d)(1) 
                of such Code is amended by striking ``or'' at the end 
                of clause (xxii), by striking ``and'' at the end of 
                clause (xxiii) and inserting ``or'', and by adding at 
                the end the following new clause:
                            ``(xxiv) section 6050X (relating to returns 
                        relating to health insurance coverage), and''.
                    (B) Statement.--Paragraph (2) of section 6724(d) of 
                such Code is amended by striking ``or'' at the end of 
                subparagraph (EE), by striking the period at the end of 
                subparagraph (FF) and inserting ``, or'', and by 
                inserting after subparagraph (FF) the following new 
                subparagraph:
                    ``(GG) section 6050X (relating to returns relating 
                to health insurance coverage).''.
    (c) Return Requirement.--Subsection (a) of section 6012 of such 
Code is amended by inserting after paragraph (9) the following new 
paragraph:
            ``(10) Every individual to whom section 59B(a) applies and 
        who fails to meet the requirements of section 59B(d) with 
        respect to such individual or any qualifying child (as defined 
        in section 152(c)) of such individual.''.
    (d) Clerical Amendments.--
            (1) The table of parts for subchapter A of chapter 1 of the 
        Internal Revenue Code of 1986 is amended by adding at the end 
        the following new item:

               ``Part VIII. Health Care Related Taxes.''.

            (2) The table of sections for subpart B of part III of 
        subchapter A of chapter 61 is amended by adding at the end the 
        following new item:

``Sec. 6050X. Returns relating to health insurance coverage.''.
    (e) Section 15 Not to Apply.--The amendment made by subsection (a) 
shall not be treated as a change in a rate of tax for purposes of 
section 15 of the Internal Revenue Code of 1986.
    (f) Effective Date.--
            (1) In general.--The amendments made by this section shall 
        apply to taxable years beginning after December 31, 2012.
            (2) Returns.--The amendments made by subsection (b) shall 
        apply to calendar years beginning after December 31, 2012.

                   Subpart B--Employer Responsibility

SEC. 511. ELECTION TO SATISFY HEALTH COVERAGE PARTICIPATION 
              REQUIREMENTS.

    (a) In General.--Chapter 43 of the Internal Revenue Code of 1986 is 
amended by adding at the end the following new section:

``SEC. 4980H. ELECTION WITH RESPECT TO HEALTH COVERAGE PARTICIPATION 
              REQUIREMENTS.

    ``(a) Election of Employer Responsibility to Provide Health 
Coverage.--
            ``(1) In general.--Subsection (b) shall apply to any 
        employer with respect to whom an election under paragraph (2) 
        is in effect.
            ``(2) Time and manner.--An employer may make an election 
        under this paragraph at such time and in such form and manner 
        as the Secretary may prescribe.
            ``(3) Affiliated groups.--In the case of any employer which 
        is part of a group of employers who are treated as a single 
        employer under subsection (b), (c), (m), or (o) of section 414, 
        the election under paragraph (2) shall be made by such person 
        as the Secretary may provide. Any such election, once made, 
        shall apply to all members of such group.
            ``(4) Separate elections.--Under regulations prescribed by 
        the Secretary, separate elections may be made under paragraph 
        (2) with respect to--
                    ``(A) separate lines of business, and
                    ``(B) full-time employees and employees who are not 
                full-time employees.
            ``(5) Termination of election in cases of substantial 
        noncompliance.--The Secretary may terminate the election of any 
        employer under paragraph (2) if the Secretary (in coordination 
        with the Health Choices Commissioner) determines that such 
        employer is in substantial noncompliance with the health 
        coverage participation requirements.
    ``(b) Excise Tax With Respect to Failure to Meet Health Coverage 
Participation Requirements.--
            ``(1) In general.--In the case of any employer who fails 
        (during any period with respect to which the election under 
        subsection (a) is in effect) to satisfy the health coverage 
        participation requirements with respect to any employee to whom 
        such election applies, there is hereby imposed on each such 
        failure with respect to each such employee a tax of $100 for 
        each day in the period beginning on the date such failure first 
        occurs and ending on the date such failure is corrected.
            ``(2) Limitations on amount of tax.--
                    ``(A) Tax not to apply where failure not discovered 
                exercising reasonable diligence.--No tax shall be 
                imposed by paragraph (1) on any failure during any 
                period for which it is established to the satisfaction 
                of the Secretary that the employer neither knew, nor 
                exercising reasonable diligence would have known, that 
                such failure existed.
                    ``(B) Tax not to apply to failures corrected within 
                30 days.--No tax shall be imposed by paragraph (1) on 
                any failure if--
                            ``(i) such failure was due to reasonable 
                        cause and not to willful neglect, and
                            ``(ii) such failure is corrected during the 
                        30-day period beginning on the 1st date that 
                        the employer knew, or exercising reasonable 
                        diligence would have known, that such failure 
                        existed.
                    ``(C) Overall limitation for unintentional 
                failures.--In the case of failures which are due to 
                reasonable cause and not to willful neglect, the tax 
                imposed by subsection (a) for failures during the 
                taxable year of the employer shall not exceed the 
                amount equal to the lesser of--
                            ``(i) 10 percent of the aggregate amount 
                        paid or incurred by the employer (or 
                        predecessor employer) during the preceding 
                        taxable year for employment-based health plans, 
                        or
                            ``(ii) $500,000.
                    ``(D) Coordination with other enforcement 
                provisions.--The tax imposed under paragraph (1) with 
                respect to any failure shall be reduced (but not below 
                zero) by the amount of any civil penalty collected 
                under section 502(c)(11) of the Employee Retirement 
                Income Security Act of 1974 or section 2793(g) of the 
                Public Health Service Act with respect to such failure.
    ``(c) Health Coverage Participation Requirements.--For purposes of 
this section, the term `health coverage participation requirements' 
means the requirements of part I of subtitle B of title IV of the (as 
in effect on the date of the enactment of this section).''.
    (b) Clerical Amendment.--The table of sections for chapter 43 of 
such Code is amended by adding at the end the following new item:

``Sec. 4980H. Election with respect to health coverage participation 
                            requirements.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to periods beginning after December 31, 2012.

SEC. 512. HEALTH CARE CONTRIBUTIONS OF NONELECTING EMPLOYERS.

    (a) In General.--Section 3111 of the Internal Revenue Code of 1986 
is amended by redesignating subsection (c) as subsection (d) and by 
inserting after subsection (b) the following new subsection:
    ``(c) Employers Electing Not to Provide Health Benefits.--
            ``(1) In general.--In addition to other taxes, there is 
        hereby imposed on every nonelecting employer an excise tax, 
        with respect to having individuals in his employ, equal to 8 
        percent of the wages (as defined in section 3121(a)) paid by 
        him with respect to employment (as defined in section 3121(b)).
            ``(2) Special rules for small employers.--
                    ``(A) In general.--In the case of any employer who 
                is small employer for any calendar year, paragraph (1) 
                shall be applied by substituting the applicable 
                percentage determined in accordance with the following 
                table for `8 percent':

``If the annual payroll of such          The applicable percentage is:
 employer for the preceding calendar
 year:
  Does not exceed $500,000.............  0 percent
  Exceeds $500,000, but does not exceed  2 percent
   $585,000.
  Exceeds $585,000, but does not exceed  4 percent
   $670,000.
  Exceeds $670,000, but does not exceed  6 percent
   $750,000.
 

                    ``(B) Small employer.--For purposes of this 
                paragraph, the term `small employer' means any employer 
                for any calendar year if the annual payroll of such 
                employer for the preceding calendar year does not 
                exceed $750,000.
                    ``(C) Annual payroll.--For purposes of this 
                paragraph, the term `annual payroll' means, with 
                respect to any employer for any calendar year, the 
                aggregate wages (as defined in section 3121(a)) paid by 
                him with respect to employment (as defined in section 
                3121(b)) during such calendar year.
            ``(3) Nonelecting employer.--For purposes of paragraph (1), 
        the term `nonelecting employer' means any employer for any 
        period with respect to which such employer does not have an 
        election under section 4980H(a) in effect.
            ``(4) Special rule for separate elections.--In the case of 
        an employer who makes a separate election described in section 
        4980H(a)(4) for any period, paragraph (1) shall be applied for 
        such period by taking into account only the wages paid to 
        employees who are not subject to such election.
            ``(5) Aggregation; predecessors.--For purposes of this 
        subsection--
                    ``(A) all persons treated as a single employer 
                under subsection (b), (c), (m), or (o) of section 414 
                shall be treated as 1 employer, and
                    ``(B) any reference to any person shall be treated 
                as including a reference to any predecessor of such 
                person.''.
    (b) Definitions.--Section 3121 of such Code is amended by adding at 
the end the following new subsection:
    ``(aa) Special Rules for Tax on Employers Electing Not to Provide 
Health Benefits.--For purposes of section 3111(c)--
            ``(1) Paragraphs (1), (5), and (19) of subsection (b) shall 
        not apply.
            ``(2) Paragraph (7) of subsection (b) shall apply by 
        treating all services as not covered by the retirement systems 
        referred to in subparagraphs (C) and (F) thereof.
            ``(3) Subsection (e) shall not apply and the term `State' 
        shall include the District of Columbia.''.
    (c) Conforming Amendment.--Subsection (d) of section 3111 of such 
Code, as redesignated by this section, is amended by striking ``this 
section'' and inserting ``subsections (a) and (b)''.
    (d) Application to Railroads.--
            (1) In general.--Section 3221 of such Code is amended by 
        redesignating subsection (c) as subsection (d) and by inserting 
        after subsection (b) the following new subsection:
    ``(c) Employers Electing Not to Provide Health Benefits.--
            ``(1) In general.--In addition to other taxes, there is 
        hereby imposed on every nonelecting employer an excise tax, 
        with respect to having individuals in his employ, equal to 8 
        percent of the compensation paid during any calendar year by 
        such employer for services rendered to such employer.
            ``(2) Exception for small employers.--Rules similar to the 
        rules of section 3111(c)(2) shall apply for purposes of this 
        subsection.
            ``(3) Nonelecting employer.--For purposes of paragraph (1), 
        the term `nonelecting employer' means any employer for any 
        period with respect to which such employer does not have an 
        election under section 4980H(a) in effect.
            ``(4) Special rule for separate elections.--In the case of 
        an employer who makes a separate election described in section 
        4980H(a)(4) for any period, subsection (a) shall be applied for 
        such period by taking into account only the compensation paid 
        to employees who are not subject to such election.''.
            (2) Definitions.--Subsection (e) of section 3231 of such 
        Code is amended by adding at the end the following new 
        paragraph:
            ``(13) Special rules for tax on employers electing not to 
        provide health benefits.--For purposes of section 3221(c)--
                    ``(A) Paragraph (1) shall be applied without regard 
                to the third sentence thereof.
                    ``(B) Paragraph (2) shall not apply.''.
            (3) Conforming amendment.--Subsection (d) of section 3221 
        of such Code, as redesignated by this section, is amended by 
        striking ``subsections (a) and (b), see section 3231(e)(2)'' 
        and inserting ``this section, see paragraphs (2) and (13)(B) of 
        section 3231(e)''.
    (e) Effective Date.--The amendments made by this section shall 
apply to periods beginning after December 31, 2012.

  PART 2--CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES

SEC. 521. CREDIT FOR SMALL BUSINESS EMPLOYEE HEALTH COVERAGE EXPENSES.

    (a) In General.--Subpart D of part IV of subchapter A of chapter 1 
of the Internal Revenue Code of 1986 (relating to business-related 
credits) is amended by adding at the end the following new section:

``SEC. 45R. SMALL BUSINESS EMPLOYEE HEALTH COVERAGE CREDIT.

    ``(a) In General.--For purposes of section 38, in the case of a 
qualified small employer, the small business employee health coverage 
credit determined under this section for the taxable year is an amount 
equal to the applicable percentage of the qualified employee health 
coverage expenses of such employer for such taxable year.
    ``(b) Applicable Percentage.--
            ``(1) In general.--For purposes of this section, the 
        applicable percentage is 50 percent.
            ``(2) Phaseout based on average compensation of 
        employees.--In the case of an employer whose average annual 
        employee compensation for the taxable year exceeds $20,000, the 
        percentage specified in paragraph (1) shall be reduced by a 
        number of percentage points which bears the same ratio to 50 as 
        such excess bears to $20,000.
    ``(c) Limitations.--
            ``(1) Phaseout based on employer size.--In the case of an 
        employer who employs more than 10 qualified employees during 
        the taxable year, the credit determined under subsection (a) 
        shall be reduced by an amount which bears the same ratio to the 
        amount of such credit (determined without regard to this 
        paragraph and after the application of the other provisions of 
        this section) as--
                    ``(A) the excess of--
                            ``(i) the number of qualified employees 
                        employed by the employer during the taxable 
                        year, over
                            ``(ii) 10, bears to
                    ``(B) 15.
            ``(2) Credit not allowed with respect to certain highly 
        compensated employees.--No credit shall be determined under 
        subsection (a) with respect to qualified employee health 
        coverage expenses paid or incurred with respect to any employee 
        for any taxable year if the aggregate compensation paid by the 
        employer to such employee during such taxable year exceeds 
        $80,000.
            ``(3) Credit allowed for only 2 taxable years.--No credit 
        shall be determined under subsection (a) with respect to any 
        employer for any taxable year unless the employer elects to 
        have this section apply for such taxable year. An employer may 
        elect the application of this section with respect to not more 
        than 2 taxable years.
    ``(d) Qualified Employee Health Coverage Expenses.--For purposes of 
this section--
            ``(1) In general.--The term `qualified employee health 
        coverage expenses' means, with respect to any employer for any 
        taxable year, the aggregate amount paid or incurred by such 
        employer during such taxable year for coverage of any qualified 
        employee of the employer (including any family coverage which 
        covers such employee) under qualified health coverage.
            ``(2) Qualified health coverage.--The term `qualified 
        health coverage' means acceptable coverage (as defined in 
        section 59B(d)) which--
                    ``(A) is provided pursuant to an election under 
                section 4980H(a), and
                    ``(B) satisfies the requirements referred to in 
                section 4980H(c).
    ``(e) Other Definitions.--For purposes of this section--
            ``(1) Qualified small employer.--For purposes of this 
        section, the term `qualified small employer' means any employer 
        for any taxable year if--
                    ``(A) the number of qualified employees employed by 
                such employer during the taxable year does not exceed 
                25, and
                    ``(B) the average annual employee compensation of 
                such employer for such taxable year does not exceed the 
                sum of the dollar amounts in effect under subsection 
                (b)(2).
            ``(2) Qualified employee.--The term `qualified employee' 
        means any employee of an employer for any taxable year of the 
        employer if such employee received at least $5,000 of 
        compensation from such employer for services performed in the 
        trade or business of such employer during such taxable year.
            ``(3) Average annual employee compensation.--The term 
        `average annual employee compensation' means, with respect to 
        any employer for any taxable year, the average amount of 
        compensation paid by such employer to qualified employees of 
        such employer during such taxable year.
            ``(4) Compensation.--The term `compensation' has the 
        meaning given such term in section 408(p)(6)(A).
            ``(5) Family coverage.--The term `family coverage' means 
        any coverage other than self-only coverage.
    ``(f) Special Rules.--For purposes of this section--
            ``(1) Special rule for partnerships and self-employed.--In 
        the case of a partnership (or a trade or business carried on by 
        an individual) which has one or more qualified employees 
        (determined without regard to this paragraph) with respect to 
        whom the election under section 4980H(a) applies, each partner 
        (or, in the case of a trade or business carried on by an 
        individual, such individual) shall be treated as an employee.
            ``(2) Aggregation rule.--All persons treated as a single 
        employer under subsection (b), (c), (m), or (o) of section 414 
        shall be treated as 1 employer.
            ``(3) Predecessors.--Any reference in this section to an 
        employer shall include a reference to any predecessor of such 
        employer.
            ``(4) Denial of double benefit.--Any deduction otherwise 
        allowable with respect to amounts paid or incurred for health 
        insurance coverage to which subsection (a) applies shall be 
        reduced by the amount of the credit determined under this 
        section.
            ``(5) Inflation adjustment.--In the case of any taxable 
        year beginning after 2013, each of the dollar amounts in 
        subsections (b)(2), (c)(2), and (e)(2) shall be increased by an 
        amount equal to--
                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost of living adjustment determined 
                under section 1(f)(3) for the calendar year in which 
                the taxable year begins determined by substituting 
                `calendar year 2012' for `calendar year 1992' in 
                subparagraph (B) thereof.
        If any increase determined under this paragraph is not a 
        multiple of $50, such increase shall be rounded to the next 
        lowest multiple of $50.''.
    (b) Credit to Be Part of General Business Credit.--Subsection (b) 
of section 38 of such Code (relating to general business credit) is 
amended by striking ``plus'' at the end of paragraph (34), by striking 
the period at the end of paragraph (35) and inserting ``, plus'' , and 
by adding at the end the following new paragraph:
            ``(36) in the case of a qualified small employer (as 
        defined in section 45R(e)), the small business employee health 
        coverage credit determined under section 45R(a).''.
    (c) Clerical Amendment.--The table of sections for subpart D of 
part IV of subchapter A of chapter 1 of such Code is amended by 
inserting after the item relating to section 45Q the following new 
item:

``Sec. 45R. Small business employee health coverage credit.''.
    (d) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2012.

        PART 3--LIMITATIONS ON HEALTH CARE RELATED EXPENDITURES

SEC. 531. DISTRIBUTIONS FOR MEDICINE QUALIFIED ONLY IF FOR PRESCRIBED 
              DRUG OR INSULIN.

    (a) HSAs.--Subparagraph (A) of section 223(d)(2) of the Internal 
Revenue Code of 1986 is amended by adding at the end the following: 
``Such term shall include an amount paid for medicine or a drug only if 
such medicine or drug is a prescribed drug or is insulin.''.
    (b) Archer MSAs.--Subparagraph (A) of section 220(d)(2) of such 
Code is amended by adding at the end the following: ``Such term shall 
include an amount paid for medicine or a drug only if such medicine or 
drug is a prescribed drug or is insulin.''.
    (c) Health Flexible Spending Arrangements and Health Reimbursement 
Arrangements.--Section 106 of such Code is amended by adding at the end 
the following new subsection:
    ``(f) Reimbursements for Medicine Restricted to Prescribed Drugs 
and Insulin.--For purposes of this section and section 105, 
reimbursement for expenses incurred for a medicine or a drug shall be 
treated as a reimbursement for medical expenses only if such medicine 
or drug is a prescribed drug or is insulin.''.
    (d) Effective Dates.--The amendment made by this section shall 
apply to expenses incurred after December 31, 2010.

SEC. 532. LIMITATION ON HEALTH FLEXIBLE SPENDING ARRANGEMENTS UNDER 
              CAFETERIA PLANS.

    (a) In General.--Section 125 of the Internal Revenue Code of 1986 
is amended--
            (1) by redesignating subsections (i) and (j) as subsections 
        (j) and (k), respectively, and
            (2) by inserting after subsection (h) the following new 
        subsection:
    ``(i) Limitation on Health Flexible Spending Arrangements.--
            ``(1) In general.--For purposes of this section, if a 
        benefit is provided under a cafeteria plan through employer 
        contributions to a health flexible spending arrangement, such 
        benefit shall not be treated as a qualified benefit unless the 
        cafeteria plan provides that an employee may not elect for any 
        taxable year to have salary reduction contributions in excess 
        of $2,500 made to such arrangement.
            ``(2) Inflation adjustment.--In the case of any taxable 
        year beginning after 2013, the dollar amount in paragraph (1) 
        shall be increased by an amount equal to--
                    ``(A) such dollar amount, multiplied by
                    ``(B) the cost of living adjustment determined 
                under section 1(f)(3) for the calendar year in which 
                the taxable year begins determined by substituting 
                `calendar year 2012' for `calendar year 1992' in 
                subparagraph (B) thereof.
        If any increase determined under this paragraph is not a 
        multiple of $50, such increase shall be rounded to the next 
        lowest multiple of $50.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2012.

SEC. 533. INCREASE IN PENALTY FOR NONQUALIFIED DISTRIBUTIONS FROM 
              HEALTH SAVINGS ACCOUNTS.

    (a) In General.--Subparagraph (A) of section 223(f)(4) of the 
Internal Revenue Code of 1986 is amended by striking ``10 percent'' and 
inserting ``20 percent''.
    (b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after December 31, 2010.

SEC. 534. DENIAL OF DEDUCTION FOR FEDERAL SUBSIDIES FOR PRESCRIPTION 
              DRUG PLANS WHICH HAVE BEEN EXCLUDED FROM GROSS INCOME.

    (a) In General.--Section 139A of the Internal Revenue Code of 1986 
is amended by striking the second sentence.
    (b) Effective Date.--The amendment made by this section shall apply 
to taxable years beginning after December 31, 2010.

     PART 4--OTHER PROVISIONS TO CARRY OUT HEALTH INSURANCE REFORM

SEC. 541. DISCLOSURES TO CARRY OUT HEALTH INSURANCE EXCHANGE SUBSIDIES.

    (a) In General.--Subsection (l) of section 6103 of the Internal 
Revenue Code of 1986 is amended by adding at the end the following new 
paragraph:
            ``(21) Disclosure of return information to carry out health 
        insurance exchange subsidies.--
                    ``(A) In general.--The Secretary, upon written 
                request from the Health Choices Commissioner or the 
                head of a State-based health insurance exchange 
                approved for operation under section 308 of the , shall 
                disclose to officers and employees of the Health 
                Choices Administration or such State-based health 
                insurance exchange, as the case may be, return 
                information of any taxpayer whose income is relevant in 
                determining any affordability credit described in 
                subtitle C of title III of the . Such return 
                information shall be limited to--
                            ``(i) taxpayer identity information with 
                        respect to such taxpayer,
                            ``(ii) the filing status of such taxpayer,
                            ``(iii) the modified adjusted gross income 
                        of such taxpayer (as defined in section 
                        59B(e)(5)),
                            ``(iv) the number of dependents of the 
                        taxpayer,
                            ``(v) such other information as is 
                        prescribed by the Secretary by regulation as 
                        might indicate whether the taxpayer is eligible 
                        for such affordability credits (and the amount 
                        thereof), and
                            ``(vi) the taxable year with respect to 
                        which the preceding information relates or, if 
                        applicable, the fact that such information is 
                        not available.
                    ``(B) Restriction on use of disclosed 
                information.--Return information disclosed under 
                subparagraph (A) may be used by officers and employees 
                of the Health Choices Administration or such State-
                based health insurance exchange, as the case may be, 
                only for the purposes of, and to the extent necessary 
                in, establishing and verifying the appropriate amount 
                of any affordability credit described in subtitle C of 
                title III of the and providing for the repayment of any 
                such credit which was in excess of such appropriate 
                amount.''.
    (b) Procedures and Recordkeeping Related to Disclosures.--Paragraph 
(4) of section 6103(p) of such Code is amended--
            (1) by inserting ``, or any entity described in subsection 
        (l)(21),'' after ``or (20)'' in the matter preceding 
        subparagraph (A),
            (2) by inserting ``or any entity described in subsection 
        (l)(21),'' after ``or (o)(1)(A),'' in subparagraph (F)(ii), and
            (3) by inserting ``or any entity described in subsection 
        (l)(21),'' after ``or (20),'' both places it appears in the 
        matter after subparagraph (F).
    (c) Unauthorized Disclosure or Inspection.--Paragraph (2) of 
section 7213(a) of such Code is amended by striking ``or (20)'' and 
inserting ``(20), or (21)''.

SEC. 542. OFFERING OF EXCHANGE-PARTICIPATING HEALTH BENEFITS PLANS 
              THROUGH CAFETERIA PLANS.

    (a) In General.--Subsection (f) of section 125 of the Internal 
Revenue Code of 1986 is amended by adding at the end the following new 
paragraph:
            ``(3) Certain exchange-participating health benefits plans 
        not qualified.--
                    ``(A) In general.--The term `qualified benefit' 
                shall not include any exchange-participating health 
                benefits plan (as defined in section 101(c) of the ).
                    ``(B) Exception for exchange-eligible employers.--
                Subparagraph (A) shall not apply with respect to any 
                employee if such employee's employer is an exchange-
                eligible employer (as defined in section 302 of the 
                ).''.
    (b) Conforming Amendments.--Subsection (f) of section 125 of such 
Code is amended--
            (1) by striking ``For purposes of this section, the term'' 
        and inserting ``For purposes of this section--
    ``(1) In General.--The term'', and
            (2) by striking ``Such term shall not include'' and 
        inserting the following:
            ``(2) Long-term care insurance not qualified.--The term 
        `qualified benefit' shall not include''.
    (c) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2012.

SEC. 543. EXCLUSION FROM GROSS INCOME OF PAYMENTS MADE UNDER 
              REINSURANCE PROGRAM FOR RETIREES.

    (a) In General.--Section 139A of the Internal Revenue Code of 1986 
is amended--
            (1) by striking ``Gross income'' and inserting the 
        following:
    ``(a) Federal Subsidies for Prescription Drug Plans.--Gross 
income'', and
            (2) by adding at the end the following new subsection:
    ``(b) Federal Reinsurance Program for Retirees.--A rule similar to 
the rule of subsection (a) shall apply with respect to payments made 
under section 111 of the Affordable Health Care for America Act.''.
    (b) Conforming Amendment.--The heading of section 139A of such Code 
(and the item relating to such section in the table of sections for 
part III of subchapter B of chapter 1 of such Code) is amended by 
inserting ``and retiree health plans'' after ``prescription drug 
plans''.
    (c) Effective Date.--The amendments made by this section shall 
apply to taxable years ending after the date of the enactment of this 
Act.

SEC. 544. CLASS PROGRAM TREATED IN SAME MANNER AS LONG-TERM CARE 
              INSURANCE.

    (a) In General.--Subsection (f) of section 7702B of the Internal 
Revenue Code of 1986 is amended--
            (1) by striking ``State long-term care plan'' in paragraph 
        (1)(A) and inserting ``government long-term care plan'',
            (2) by redesignating paragraph (2) as paragraph (3), and
            (3) by inserting after paragraph (2) the following new 
        paragraph:
            ``(2) Government long-term care plan.--For purposes of this 
        subsection, the term `government long-term care plan' means--
                    ``(A) the CLASS program established under title 
                XXXII of the Public Health Service Act, and
                    ``(B) any State long-term care plan.''.
    (b) Conforming Amendments.--
            (1) Paragraph (3) of section 7702B(f) of such Code, as 
        redesignated by subsection (a), is amended by striking 
        ``paragraph (1)'' and inserting ``this subsection''.
            (2) Subsection (f) of section 7702(B) of such Code is 
        amended by striking ``State-maintained'' in the heading thereof 
        and inserting ``Government''.
    (c) Effective Date.--The amendments made by this section shall 
apply to taxable years ending after December 31, 2010.

SEC. 545. EXCLUSION FROM GROSS INCOME FOR MEDICAL CARE PROVIDED FOR 
              INDIANS.

    (a) In General.--Part III of subchapter B of chapter 1 of the 
Internal Revenue Code of 1986 (relating to items specifically excluded 
from gross income) is amended by inserting after section 139C the 
following new section:

``SEC. 139D. MEDICAL CARE PROVIDED FOR INDIANS.

    ``(a) In General.--Gross income does not include--
            ``(1) health services or benefits provided or purchased by 
        the Indian Health Service, either directly or indirectly, 
        through a grant to or a contract or compact with an Indian 
        tribe or tribal organization or through programs of third 
        parties funded by the Indian Health Service,
            ``(2) medical care provided by an Indian tribe or tribal 
        organization to a member of an Indian tribe (including for this 
        purpose, to the member's spouse or dependents) through any one 
        of the following: provided or purchased medical care services; 
        accident or health insurance (or an arrangement having the 
        effect of accident or health insurance); or amounts paid, 
        directly or indirectly, to reimburse the member for expenses 
        incurred for medical care,
            ``(3) the value of accident or health plan coverage 
        provided by an Indian tribe or tribal organization for medical 
        care to a member of an Indian tribe (including for this 
        purpose, coverage that extends to such member's spouse or 
        dependents) under an accident or health plan (or through an 
        arrangement having the effect of accident or health insurance), 
        and
            ``(4) any other medical care provided by an Indian tribe 
        that supplements, replaces, or substitutes for the programs and 
        services provided by the Federal Government to Indian tribes or 
        Indians.
    ``(b) Definitions.--For purposes of this section--
            ``(1) In general.--The terms `accident or health insurance' 
        and `accident or health plan' have the same meaning as when 
        used in sections 104 and 106.
            ``(2) Medical care.--The term `medical care' has the 
        meaning given such term in section 213.
            ``(3) Dependent.--The term `dependent' has the meaning 
        given such term in section 152, determined without regard to 
        subsections (b)(1), (b)(2), and (d)(1)(B).
            ``(4) Indian tribe.--The term `Indian tribe' means any 
        Indian tribe, band, nation, pueblo, or other organized group or 
        community, including any Alaska Native village, or regional or 
        village corporation, as defined in, or established pursuant to, 
        the Alaska Native Claims Settlement Act (43 U.S.C. 1601 et 
        seq.), which is recognized as eligible for the special programs 
        and services provided by the United States to Indians because 
        of their status as Indians.
            ``(5) Tribal organization.--The term `tribal organization' 
        has the meaning given such term in section 4(l) of the Indian 
        Self-Determination and Education Assistance Act (25 U.S.C. 
        450b(l)).''.
    (b) Clerical Amendment.--The table of sections for such part III is 
amended by inserting after the item relating to section 139C the 
following new item:

``Sec. 139D. Medical care provided for Indians.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to health benefits and coverage provided after the date of 
enactment of this Act.
    (d) No Inference.--Nothing in the amendments made by this section 
shall be construed to create an inference with respect to the exclusion 
from gross income of--
            (1) benefits provided by Indian tribes that are not within 
        the scope of this section, and
            (2) health benefits or coverage provided by Indian tribes 
        prior to the effective date of this section.

                  Subtitle B--Other Revenue Provisions

                       PART 1--GENERAL PROVISIONS

SEC. 551. SURCHARGE ON HIGH INCOME INDIVIDUALS.

    (a) In General.--Part VIII of subchapter A of chapter 1 of the 
Internal Revenue Code of 1986, as added by this title, is amended by 
adding at the end the following new subpart:

           ``Subpart B--Surcharge on High Income Individuals

``Sec. 59C. Surcharge on high income individuals.

``SEC. 59C. SURCHARGE ON HIGH INCOME INDIVIDUALS.

    ``(a) General Rule.--In the case of a taxpayer other than a 
corporation, there is hereby imposed (in addition to any other tax 
imposed by this subtitle) a tax equal to 5.4 percent of so much of the 
modified adjusted gross income of the taxpayer as exceeds $1,000,000.
    ``(b) Taxpayers Not Making a Joint Return.--In the case of any 
taxpayer other than a taxpayer making a joint return under section 6013 
or a surviving spouse (as defined in section 2(a)), subsection (a) 
shall be applied by substituting `$500,000' for `$1,000,000'.
    ``(c) Modified Adjusted Gross Income.--For purposes of this 
section, the term `modified adjusted gross income' means adjusted gross 
income reduced by any deduction (not taken into account in determining 
adjusted gross income) allowed for investment interest (as defined in 
section 163(d)). In the case of an estate or trust, adjusted gross 
income shall be determined as provided in section 67(e).
    ``(d) Special Rules.--
            ``(1) Nonresident alien.--In the case of a nonresident 
        alien individual, only amounts taken into account in connection 
        with the tax imposed under section 871(b) shall be taken into 
        account under this section.
            ``(2) Citizens and residents living abroad.--The dollar 
        amount in effect under subsection (a) (after the application of 
        subsection (b)) shall be decreased by the excess of--
                    ``(A) the amounts excluded from the taxpayer's 
                gross income under section 911, over
                    ``(B) the amounts of any deductions or exclusions 
                disallowed under section 911(d)(6) with respect to the 
                amounts described in subparagraph (A).
            ``(3) Charitable trusts.--Subsection (a) shall not apply to 
        a trust all the unexpired interests in which are devoted to one 
        or more of the purposes described in section 170(c)(2)(B).
            ``(4) Not treated as tax imposed by this chapter for 
        certain purposes.--The tax imposed under this section shall not 
        be treated as tax imposed by this chapter for purposes of 
        determining the amount of any credit under this chapter or for 
        purposes of section 55.''.
    (b) Clerical Amendment.--The table of subparts for part VIII of 
subchapter A of chapter 1 of such Code, as added by this title, is 
amended by inserting after the item relating to subpart A the following 
new item:

         ``subpart b. surcharge on high income individuals.''.

    (c) Section 15 Not to Apply.--The amendment made by subsection (a) 
shall not be treated as a change in a rate of tax for purposes of 
section 15 of the Internal Revenue Code of 1986.
    (d) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2010.

SEC. 552. EXCISE TAX ON MEDICAL DEVICES.

    (a) In General.--Chapter 31 of the Internal Revenue Code of 1986 is 
amended by adding at the end the following new subchapter:

                    ``Subchapter D--Medical Devices

``Sec. 4061. Medical devices.

``SEC. 4061. MEDICAL DEVICES.

    ``(a) In General.--There is hereby imposed on the first taxable 
sale of any medical device a tax equal to 2.5 percent of the price for 
which so sold.
    ``(b) First Taxable Sale.--For purposes of this section--
            ``(1) In general.--The term `first taxable sale' means the 
        first sale, for a purpose other than for resale, after 
        production, manufacture, or importation.
            ``(2) Exception for sales at retail establishments.--Such 
        term shall not include the sale of any medical device if--
                    ``(A) such sale is made at a retail establishment 
                on terms which are available to the general public, and
                    ``(B) such medical device is of a type (and 
                purchased in a quantity) which is purchased by the 
                general public.
            ``(3) Exception for exports, etc.--Rules similar to the 
        rules of sections 4221 (other than paragraphs (3), (4), (5), 
        and (6) of subsection (a) thereof) and 4222 shall apply for 
        purposes of this section. To the extent provided by the 
        Secretary, section 4222 may be extended to, and made applicable 
        with respect to, the exemption provided by paragraph (2).
            ``(4) Sales to patients not treated as resales.--If a 
        medical device is sold for use in connection with providing any 
        health care service to an individual, such sale shall not be 
        treated as being for the purpose of resale (even if such device 
        is sold to such individual).
    ``(c) Other Definitions and Special Rules.--For purposes of this 
section--
            ``(1) Medical device.--The term `medical device' means any 
        device (as defined in section 201(h) of the Federal Food, Drug, 
        and Cosmetic Act) intended for humans.
            ``(2) Lease treated as sale.--Rules similar to the rules of 
        section 4217 shall apply.
            ``(3) Use treated as sale.--
                    ``(A) In general.--If any person uses a medical 
                device before the first taxable sale of such device, 
                then such person shall be liable for tax under such 
                subsection in the same manner as if such use were the 
                first taxable sale of such device.
                    ``(B) Exceptions.--The preceding sentence shall not 
                apply to--
                            ``(i) use of a medical device as material 
                        in the manufacture or production of, or as a 
                        component part of, another medical device to be 
                        manufactured or produced by such person, or
                            ``(ii) use of a medical device after a sale 
                        described in subsection (b)(2).
            ``(4) Determination of price.--
                    ``(A) In general.--Rules similar to the rules of 
                subsections (a), (c), and (d) of section 4216 shall 
                apply for purposes of this section.
                    ``(B) Constructive sale price.--If--
                            ``(i) a medical device is sold (otherwise 
                        than through an arm's length transaction) at 
                        less than the fair market price, or
                            ``(ii) a person is liable for tax for a use 
                        described in paragraph (3),
                the tax under this section shall be computed on the 
                price for which such or similar devices are sold in the 
                ordinary course of trade as determined by the 
                Secretary.
            ``(5) Resales pursuant to certain contract arrangements.--
                    ``(A) In general.--In the case of a specified 
                contract sale of a medical device, the seller referred 
                to in subparagraph (B)(i) shall be entitled to recover 
                from the producer, manufacturer, or importer referred 
                to in subparagraph (B)(ii) the amount of the tax paid 
                by such seller under this section with respect to such 
                sale.
                    ``(B) Specified contract sale.--For purposes of 
                this paragraph, the term `specified contract sale' 
                means, with respect to any medical device, the first 
                taxable sale of such device if--
                            ``(i) the seller is not the producer, 
                        manufacturer, or importer of such device,
                            ``(ii) the price at which such device is so 
                        sold is determined in accordance with a 
                        contract between the producer, manufacturer, or 
                        importer of such device and the person to whom 
                        such device is so sold.
                    ``(C) Special rules related to credits and 
                refunds.--In the case of any credit or refund under 
                section 6416 of the tax imposed under this section on a 
                specified contract sale of a medical device--
                            ``(i) such credit or refund shall be 
                        allowed or made only if the seller has filed 
                        with the Secretary the written consent of the 
                        producer, manufacturer, or importer referred to 
                        in subparagraph (B)(ii) to the allowance of 
                        such credit or the making of such refund, and
                            ``(ii) the amount of tax taken into account 
                        under subparagraph (A) shall be reduced by the 
                        amount of such credit or refund.''.
    (b) Conforming Amendments.--
            (1) Paragraph (2) of section 6416(b) of such Code is 
        amended--
                    (A) by inserting ``or 4061'' after ``under section 
                4051'', and
                    (B) by adding at the end the following: ``In the 
                case of the tax imposed by section 4061, subparagraphs 
                (B), (C), (D), and (E) shall not apply.''.
            (2) The table of subchapters for chapter 31 of such Code is 
        amended by adding at the end the following new item:

                  ``subchapter d. medical devices.''.

    (c) Effective Date.--The amendments made by this section shall 
apply to sales (and leases and uses treated as sales) after December 
31, 2012.

SEC. 553. EXPANSION OF INFORMATION REPORTING REQUIREMENTS.

    (a) In General.--Section 6041 of the Internal Revenue Code of 1986 
is amended by adding at the end the following new subsections:
    ``(h) Application to Corporations.--Notwithstanding any regulation 
prescribed by the Secretary before the date of the enactment of this 
subsection, for purposes of this section the term `person' includes any 
corporation that is not an organization exempt from tax under section 
501(a).
    ``(i) Regulations.--The Secretary may prescribe such regulations 
and other guidance as may be appropriate or necessary to carry out the 
purposes of this section, including rules to prevent duplicative 
reporting of transactions.''.
    (b) Payments for Property and Other Gross Proceeds.--Subsection (a) 
of section 6041 of the Internal Revenue Code of 1986 is amended--
            (1) by inserting ``amounts in consideration for property,'' 
        after ``wages,'',
            (2) by inserting ``gross proceeds,'' after ``emoluments, or 
        other'', and
            (3) by inserting ``gross proceeds,'' after ``setting forth 
        the amount of such''.
    (c) Effective Date.--The amendments made by this section shall 
apply to payments made after December 31, 2011.

SEC. 554. DELAY IN APPLICATION OF WORLDWIDE ALLOCATION OF INTEREST.

    (a) In General.--Paragraphs (5)(D) and (6) of section 864(f) of the 
Internal Revenue Code of 1986 are each amended by striking ``December 
31, 2010'' and inserting ``December 31, 2019''.
    (b) Transition.--Subsection (f) of section 864 of such Code is 
amended by striking paragraph (7).

                  PART 2--PREVENTION OF TAX AVOIDANCE

SEC. 561. LIMITATION ON TREATY BENEFITS FOR CERTAIN DEDUCTIBLE 
              PAYMENTS.

    (a) In General.--Section 894 of the Internal Revenue Code of 1986 
(relating to income affected by treaty) is amended by adding at the end 
the following new subsection:
    ``(d) Limitation on Treaty Benefits for Certain Deductible 
Payments.--
            ``(1) In general.--In the case of any deductible related-
        party payment, any withholding tax imposed under chapter 3 (and 
        any tax imposed under subpart A or B of this part) with respect 
        to such payment may not be reduced under any treaty of the 
        United States unless any such withholding tax would be reduced 
        under a treaty of the United States if such payment were made 
        directly to the foreign parent corporation.
            ``(2) Deductible related-party payment.--For purposes of 
        this subsection, the term `deductible related-party payment' 
        means any payment made, directly or indirectly, by any person 
        to any other person if the payment is allowable as a deduction 
        under this chapter and both persons are members of the same 
        foreign controlled group of entities.
            ``(3) Foreign controlled group of entities.--For purposes 
        of this subsection--
                    ``(A) In general.--The term `foreign controlled 
                group of entities' means a controlled group of entities 
                the common parent of which is a foreign corporation.
                    ``(B) Controlled group of entities.--The term 
                `controlled group of entities' means a controlled group 
                of corporations as defined in section 1563(a)(1), 
                except that--
                            ``(i) `more than 50 percent' shall be 
                        substituted for `at least 80 percent' each 
                        place it appears therein, and
                            ``(ii) the determination shall be made 
                        without regard to subsections (a)(4) and (b)(2) 
                        of section 1563.
                A partnership or any other entity (other than a 
                corporation) shall be treated as a member of a 
                controlled group of entities if such entity is 
                controlled (within the meaning of section 954(d)(3)) by 
                members of such group (including any entity treated as 
                a member of such group by reason of this sentence).
            ``(4) Foreign parent corporation.--For purposes of this 
        subsection, the term `foreign parent corporation' means, with 
        respect to any deductible related-party payment, the common 
        parent of the foreign controlled group of entities referred to 
        in paragraph (3)(A).
            ``(5) Regulations.--The Secretary may prescribe such 
        regulations or other guidance as are necessary or appropriate 
        to carry out the purposes of this subsection, including 
        regulations or other guidance which provide for--
                    ``(A) the treatment of two or more persons as 
                members of a foreign controlled group of entities if 
                such persons would be the common parent of such group 
                if treated as one corporation, and
                    ``(B) the treatment of any member of a foreign 
                controlled group of entities as the common parent of 
                such group if such treatment is appropriate taking into 
                account the economic relationships among such 
                entities.''.
    (b) Effective Date.--The amendment made by this section shall apply 
to payments made after the date of the enactment of this Act.

SEC. 562. CODIFICATION OF ECONOMIC SUBSTANCE DOCTRINE; PENALTIES.

    (a) In General.--Section 7701 of the Internal Revenue Code of 1986 
is amended by redesignating subsection (o) as subsection (p) and by 
inserting after subsection (n) the following new subsection:
    ``(o) Clarification of Economic Substance Doctrine.--
            ``(1) Application of doctrine.--In the case of any 
        transaction to which the economic substance doctrine is 
        relevant, such transaction shall be treated as having economic 
        substance only if--
                    ``(A) the transaction changes in a meaningful way 
                (apart from Federal income tax effects) the taxpayer's 
                economic position, and
                    ``(B) the taxpayer has a substantial purpose (apart 
                from Federal income tax effects) for entering into such 
                transaction.
            ``(2) Special rule where taxpayer relies on profit 
        potential.--
                    ``(A) In general.--The potential for profit of a 
                transaction shall be taken into account in determining 
                whether the requirements of subparagraphs (A) and (B) 
                of paragraph (1) are met with respect to the 
                transaction only if the present value of the reasonably 
                expected pre-tax profit from the transaction is 
                substantial in relation to the present value of the 
                expected net tax benefits that would be allowed if the 
                transaction were respected.
                    ``(B) Treatment of fees and foreign taxes.--Fees 
                and other transaction expenses and foreign taxes shall 
                be taken into account as expenses in determining pre-
                tax profit under subparagraph (A).
            ``(3) State and local tax benefits.--For purposes of 
        paragraph (1), any State or local income tax effect which is 
        related to a Federal income tax effect shall be treated in the 
        same manner as a Federal income tax effect.
            ``(4) Financial accounting benefits.--For purposes of 
        paragraph (1)(B), achieving a financial accounting benefit 
        shall not be taken into account as a purpose for entering into 
        a transaction if the origin of such financial accounting 
        benefit is a reduction of Federal income tax.
            ``(5) Definitions and special rules.--For purposes of this 
        subsection--
                    ``(A) Economic substance doctrine.--The term 
                `economic substance doctrine' means the common law 
                doctrine under which tax benefits under subtitle A with 
                respect to a transaction are not allowable if the 
                transaction does not have economic substance or lacks a 
                business purpose.
                    ``(B) Exception for personal transactions of 
                individuals.--In the case of an individual, paragraph 
                (1) shall apply only to transactions entered into in 
                connection with a trade or business or an activity 
                engaged in for the production of income.
                    ``(C) Other common law doctrines not affected.--
                Except as specifically provided in this subsection, the 
                provisions of this subsection shall not be construed as 
                altering or supplanting any other rule of law, and the 
                requirements of this subsection shall be construed as 
                being in addition to any such other rule of law.
                    ``(D) Determination of application of doctrine not 
                affected.--The determination of whether the economic 
                substance doctrine is relevant to a transaction (or 
                series of transactions) shall be made in the same 
                manner as if this subsection had never been enacted.
            ``(6) Regulations.--The Secretary shall prescribe such 
        regulations as may be necessary or appropriate to carry out the 
        purposes of this subsection.''.
    (b) Penalty for Underpayments Attributable to Transactions Lacking 
Economic Substance.--
            (1) In general.--Subsection (b) of section 6662 of such 
        Code is amended by inserting after paragraph (5) the following 
        new paragraph:
            ``(6) Any disallowance of claimed tax benefits by reason of 
        a transaction lacking economic substance (within the meaning of 
        section 7701(o)) or failing to meet the requirements of any 
        similar rule of law.''.
            (2) Increased penalty for nondisclosed transactions.--
        Section 6662 of such Code is amended by adding at the end the 
        following new subsection:
    ``(i) Increase in Penalty in Case of Nondisclosed Noneconomic 
Substance Transactions.--
            ``(1) In general.--In the case of any portion of an 
        underpayment which is attributable to one or more nondisclosed 
        noneconomic substance transactions, subsection (a) shall be 
        applied with respect to such portion by substituting `40 
        percent' for `20 percent'.
            ``(2) Nondisclosed noneconomic substance transactions.--For 
        purposes of this subsection, the term `nondisclosed noneconomic 
        substance transaction' means any portion of a transaction 
        described in subsection (b)(6) with respect to which the 
        relevant facts affecting the tax treatment are not adequately 
        disclosed in the return nor in a statement attached to the 
        return.
            ``(3) Special rule for amended returns.--Except as provided 
        in regulations, in no event shall any amendment or supplement 
        to a return of tax be taken into account for purposes of this 
        subsection if the amendment or supplement is filed after the 
        earlier of the date the taxpayer is first contacted by the 
        Secretary regarding the examination of the return or such other 
        date as is specified by the Secretary.''.
            (3) Conforming amendment.--Subparagraph (B) of section 
        6662A(e)(2) of such Code is amended--
                    (A) by striking ``section 6662(h)'' and inserting 
                ``subsections (h) or (i) of section 6662'', and
                    (B) by striking ``gross valuation misstatement 
                penalty'' in the heading and inserting ``certain 
                increased underpayment penalties''.
    (c) Reasonable Cause Exception Not Applicable to Noneconomic 
Substance Transactions and Tax Shelters.--
            (1) Reasonable cause exception for underpayments.--
        Subsection (c) of section 6664 of such Code is amended--
                    (A) by redesignating paragraphs (2) and (3) as 
                paragraphs (3) and (4), respectively,
                    (B) by striking ``paragraph (2)'' in paragraph 
                (4)(A), as so redesignated, and inserting ``paragraph 
                (3)'', and
                    (C) by inserting after paragraph (1) the following 
                new paragraph:
            ``(2) Exception.--Paragraph (1) shall not apply to any 
        portion of an underpayment which is attributable to one or more 
        tax shelters (as defined in section 6662(d)(2)(C)) or 
        transactions described in section 6662(b)(6).''.
            (2) Reasonable cause exception for reportable transaction 
        understatements.--Subsection (d) of section 6664 of such Code 
        is amended--
                    (A) by redesignating paragraphs (2) and (3) as 
                paragraphs (3) and (4), respectively,
                    (B) by striking ``paragraph (2)(C)'' in paragraph 
                (4), as so redesignated, and inserting ``paragraph 
                (3)(C)'', and
                    (C) by inserting after paragraph (1) the following 
                new paragraph:
            ``(2) Exception.--Paragraph (1) shall not apply to any 
        portion of a reportable transaction understatement which is 
        attributable to one or more tax shelters (as defined in section 
        6662(d)(2)(C)) or transactions described in section 
        6662(b)(6).''.
    (d) Application of Penalty for Erroneous Claim for Refund or Credit 
to Noneconomic Substance Transactions.--Section 6676 of such Code is 
amended by redesignating subsection (c) as subsection (d) and inserting 
after subsection (b) the following new subsection:
    ``(c) Noneconomic Substance Transactions Treated as Lacking 
Reasonable Basis.--For purposes of this section, any excessive amount 
which is attributable to any transaction described in section 
6662(b)(6) shall not be treated as having a reasonable basis.''.
    (e) Effective Date.--
            (1) In general.--Except as otherwise provided in this 
        subsection, the amendments made by this section shall apply to 
        transactions entered into after the date of the enactment of 
        this Act.
            (2) Underpayments.--The amendments made by subsections (b) 
        and (c)(1) shall apply to underpayments attributable to 
        transactions entered into after the date of the enactment of 
        this Act.
            (3) Understatements.--The amendments made by subsection 
        (c)(2) shall apply to understatements attributable to 
        transactions entered into after the date of the enactment of 
        this Act.
            (4) Refunds and credits.--The amendment made by subsection 
        (d) shall apply to refunds and credits attributable to 
        transactions entered into after the date of the enactment of 
        this Act.

SEC. 563. CERTAIN LARGE OR PUBLICLY TRADED PERSONS MADE SUBJECT TO A 
              MORE LIKELY THAN NOT STANDARD FOR AVOIDING PENALTIES ON 
              UNDERPAYMENTS.

    (a) In General.--Subsection (c) of section 6664 of the Internal 
Revenue Code of 1986, as amended by section 562, is amended--
            (1) by redesignating paragraphs (3) and (4) as paragraphs 
        (4) and (5), respectively,
            (2) by striking ``paragraph (3)'' in paragraph (4)(A), as 
        so redesignated, and inserting ``paragraph (4)'', and
            (3) by inserting after paragraph (2) the following new 
        paragraph:
            ``(3) Special rule for certain large or publicly traded 
        persons.--
                    ``(A) In general.--In the case of any specified 
                person, paragraph (1) shall apply to the portion of an 
                underpayment which is attributable to any item only if 
                such person has a reasonable belief that the tax 
                treatment of such item by such person is more likely 
                than not the proper tax treatment of such item.
                    ``(B) Specified person.--For purposes of this 
                paragraph, the term `specified person' means--
                            ``(i) any person required to file periodic 
                        or other reports under section 13 of the 
                        Securities Exchange Act of 1934, and
                            ``(ii) any corporation with gross receipts 
                        in excess of $100,000,000 for the taxable year 
                        involved.
                All persons treated as a single employer under section 
                52(a) shall be treated as one person for purposes of 
                clause (ii).''.
    (b) Nonapplication of Substantial Authority and Reasonable Basis 
Standards for Reducing Understatements.--Paragraph (2) of section 
6662(d) of such Code is amended by adding at the end the following new 
subparagraph:
                    ``(D) Reduction not to apply to certain large or 
                publicly traded persons.--Subparagraph (B) shall not 
                apply to any specified person (as defined in section 
                6664(c)(3)(B)).''.
    (c) Effective Date.--
            (1) In general.--Except as provided in paragraph (2), the 
        amendments made by this section shall apply to underpayments 
        attributable to transactions entered into after the date of the 
        enactment of this Act.
            (2) Nonapplication of understatement reduction.--The 
        amendment made by subsection (b) shall apply to understatements 
        attributable to transactions entered into after the date of the 
        enactment of this Act.

                   PART 3--PARITY IN HEALTH BENEFITS

SEC. 571. CERTAIN HEALTH RELATED BENEFITS APPLICABLE TO SPOUSES AND 
              DEPENDENTS EXTENDED TO ELIGIBLE BENEFICIARIES.

    (a) Application of Accident and Health Plans to Eligible 
Beneficiaries.--
            (1) Exclusion of contributions.--Section 106 of the 
        Internal Revenue Code of 1986 (relating to contributions by 
        employer to accident and health plans), as amended by section 
        531, is amended by adding at the end the following new 
        subsection:
    ``(g) Coverage Provided for Eligible Beneficiaries of Employees.--
            ``(1) In general.--Subsection (a) shall apply with respect 
        to any eligible beneficiary of the employee.
            ``(2) Eligible beneficiary.--For purposes of this 
        subsection, the term `eligible beneficiary' means any 
        individual who is eligible to receive benefits or coverage 
        under an accident or health plan.''.
            (2) Exclusion of amounts expended for medical care.--The 
        first sentence of section 105(b) of such Code (relating to 
        amounts expended for medical care) is amended--
                    (A) by striking ``and his dependents'' and 
                inserting ``his dependents'', and
                    (B) by inserting before the period the following: 
                ``and any eligible beneficiary (within the meaning of 
                section 106(g)) with respect to the taxpayer''.
            (3) Payroll taxes.--
                    (A) Section 3121(a)(2) of such Code is amended--
                            (i) by striking ``or any of his 
                        dependents'' in the matter preceding 
                        subparagraph (A) and inserting ``, any of his 
                        dependents, or any eligible beneficiary (within 
                        the meaning of section 106(g)) with respect to 
                        the employee'',
                            (ii) by striking ``or any of his 
                        dependents,'' in subparagraph (A) and inserting 
                        ``, any of his dependents, or any eligible 
                        beneficiary (within the meaning of section 
                        106(g)) with respect to the employee,'', and
                            (iii) by striking ``and their dependents'' 
                        both places it appears and inserting ``and such 
                        employees' dependents and eligible 
                        beneficiaries (within the meaning of section 
                        106(g))''.
                    (B) Section 3231(e)(1) of such Code is amended--
                            (i) by striking ``or any of his 
                        dependents'' and inserting ``, any of his 
                        dependents, or any eligible beneficiary (within 
                        the meaning of section 106(g)) with respect to 
                        the employee,'', and
                            (ii) by striking ``and their dependents'' 
                        both places it appears and inserting ``and such 
                        employees' dependents and eligible 
                        beneficiaries (within the meaning of section 
                        106(g))''.
                    (C) Section 3306(b)(2) of such Code is amended--
                            (i) by striking ``or any of his 
                        dependents'' in the matter preceding 
                        subparagraph (A) and inserting ``, any of his 
                        dependents, or any eligible beneficiary (within 
                        the meaning of section 106(g)) with respect to 
                        the employee,'',
                            (ii) by striking ``or any of his 
                        dependents'' in subparagraph (A) and inserting 
                        ``, any of his dependents, or any eligible 
                        beneficiary (within the meaning of section 
                        106(g)) with respect to the employee'', and
                            (iii) by striking ``and their dependents'' 
                        both places it appears and inserting ``and such 
                        employees' dependents and eligible 
                        beneficiaries (within the meaning of section 
                        106(g))''.
                    (D) Section 3401(a) of such Code is amended by 
                striking ``or'' at the end of paragraph (22), by 
                striking the period at the end of paragraph (23) and 
                inserting ``; or'', and by inserting after paragraph 
                (23) the following new paragraph:
            ``(24) for any payment made to or for the benefit of an 
        employee or any eligible beneficiary (within the meaning of 
        section 106(g)) if at the time of such payment it is reasonable 
        to believe that the employee will be able to exclude such 
        payment from income under section 106 or under section 105 by 
        reference in section 105(b) to section 106(g).''.
    (b) Expansion of Dependency for Purposes of Deduction for Health 
Insurance Costs of Self-employed Individuals.--
            (1) In general.--Paragraph (1) of section 162(l) of the 
        Internal Revenue Code of 1986 (relating to special rules for 
        health insurance costs of self-employed individuals) is amended 
        to read as follows:
            ``(1) Allowance of deduction.--In the case of a taxpayer 
        who is an employee within the meaning of section 401(c)(1), 
        there shall be allowed as a deduction under this section an 
        amount equal to the amount paid during the taxable year for 
        insurance which constitutes medical care for--
                    ``(A) the taxpayer,
                    ``(B) the taxpayer's spouse,
                    ``(C) the taxpayer's dependents,
                    ``(D) any individual who--
                            ``(i) satisfies the age requirements of 
                        section 152(c)(3)(A),
                            ``(ii) bears a relationship to the taxpayer 
                        described in section 152(d)(2)(H), and
                            ``(iii) meets the requirements of section 
                        152(d)(1)(C), and
                    ``(E) one individual who--
                            ``(i) does not satisfy the age requirements 
                        of section 152(c)(3)(A),
                            ``(ii) bears a relationship to the taxpayer 
                        described in section 152(d)(2)(H),
                            ``(iii) meets the requirements of section 
                        152(d)(1)(D), and
                            ``(iv) is not the spouse of the taxpayer 
                        and does not bear any relationship to the 
                        taxpayer described in subparagraphs (A) through 
                        (G) of section 152(d)(2).''.
            (2) Conforming amendment.--Subparagraph (B) of section 
        162(l)(2) of such Code is amended by inserting ``, any 
        dependent, or individual described in subparagraph (D) or (E) 
        of paragraph (1) with respect to'' after ``spouse''.
    (c) Extension to Eligible Beneficiaries of Sick and Accident 
Benefits Provided to Members of a Voluntary Employees' Beneficiary 
Association and Their Dependents.--Section 501(c)(9) of the Internal 
Revenue Code of 1986 (relating to list of exempt organizations) is 
amended by adding at the end the following new sentence: ``For purposes 
of providing for the payment of sick and accident benefits to members 
of such an association and their dependents, the term `dependents' 
shall include any individual who is an eligible beneficiary (within the 
meaning of section 106(g)), as determined under the terms of a medical 
benefit, health insurance, or other program under which members and 
their dependents are entitled to sick and accident benefits.''.
    (d) Flexible Spending Arrangements and Health Reimbursement 
Arrangements.--The Secretary of Treasury shall issue guidance of 
general applicability providing that medical expenses that otherwise 
qualify--
            (1) for reimbursement from a flexible spending arrangement 
        under regulations in effect on the date of the enactment of 
        this Act may be reimbursed from an employee's flexible spending 
        arrangement, notwithstanding the fact that such expenses are 
        attributable to any individual who is not the employee's spouse 
        or dependent (within the meaning of section 105(b) of the 
        Internal Revenue Code of 1986) but is an eligible beneficiary 
        (within the meaning of section 106(g) of such Code) under the 
        flexible spending arrangement with respect to the employee, and
            (2) for reimbursement from a health reimbursement 
        arrangement under regulations in effect on the date of the 
        enactment of this Act may be reimbursed from an employee's 
        health reimbursement arrangement, notwithstanding the fact that 
        such expenses are attributable to an individual who is not a 
        spouse or dependent (within the meaning of section 105(b) of 
        such Code) but is an eligible beneficiary (within the meaning 
        of section 106(g) of such Code) under the health reimbursement 
        arrangement with respect to the employee.
    (e) Effective Date.--The amendments made by this section shall 
apply to taxable years beginning after December 31, 2009.

             DIVISION B--MEDICARE AND MEDICAID IMPROVEMENTS

SEC. 1001. TABLE OF CONTENTS OF DIVISION.

    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

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

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.
              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.
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.
           Subtitle D--Physician Payments Sunshine Provision

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.
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.
                      TITLE VII--MEDICAID AND CHIP

Sec. 1. Table of contents [Temporary].
                 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

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).
                         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.
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.
Sec. 1909. Disregard under the Supplemental Security Income program of 
                            compensation for participation in clinical 
                            trials for rare diseases or conditions.

                  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.

    (a) In General.--Section 1888(e)(4)(E)(ii) of the Social Security 
Act (42 U.S.C. 1395yy(e)(4)(E)(ii)) is amended--
            (1) in subclause (III), by striking ``and'' at the end;
            (2) by redesignating subclause (IV) as subclause (VI); and
            (3) by inserting after subclause (III) the following new 
        subclauses:
                                    ``(IV) for each of fiscal years 
                                2004 through 2009, the rate computed 
                                for the previous fiscal year increased 
                                by the skilled nursing facility market 
                                basket percentage change for the fiscal 
                                year involved;
                                    ``(V) for fiscal year 2010, the 
                                rate computed for the previous fiscal 
                                year; and''.
    (b) Delayed Effective Date.--Section 1888(e)(4)(E)(ii)(V) of the 
Social Security Act, as inserted by subsection (a)(3), shall not apply 
to payment for days before January 1, 2010.

SEC. 1102. INPATIENT REHABILITATION FACILITY PAYMENT UPDATE.

    (a) In General.--Section 1886(j)(3)(C) of the Social Security Act 
(42 U.S.C. 1395ww(j)(3)(C)) is amended by striking ``and 2009'' and 
inserting ``through 2010''.
    (b) Delayed Effective Date.--The amendment made by subsection (a) 
shall not apply to payment units occurring before January 1, 2010.

SEC. 1103. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET 
              UPDATES THAT DO NOT ALREADY INCORPORATE SUCH 
              IMPROVEMENTS.

    (a) Inpatient Acute Hospitals.--Section 1886(b)(3)(B) of the Social 
Security Act (42 U.S.C. 1395ww(b)(3)(B)) is amended--
            (1) in clause (iii)--
                    (A) by striking ``(iii) For purposes of this 
                subparagraph,'' and inserting ``(iii)(I) For purposes 
                of this subparagraph, subject to the productivity 
                adjustment described in subclause (II),''; and
                    (B) by adding at the end the following new 
                subclause:
    ``(II) The productivity adjustment described in this subclause, 
with respect to an increase or change for a fiscal year or year or cost 
reporting period, or other annual period, is a productivity offset in 
the form of a reduction in such increase or change equal to the 
percentage change in the 10-year moving average of annual economy-wide 
private nonfarm business multi-factor productivity (as recently 
published in final form before the promulgation or publication of such 
increase for the year or period involved). Except as otherwise 
provided, any reference to the increase described in this clause shall 
be a reference to the percentage increase described in subclause (I) 
minus the percentage change under this subclause.'';
            (2) in the first sentence of clause (viii)(I), by inserting 
        ``(but not below zero)'' after ``shall be reduced''; and
            (3) in the first sentence of clause (ix)(I)--
                    (A) by inserting ``(determined without regard to 
                clause (iii)(II))'' after ``clause (i)'' the second 
                time it appears; and
                    (B) by inserting ``(but not below zero)'' after 
                ``reduced''.
    (b) Skilled Nursing Facilities.--Section 1888(e)(5)(B) of such Act 
(42 U.S.C. 1395yy(e)(5)(B)) is amended by inserting ``subject to the 
productivity adjustment described in section 1886(b)(3)(B)(iii)(II)'' 
after ``as calculated by the Secretary''.
    (c) Long Term Care Hospitals.--Section 1886(m) of the Social 
Security Act (42 U.S.C. 1395ww(m)) is amended by adding at the end the 
following new paragraph:
            ``(3) Productivity adjustment.--In implementing the system 
        described in paragraph (1) for discharges occurring on or after 
        January 1, 2010, during the rate year ending in 2010 or any 
        subsequent rate year for a hospital, to the extent that an 
        annual percentage increase factor applies to a standard Federal 
        rate for such discharges for the hospital, such factor shall be 
        subject to the productivity adjustment described in subsection 
        (b)(3)(B)(iii)(II).''.
    (d) Inpatient Rehabilitation Facilities.--The second sentence of 
section 1886(j)(3)(C) of the Social Security Act (42 U.S.C. 
1395ww(j)(3)(C)) is amended by inserting ``(subject to the productivity 
adjustment described in subsection (b)(3)(B)(iii)(II))'' after 
``appropriate percentage increase''.
    (e) Psychiatric Hospitals.--Section 1886 of the Social Security Act 
(42 U.S.C. 1395ww) is amended by adding at the end the following new 
subsection:
    ``(o) Prospective Payment for Psychiatric Hospitals.--
            ``(1) Reference to establishment and implementation of 
        system.--For provisions related to the establishment and 
        implementation of a prospective payment system for payments 
        under this title for inpatient hospital services furnished by 
        psychiatric hospitals (as described in clause (i) of subsection 
        (d)(1)(B) and psychiatric units (as described in the matter 
        following clause (v) of such subsection), see section 124 of 
        the Medicare, Medicaid, and SCHIP Balanced Budget Refinement 
        Act of 1999.
            ``(2) Productivity adjustment.--In implementing the system 
        described in paragraph (1) for days occurring during the rate 
        year ending in 2011 or any subsequent rate year for a 
        psychiatric hospital or unit described in such paragraph, to 
        the extent that an annual percentage increase factor applies to 
        a base rate for such days for the hospital or unit, 
        respectively, such factor shall be subject to the productivity 
        adjustment described in subsection (b)(3)(B)(iii)(II).''.
    (f) Hospice Care.--Subclause (VII) of section 1814(i)(1)(C)(ii) of 
the Social Security Act (42 U.S.C. 1395f(i)(1)(C)(ii)) is amended by 
inserting after ``the market basket percentage increase'' the 
following: ``(which is subject to the productivity adjustment described 
in section 1886(b)(3)(B)(iii)(II))''.
    (g) Effective Dates.--
            (1) IPPS.--The amendments made by subsection (a) shall 
        apply to annual increases effected for fiscal years beginning 
        with fiscal year 2010, but only with respect to discharges 
        occurring on or after January 1, 2010.
            (2) SNF and irf.--The amendments made by subsections (b) 
        and (d) shall apply to annual increases effected for fiscal 
        years beginning with fiscal year 2011.
            (3) Hospice care.--The amendment made by subsection (f) 
        shall apply to annual increases effected for fiscal years 
        beginning with fiscal year 2010, but only with respect to days 
        of care occurring on or after January 1, 2010.

                PART 2--OTHER MEDICARE PART A PROVISIONS

SEC. 1111. PAYMENTS TO SKILLED NURSING FACILITIES.

    (a) Change in Recalibration Factor.--
            (1) Analysis.--The Secretary of Health and Human Services 
        shall conduct, using calendar year 2006 claims data, an initial 
        analysis comparing total payments under title XVIII of the 
        Social Security Act for skilled nursing facility services under 
        the RUG-53 and under the RUG-44 classification systems.
            (2) Adjustment in recalibration factor.--Based on the 
        initial analysis under paragraph (1), the Secretary shall 
        adjust the case mix indexes under section 1888(e)(4)(G)(i) of 
        the Social Security Act (42 U.S.C. 1395yy(e)(4)(G)(i)) for 
        fiscal year 2010 by the appropriate recalibration factor as 
        proposed in the proposed rule for Medicare skilled nursing 
        facilities issued by such Secretary on May 12, 2009 (74 Federal 
        Register 22214 et seq.).
    (b) Change in Payment for Nontherapy Ancillary (NTA) Services and 
Therapy Services.--
            (1) Changes under current snf classification system.--
                    (A) In general.--Subject to subparagraph (B), the 
                Secretary of Health and Human Services shall, under the 
                system for payment of skilled nursing facility services 
                under section 1888(e) of the Social Security Act (42 
                U.S.C. 1395yy(e)), increase payment by 10 percent for 
                non-therapy ancillary services (as specified by the 
                Secretary in the notice issued on November 27, 1998 (63 
                Federal Register 65561 et seq.)) and shall decrease 
                payment for the therapy case mix component of such 
                rates by 5.5 percent.
                    (B) Effective date.--The changes in payment 
                described in subparagraph (A) shall apply for days on 
                or after January 1, 2010, and until the Secretary 
                implements an alternative case mix classification 
                system for payment of skilled nursing facility services 
                under section 1888(e) of the Social Security Act (42 
                U.S.C. 1395yy(e)).
                    (C) Implementation.--Notwithstanding any other 
                provision of law, the Secretary may implement by 
                program instruction or otherwise the provisions of this 
                paragraph.
            (2) Changes under a future snf case mix classification 
        system.--
                    (A) Analysis.--
                            (i) In general.--The Secretary of Health 
                        and Human Services shall analyze payments for 
                        non-therapy ancillary services under a future 
                        skilled nursing facility classification system 
                        to ensure the accuracy of payment for non-
                        therapy ancillary services. Such analysis shall 
                        consider use of appropriate predictors which 
                        may include age, physical and mental status, 
                        ability to perform activities of daily living, 
                        prior nursing home stay, diagnoses, broad RUG 
                        category, and a proxy for length of stay.
                            (ii) Application.--Such analysis shall be 
                        conducted in a manner such that the future 
                        skilled nursing facility classification system 
                        is implemented to apply to services furnished 
                        during a fiscal year beginning with fiscal year 
                        2011.
                    (B) Consultation.--In conducting the analysis under 
                subparagraph (A), the Secretary shall consult with 
                interested parties, including the Medicare Payment 
                Advisory Commission and other interested stakeholders, 
                to identify appropriate predictors of nontherapy 
                ancillary costs.
                    (C) Rulemaking.--The Secretary shall include the 
                result of the analysis under subparagraph (A) in the 
                fiscal year 2011 rulemaking cycle for purposes of 
                implementation beginning for such fiscal year.
                    (D) Implementation.--Subject to subparagraph (E) 
                and consistent with subparagraph (A)(ii), the Secretary 
                shall implement changes to payments for non-therapy 
                ancillary services (which shall include a separate rate 
                component for non-therapy ancillary services and may 
                include use of a model that predicts payment amounts 
                applicable for non-therapy ancillary services) under 
                such future skilled nursing facility services 
                classification system as the Secretary determines 
                appropriate based on the analysis conducted pursuant to 
                subparagraph (A).
                    (E) Budget neutrality.--The Secretary shall 
                implement changes described in subparagraph (D) in a 
                manner such that the estimated expenditures under such 
                future skilled nursing facility services classification 
                system for a fiscal year beginning with fiscal year 
                2011 with such changes would be equal to the estimated 
                expenditures that would otherwise occur under title 
                XVIII of the Social Security Act under such future 
                skilled nursing facility services classification system 
                for such year without such changes.
    (c) Outlier Policy for NTA and Therapy.--Section 1888(e) of the 
Social Security Act (42 U.S.C. 1395yy(e)) is amended by adding at the 
end the following new paragraph:
            ``(13) Outliers for nta and therapy.--
                    ``(A) In general.--With respect to outliers because 
                of unusual variations in the type or amount of 
                medically necessary care, beginning with October 1, 
                2010, the Secretary--
                            ``(i) shall provide for an addition or 
                        adjustment to the payment amount otherwise made 
                        under this section with respect to non-therapy 
                        ancillary services in the case of such 
                        outliers; and
                            ``(ii) may provide for such an addition or 
                        adjustment to the payment amount otherwise made 
                        under this section with respect to therapy 
                        services in the case of such outliers.
                    ``(B) Outliers based on aggregate costs.--Outlier 
                adjustments or additional payments described in 
                subparagraph (A) shall be based on aggregate costs 
                during a stay in a skilled nursing facility and not on 
                the number of days in such stay.
                    ``(C) Budget neutrality.--The Secretary shall 
                reduce estimated payments that would otherwise be made 
                under the prospective payment system under this 
                subsection with respect to a fiscal year by 2 percent. 
                The total amount of the additional payments or payment 
                adjustments for outliers made under this paragraph with 
                respect to a fiscal year may not exceed 2 percent of 
                the total payments projected or estimated to be made 
                based on the prospective payment system under this 
                subsection for the fiscal year.''.
    (d) Conforming Amendments.--Section 1888(e)(8) of such Act (42 
U.S.C. 1395yy(e)(8)) is amended--
            (1) in subparagraph (A)--
                    (A) by striking ``and'' before ``adjustments''; and
                    (B) by inserting ``, and adjustment under section 
                1111(b) of the Affordable Health Care for America Act'' 
                before the semicolon at the end;
            (2) in subparagraph (B), by striking ``and'';
            (3) in subparagraph (C), by striking the period and 
        inserting ``; and''; and
            (4) by adding at the end the following new subparagraph:
                    ``(D) the establishment of outliers under paragraph 
                (13).''.

SEC. 1112. MEDICARE DSH REPORT AND PAYMENT ADJUSTMENTS IN RESPONSE TO 
              COVERAGE EXPANSION.

    (a) DSH Report.--
            (1) In general.--Not later than January 1, 2016, the 
        Secretary of Health and Human Services shall submit to Congress 
        a report on Medicare DSH taking into account the impact of the 
        health care reforms carried out under division A in reducing 
        the number of uninsured individuals. The report shall include 
        recommendations relating to the following:
                    (A) The appropriate amount, targeting, and 
                distribution of Medicare DSH to compensate for higher 
                Medicare costs associated with serving low-income 
                beneficiaries (taking into account variations in the 
                empirical justification for Medicare DSH attributable 
                to hospital characteristics, including bed size), 
                consistent with the original intent of Medicare DSH.
                    (B) The appropriate amount, targeting, and 
                distribution of Medicare DSH to hospitals given their 
                continued uncompensated care costs, to the extent such 
                costs remain.
            (2) Coordination with medicaid dsh report.--The Secretary 
        shall coordinate the report under this subsection with the 
        report on Medicaid DSH under section 1704(a).
    (b) Payment Adjustments in Response to Coverage Expansion.--
            (1) In general.--If there is a significant decrease in the 
        national rate of uninsurance as a result of this Act (as 
        determined under paragraph (2)(A)), then the Secretary of 
        Health and Human Services shall, beginning in fiscal year 2017, 
        implement the following adjustments to Medicare DSH:
                    (A) In lieu of the amount of Medicare DSH payment 
                that would otherwise be made under section 
                1886(d)(5)(F) of the Social Security Act, the amount of 
                Medicare DSH payment shall be an amount based on the 
                recommendations of the report under subsection 
                (a)(1)(A) and shall take into account variations in the 
                empirical justification for Medicare DSH attributable 
                to hospital characteristics, including bed size.
                    (B) Subject to paragraph (3), make an additional 
                payment to a hospital by an amount that is estimated 
                based on the amount of uncompensated care provided by 
                the hospital based on criteria for uncompensated care 
                as determined by the Secretary, which shall exclude bad 
                debt.
            (2) Significant decrease in national rate of uninsurance as 
        a result of this act.--For purposes of this subsection--
                    (A) In general.--There is a ``significant decrease 
                in the national rate of uninsurance as a result of this 
                Act'' if there is a decrease in the national rate of 
                uninsurance (as defined in subparagraph (B)) from 2012 
                to 2014 that exceeds 8 percentage points.
                    (B) National rate of uninsurance defined.--The term 
                ``national rate of uninsurance'' means, for a year, 
                such rate for the under-65 population for the year as 
                determined and published by the Bureau of the Census in 
                its Current Population Survey in or about September of 
                the succeeding year.
            (3) Uncompensated care increase.--
                    (A) Computation of dsh savings.--For each fiscal 
                year (beginning with fiscal year 2017), the Secretary 
                shall estimate the aggregate reduction in the amount of 
                Medicare DSH payment that would be expected to result 
                from the adjustment under paragraph (1)(A).
                    (B) Structure of payment increase.--The Secretary 
                shall compute the additional payment to a hospital as 
                described in paragraph (1)(B) for a fiscal year in 
                accordance with a formula established by the Secretary 
                that provides that--
                            (i) the estimated aggregate amount of such 
                        increase for the fiscal year does not exceed 50 
                        percent of the aggregate reduction in Medicare 
                        DSH estimated by the Secretary for such fiscal 
                        year; and
                            (ii) hospitals with higher levels of 
                        uncompensated care receive a greater increase.
    (c) Medicare DSH.--In this section, the term ``Medicare DSH'' means 
adjustments in payments under section 1886(d)(5)(F) of the Social 
Security Act (42 U.S.C. 1395ww(d)(5)(F)) for inpatient hospital 
services furnished by disproportionate share hospitals.

SEC. 1113. EXTENSION OF HOSPICE REGULATION MORATORIUM.

    Section 4301(a) of division B of the American Recovery and 
Reinvestment Act of 2009 (Public Law 111-5) is amended--
            (1) by striking ``October 1, 2009'' and inserting ``October 
        1, 2010''; and
            (2) by striking ``for fiscal year 2009'' and inserting 
        ``for fiscal years 2009 and 2010''.

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.

    (a) Ordering Post-hospital Extended Care Services.--Section 1814(a) 
of the Social Security Act (42 U.S.C. 1395f(a)) is amended--
            (1) in paragraph (2) in the matter preceding subparagraph 
        (A), is amended by striking ``nurse practitioner or clinical 
        nurse specialist'' and inserting ``nurse practitioner, a 
        clinical nurse specialist, or a physician assistant''.
            (2) in the second sentence, by striking ``or clinical nurse 
        specialist'' and inserting ``clinical nurse specialist, or 
        physician assistant''.
    (b) Recognition of Attending Physician Assistants as Attending 
Physicians to Serve Hospice Patients.--
            (1) In general.--Section 1861(dd)(3)(B) of such Act (42 
        U.S.C. 1395x(dd)(3)(B)) is amended--
                    (A) by striking ``or nurse'' and inserting ``, the 
                nurse''; and
                    (B) by inserting ``or the physician assistant (as 
                defined in such subsection),'' after ``subsection 
                (aa)(5)),''.
            (2) Conforming amendment.--Section 1814(a)(7)(A)(i)(I) of 
        such Act (42 U.S.C. 1395f(a)(7)(A)(i)(I)) is amended by 
        inserting ``or a physician assistant'' after ``a nurse 
        practitioner''.
            (3) Construction.--Nothing in the amendments made by this 
        subsection shall be construed as changing the requirements of 
        section 1842(b)(6)(C) of the Social Security Act (42 U.S.C. 
        1395u(b)(6)(C)) with respect to payment for services of 
        physician assistants under part B of title XVIII of such Act.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2010.

                Subtitle B--Provisions Related to Part B

                      PART 1--PHYSICIANS' SERVICES

SEC. 1121. RESOURCE-BASED FEEDBACK PROGRAM FOR PHYSICIANS IN MEDICARE.

    Section 1848(n) of the Social Security Act (42 U.S.C. 1395w-4(n)) 
is amended by adding at the end the following new paragraph:
            ``(9) Feedback implementation plan.--
                    ``(A) Timeline for feedback program.--
                            ``(i) Evaluation.--During 2011 the 
                        Secretary shall conduct the evaluation 
                        specified in subparagraph (E)(i).
                            ``(ii) Expansion.--The Secretary shall 
                        expand the Program under this subsection as 
                        specified in subparagraph (E)(ii).
                    ``(B) Establishment of nature of reports.--
                            ``(i) In general.--The Secretary shall 
                        develop and specify the nature of the reports 
                        that will be disseminated under this 
                        subsection, based on results and findings from 
                        the Program under this subsection as in 
                        existence before the date of the enactment of 
                        this paragraph. Such reports may be based on a 
                        per capita basis, an episode basis that 
                        combines separate but clinically related 
                        physicians' services and other items and 
                        services furnished or ordered by a physician 
                        into an episode of care, as appropriate, or 
                        both.
                            ``(ii) Timeline for development.--The 
                        nature of the reports described in clause (i) 
                        shall be developed by not later than January 1, 
                        2012.
                            ``(iii) Public availability.--The Secretary 
                        shall make the details of the nature of the 
                        reports developed under clause (i) available to 
                        the public.
                    ``(C) Analysis of data.--The Secretary shall, for 
                purposes of preparing reports under this subsection, 
                establish methodologies as appropriate such as to--
                            ``(i) attribute items and services, in 
                        whole or in part, to physicians;
                            ``(ii) identify appropriate physicians for 
                        purposes of comparison under subparagraph 
                        (B)(i); and
                            ``(iii) aggregate items and services 
                        attributed to a physician under clause (i) into 
                        a composite measure per individual.
                    ``(D) Feedback program.--The Secretary shall engage 
                in efforts to disseminate reports under this 
                subsection. In disseminating such reports, the 
                Secretary shall consider the following:
                            ``(i) Direct meetings between contracted 
                        physicians, facilitated by the Secretary, to 
                        discuss the contents of reports under this 
                        subsection, including any reasons for 
                        divergence from local or national averages.
                            ``(ii) Contract with local, non-profit 
                        entities engaged in quality improvement efforts 
                        at the community level. Such entities shall use 
                        the reports under this subsection, or such 
                        equivalent tool as specified by the Secretary. 
                        Any exchange of data under this paragraph shall 
                        be protected by appropriate privacy safeguards.
                            ``(iii) Mailings or other methods of 
                        communication that facilitate large-scale 
                        dissemination.
                            ``(iv) Other methods specified by the 
                        Secretary.
                    ``(E) Evaluation and expansion.--
                            ``(i) Evaluation.--The Secretary shall 
                        evaluate the methods specified in subparagraph 
                        (D) with regard to their efficacy in changing 
                        practice patterns to improve quality and 
                        decrease costs.
                            ``(ii) Expansion.--Taking into account the 
                        cost of each method specified in subparagraph 
                        (D), the Secretary shall develop a plan to 
                        disseminate reports under this subsection in a 
                        significant manner in the regions and cities of 
                        the country with the highest utilization of 
                        services under this title. To the extent 
                        practicable, reports under this subsection 
                        shall be disseminated to increasing numbers of 
                        physicians each year, such that during 2014 and 
                        subsequent years, reports are disseminated at 
                        least to physicians with utilization rates 
                        among the highest 5 percent of the nation, 
                        subject the authority to focus under paragraph 
                        (4).
                    ``(F) Administration.--
                            ``(i) Chapter 35 of title 44, United States 
                        Code shall not apply to this paragraph.
                            ``(ii) Notwithstanding any other provision 
                        of law, the Secretary may implement the 
                        provisions of this paragraph by program 
                        instruction or otherwise.''.

SEC. 1122. MISVALUED CODES UNDER THE PHYSICIAN FEE SCHEDULE.

    (a) In General.--Section 1848(c)(2) of the Social Security Act (42 
U.S.C. 1395w-4(c)(2)) is amended by adding at the end the following new 
subparagraphs:
                    ``(K) Potentially misvalued codes.--
                            ``(i) In general.--The Secretary shall--
                                    ``(I) periodically identify 
                                services as being potentially misvalued 
                                using criteria specified in clause 
                                (ii); and
                                    ``(II) review and make appropriate 
                                adjustments to the relative values 
                                established under this paragraph for 
                                services identified as being 
                                potentially misvalued under subclause 
                                (I).
                            ``(ii) Identification of potentially 
                        misvalued codes.--For purposes of identifying 
                        potentially misvalued services pursuant to 
                        clause (i)(I), the Secretary shall examine (as 
                        the Secretary determines to be appropriate) 
                        codes (and families of codes as appropriate) 
                        for which there has been the fastest growth; 
                        codes (and families of codes as appropriate) 
                        that have experienced substantial changes in 
                        practice expenses; codes for new technologies 
                        or services within an appropriate period (such 
                        as three years) after the relative values are 
                        initially established for such codes; multiple 
                        codes that are frequently billed in conjunction 
                        with furnishing a single service; codes with 
                        low relative values, particularly those that 
                        are often billed multiple times for a single 
                        treatment; codes which have not been subject to 
                        review since the implementation of the RBRVS 
                        (the so-called `Harvard-valued codes'); and 
                        such other codes determined to be appropriate 
                        by the Secretary.
                            ``(iii) Review and adjustments.--
                                    ``(I) The Secretary may use 
                                existing processes to receive 
                                recommendations on the review and 
                                appropriate adjustment of potentially 
                                misvalued services described clause 
                                (i)(II).
                                    ``(II) The Secretary may conduct 
                                surveys, other data collection 
                                activities, studies, or other analyses 
                                as the Secretary determines to be 
                                appropriate to facilitate the review 
                                and appropriate adjustment described in 
                                clause (i)(II).
                                    ``(III) The Secretary may use 
                                analytic contractors to identify and 
                                analyze services identified under 
                                clause (i)(I), conduct surveys or 
                                collect data, and make recommendations 
                                on the review and appropriate 
                                adjustment of services described in 
                                clause (i)(II).
                                    ``(IV) The Secretary may coordinate 
                                the review and appropriate adjustment 
                                described in clause (i)(II) with the 
                                periodic review described in 
                                subparagraph (B).
                                    ``(V) As part of the review and 
                                adjustment described in clause (i)(II), 
                                including with respect to codes with 
                                low relative values described in clause 
                                (ii), the Secretary may make 
                                appropriate coding revisions (including 
                                using existing processes for 
                                consideration of coding changes) which 
                                may include consolidation of individual 
                                services into bundled codes for payment 
                                under the fee schedule under subsection 
                                (b).
                                    ``(VI) The provisions of 
                                subparagraph (B)(ii)(II) shall apply to 
                                adjustments to relative value units 
                                made pursuant to this subparagraph in 
                                the same manner as such provisions 
                                apply to adjustments under subparagraph 
                                (B)(ii)(II).
                    ``(L) Validating relative value units.--
                            ``(i) In general.--The Secretary shall 
                        establish a process to validate relative value 
                        units under the fee schedule under subsection 
                        (b).
                            ``(ii) Components and elements of work.--
                        The process described in clause (i) may include 
                        validation of work elements (such as time, 
                        mental effort and professional judgment, 
                        technical skill and physical effort, and stress 
                        due to risk) involved with furnishing a service 
                        and may include validation of the pre, post, 
                        and intra-service components of work.
                            ``(iii) Scope of codes.--The validation of 
                        work relative value units shall include a 
                        sampling of codes for services that is the same 
                        as the codes listed under subparagraph (K)(ii)
                            ``(iv) Methods.--The Secretary may conduct 
                        the validation under this subparagraph using 
                        methods described in subclauses (I) through (V) 
                        of subparagraph (K)(iii) as the Secretary 
                        determines to be appropriate.
                            ``(v) Adjustments.--The Secretary shall 
                        make appropriate adjustments to the work 
                        relative value units under the fee schedule 
                        under subsection (b). The provisions of 
                        subparagraph (B)(ii)(II) shall apply to 
                        adjustments to relative value units made 
                        pursuant to this subparagraph in the same 
                        manner as such provisions apply to adjustments 
                        under subparagraph (B)(ii)(II).''.
    (b) Implementation.--
            (1) Funding.--For purposes of carrying out the provisions 
        of subparagraphs (K) and (L) of 1848(c)(2) of the Social 
        Security Act, as added by subsection (a), in addition to funds 
        otherwise available, out of any funds in the Treasury not 
        otherwise appropriated, there are appropriated to the Secretary 
        of Health and Human Services for the Center for Medicare & 
        Medicaid Services Program Management Account $20,000,000 for 
        fiscal year 2010 and each subsequent fiscal year. Amounts 
        appropriated under this paragraph for a fiscal year shall be 
        available until expended.
            (2) Administration.--
                    (A) Chapter 35 of title 44, United States Code and 
                the provisions of the Federal Advisory Committee Act (5 
                U.S.C. App.) shall not apply to this section or the 
                amendment made by this section.
                    (B) Notwithstanding any other provision of law, the 
                Secretary may implement subparagraphs (K) and (L) of 
                1848(c)(2) of the Social Security Act, as added by 
                subsection (a), by program instruction or otherwise.
                    (C) Section 4505(d) of the Balanced Budget Act of 
                1997 is repealed.
                    (D) Except for provisions related to 
                confidentiality of information, the provisions of the 
                Federal Acquisition Regulation shall not apply to this 
                section or the amendment made by this section.
            (3) Focusing cms resources on potentially overvalued 
        codes.--Section 1868(a) of the Social Security Act (42 
        1395ee(a)) is repealed.

SEC. 1123. PAYMENTS FOR EFFICIENT AREAS.

    Section 1833 of the Social Security Act (42 U.S.C. 1395l) is 
amended by adding at the end the following new subsection:
    ``(x) Incentive Payments for Efficient Areas.--
            ``(1) In general.--In the case of services furnished under 
        the physician fee schedule under section 1848 on or after 
        January 1, 2011, and before January 1, 2013, by a supplier that 
        is paid under such fee schedule in an efficient area (as 
        identified under paragraph (2)), in addition to the amount of 
        payment that would otherwise be made for such services under 
        this part, there also shall be paid (on a monthly or quarterly 
        basis) an amount equal to 5 percent of the payment amount for 
        the services under this part.
            ``(2) Identification of efficient areas.--
                    ``(A) In general.--Based upon available data, the 
                Secretary shall identify those counties or equivalent 
                areas in the United States in the lowest fifth 
                percentile of utilization based on per capita spending 
                under this part and part A for services provided in the 
                most recent year for which data are available as of the 
                date of the enactment of this subsection, as 
                standardized to eliminate the effect of geographic 
                adjustments in payment rates.
                    ``(B) Identification of counties where service is 
                furnished..--For purposes of paying the additional 
                amount specified in paragraph (1), if the Secretary 
                uses the 5-digit postal ZIP Code where the service is 
                furnished, the dominant county of the postal ZIP Code 
                (as determined by the United States Postal Service, or 
                otherwise) shall be used to determine whether the 
                postal ZIP Code is in a county described in 
                subparagraph (A).
                    ``(C) Limitation on review.--There shall be no 
                administrative or judicial review under section 1869, 
                1878, or otherwise, respecting--
                            ``(i) the identification of a county or 
                        other area under subparagraph (A); or
                            ``(ii) the assignment of a postal ZIP Code 
                        to a county or other area under subparagraph 
                        (B).
                    ``(D) Publication of list of counties; posting on 
                website.--With respect to a year for which a county or 
                area is identified under this paragraph, the Secretary 
                shall identify such counties or areas as part of the 
                proposed and final rule to implement the physician fee 
                schedule under section 1848 for the applicable year. 
                The Secretary shall post the list of counties 
                identified under this paragraph on the Internet website 
                of the Centers for Medicare & Medicaid Services.''.

SEC. 1124. MODIFICATIONS TO THE PHYSICIAN QUALITY REPORTING INITIATIVE 
              (PQRI).

    (a) Feedback.--Section 1848(m)(5) of the Social Security Act (42 
U.S.C. 1395w-4(m)(5)) is amended by adding at the end the following new 
subparagraph:
                    ``(H) Feedback.--The Secretary shall provide timely 
                feedback to eligible professionals on the performance 
                of the eligible professional with respect to 
                satisfactorily submitting data on quality measures 
                under this subsection.''.
    (b) Appeals.--Such section is further amended--
            (1) in subparagraph (E), by striking ``There shall be'' and 
        inserting ``Except as provided in subparagraph (I), there shall 
        be''; and
            (2) by adding at the end the following new subparagraph:
                    ``(I) Informal appeals process.--By not later than 
                January 1, 2011, the Secretary shall establish and have 
                in place an informal process for eligible professionals 
                to seek a review of the determination that an eligible 
                professional did not satisfactorily submit data on 
                quality measures under this subsection.''.
    (c) Integration of Physician Quality Reporting and EHR Reporting.--
Section 1848(m) of such Act is amended by adding at the end the 
following new paragraph:
            ``(7) Integration of physician quality reporting and ehr 
        reporting.--Not later than January 1, 2012, the Secretary shall 
        develop a plan to integrate clinical reporting on quality 
        measures under this subsection with reporting requirements 
        under subsection (o) relating to the meaningful use of 
        electronic health records. Such integration shall consist of 
        the following:
                    ``(A) The development of measures, the reporting of 
                which would both demonstrate--
                            ``(i) meaningful use of an electronic 
                        health record for purposes of subsection (o); 
                        and
                            ``(ii) clinical quality of care furnished 
                        to an individual.
                    ``(B) The collection of health data to identify 
                deficiencies in the quality and coordination of care 
                for individuals eligible for benefits under this part.
                    ``(C) Such other activities as specified by the 
                Secretary.''.
    (d) Extension of Incentive Payments.--Section 1848(m)(1) of such 
Act (42 U.S.C. 1395w-4(m)(1)) is amended--
            (1) in subparagraph (A), by striking ``2010'' and inserting 
        ``2012''; and
            (2) in subparagraph (B)(ii), by striking ``2009 and 2010'' 
        and inserting ``for each of the years 2009 through 2012''.

SEC. 1125. ADJUSTMENT TO MEDICARE PAYMENT LOCALITIES.

    (a) In General.--Section 1848(e) of the Social Security Act (42 
U.S.C.1395w-4(e)) is amended by adding at the end the following new 
paragraph:
            ``(6) Transition to use of msas as fee schedule areas in 
        california.--
                    ``(A) In general.--
                            ``(i) Revision.--Subject to clause (ii) and 
                        notwithstanding the previous provisions of this 
                        subsection, for services furnished on or after 
                        January 1, 2011, the Secretary shall revise the 
                        fee schedule areas used for payment under this 
                        section applicable to the State of California 
                        using the Metropolitan Statistical Area (MSA) 
                        iterative Geographic Adjustment Factor 
                        methodology as follows:
                                    ``(I) The Secretary shall configure 
                                the physician fee schedule areas using 
                                the Metropolitan Statistical Areas 
                                (each in this paragraph referred to as 
                                an `MSA'), as defined by the Director 
                                of the Office of Management and Budget 
                                and published in the Federal Register, 
                                using the most recent available 
                                decennial population data as of the 
                                date of the enactment of the Affordable 
                                Health Care for America Act, as the 
                                basis for the fee schedule areas.
                                    ``(II) For purposes of this clause, 
                                the Secretary shall treat all areas not 
                                included in an MSA as a single rest of 
                                the State MSA.
                                    ``(III) The Secretary shall list 
                                all MSAs within the State by Geographic 
                                Adjustment Factor described in 
                                paragraph (2) (in this paragraph 
                                referred to as a `GAF') in descending 
                                order.
                                    ``(IV) In the first iteration, the 
                                Secretary shall compare the GAF of the 
                                highest cost MSA in the State to the 
                                weighted-average GAF of all the 
                                remaining MSAs in the State (including 
                                the rest of State MSA described in 
                                subclause (II)). If the ratio of the 
                                GAF of the highest cost MSA to the 
                                weighted-average of the GAF of 
                                remaining lower cost MSAs is 1.05 or 
                                greater, the highest cost MSA shall be 
                                a separate fee schedule area.
                                    ``(V) In the next iteration, the 
                                Secretary shall compare the GAF of the 
                                MSA with the second-highest GAF to the 
                                weighted-average GAF of the all the 
                                remaining MSAs (excluding MSAs that 
                                become separate fee schedule areas). If 
                                the ratio of the second-highest MSA's 
                                GAF to the weighted-average of the 
                                remaining lower cost MSAs is 1.05 or 
                                greater, the second-highest MSA shall 
                                be a separate fee schedule area. ``(VI) 
                                The iterative process shall continue 
                                until the ratio of the GAF of the MSA 
                                with highest remaining GAF to the 
                                weighted-average of the remaining MSAs 
                                with lower GAFS is less than 1.05, and 
                                the remaining group of MSAs with lower 
                                GAFS shall be treated as a single fee 
                                schedule area.
                                    ``(VI) For purposes of the 
                                iterative process described in this 
                                clause, if two MSAs have identical 
                                GAFs, they shall be combined.
                            ``(ii) Transition.--For services furnished 
                        on or after January 1, 2011, and before January 
                        1, 2016, in the State of California, after 
                        calculating the work, practice expense, and 
                        malpractice geographic indices that would 
                        otherwise be determined under clauses (i), 
                        (ii), and (iii) of paragraph (1)(A) for a fee 
                        schedule area determined under clause (i), if 
                        the index for a county within a fee schedule 
                        area is less than the index in effect for such 
                        county on December 31, 2010, the Secretary 
                        shall instead apply the index in effect for 
                        such county on such date.
                    ``(B) Subsequent revisions.--After the transition 
                described in subparagraph (A)(ii), not less than every 
                3 years the Secretary shall review and update the fee 
                schedule areas using the methodology described in 
                subparagraph (A)(i) and any updated MSAs as defined by 
                the Director of the Office of Management and Budget and 
                published in the Federal Register. The Secretary shall 
                review and make any changes pursuant to such reviews 
                concurrent with the application of the periodic review 
                of the adjustment factors required under paragraph 
                (1)(C) for California.
                    ``(C) References to fee schedule areas.--Effective 
                for services furnished on or after January 1, 2011, for 
                the State of California, any reference in this section 
                to a fee schedule area shall be deemed a reference to 
                an MSA in the State (including the single rest of state 
                MSA described in subparagraph (A)(i)(II)).''.
    (b) Conforming Amendment to Definition of Fee Schedule Area.--
Section 1848(j)(2) of the Social Security Act (42 U.S.C. 1395w(j)(2)) 
is amended by striking ``The term'' and inserting ``Except as provided 
in subsection (e)(6)(C), the term''.

                     PART 2--MARKET BASKET UPDATES

SEC. 1131. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET 
              UPDATES THAT DO NOT ALREADY INCORPORATE SUCH 
              IMPROVEMENTS.

    (a) Outpatient Hospitals.--
            (1) In general.--Section 1833(t)(3)(C)(iv) of the Social 
        Security Act (42 U.S.C. 1395l(t)(3)(C)(iv)) is amended----
                    (A) in the first sentence--
                            (i) by inserting ``(which is subject to the 
                        productivity adjustment described in subclause 
                        (II) of such section)'' after 
                        ``1886(b)(3)(B)(iii)''; and
                            (ii) by inserting ``(but not below 0)'' 
                        after ``reduced''; and
                    (B) in the second sentence, by inserting ``and 
                which is subject, beginning with 2010, to the 
                productivity adjustment described in section 
                1886(b)(3)(B)(iii)(II)''.
            (2) Effective date.--The amendments made by this subsection 
        shall apply to increase factors for services furnished in years 
        beginning with 2010.
    (b) Ambulance Services.--Section 1834(l)(3)(B) of such Act (42 
U.S.C. 1395m(l)(3)(B))) is amended by inserting before the period at 
the end the following: ``and, in the case of years beginning with 2010, 
subject to the productivity adjustment described in section 
1886(b)(3)(B)(iii)(II)''.
    (c) Ambulatory Surgical Center Services.--Section 1833(i)(2)(D) of 
such Act (42 U.S.C. 1395l(i)(2)(D)) is amended--
            (1) by redesignating clause (v) as clause (vi); and
            (2) by inserting after clause (iv) the following new 
        clause:
    ``(v) In implementing the system described in clause (i), for 
services furnished during 2010 or any subsequent year, to the extent 
that an annual percentage change factor applies, such factor shall be 
subject to the productivity adjustment described in section 
1886(b)(3)(B)(iii)(II).''.
    (d) Laboratory Services.--Section 1833(h)(2)(A) of such Act (42 
U.S.C. 1395l(h)(2)(A)) is amended--
            (1) in clause (i), by striking ``for each of the years 2009 
        through 2013'' and inserting ``for 2009''; and
            (2) clause (ii)--
                    (A) by striking ``and'' at the end of subclause 
                (III);
                    (B) by striking the period at the end of subclause 
                (IV) and inserting ``; and''; and
                    (C) by adding at the end the following new 
                subclause:
            ``(V) the annual adjustment in the fee schedules determined 
        under clause (i) for years beginning with 2010 shall be subject 
        to the productivity adjustment described in section 
        1886(b)(3)(B)(iii)(II).''.
    (e) Certain Durable Medical Equipment.--Section 1834(a)(14) of such 
Act (42 U.S.C. 1395m(a)(14)) is amended--
            (1) in subparagraph (K), by inserting before the semicolon 
        at the end the following: ``, subject to the productivity 
        adjustment described in section 1886(b)(3)(B)(iii)(II)'';
            (2) in subparagraph (L)(i), by inserting after ``June 
        2013,'' the following: ``subject to the productivity adjustment 
        described in section 1886(b)(3)(B)(iii)(II),'';
            (3) in subparagraph (L)(ii), by inserting after ``June 
        2013'' the following: ``, subject to the productivity 
        adjustment described in section 1886(b)(3)(B)(iii)(II)''; and
            (4) in subparagraph (M), by inserting before the period at 
        the end the following: ``, subject to the productivity 
        adjustment described in section 1886(b)(3)(B)(iii)(II)''.

                        PART 3--OTHER PROVISIONS

SEC. 1141. RENTAL AND PURCHASE OF POWER-DRIVEN WHEELCHAIRS.

    (a) In General.--Section 1834(a)(7)(A)(iii) of the Social Security 
Act (42 U.S.C. 1395m(a)(7)(A)(iii)) is amended--
            (1) in the heading, by inserting ``certain complex 
        rehabilitative'' after ``option for''; and
            (2) by striking ``power-driven wheelchair'' and inserting 
        ``complex rehabilitative power-driven wheelchair recognized by 
        the Secretary as classified within group 3 or higher''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
take effect on January 1, 2011, and shall apply to power-driven 
wheelchairs furnished on or after such date. Such amendments shall not 
apply to contracts entered into under section 1847 of the Social 
Security Act (42 U.S.C. 1395w-3) pursuant to a bid submitted under such 
section before October 1, 2010, under subsection (a)(1)(B)(i)(I) of 
such section.

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.

    (a) In General.--Section 1834(a)(7)(A) of the Social Security Act 
(42 U.S.C. 1395m(a)(7)(A)) is amended--
            (1) in clause (ii)--
                    (A) by striking ``rental.--On'' and inserting 
                ``rental.--
                                    ``(I) In general.--Except as 
                                provided in subclause (II), on''; and
                    (B) by adding at the end the following new 
                subclause:
                                    ``(II) Option to accept or reject 
                                transfer of title to group 3 support 
                                surface.--
                                            ``(aa) In general.--During 
                                        the 10th continuous month 
                                        during which payment is made 
                                        for the rental of a Group 3 
                                        Support Surface under clause 
                                        (i), the supplier of such item 
                                        shall offer the individual the 
                                        option to accept or reject 
                                        transfer of title to a Group 3 
                                        Support Surface after the 13th 
                                        continuous month during which 
                                        payment is made for the rental 
                                        of the Group 3 Support Surface 
                                        under clause (i). Such title 
                                        shall be transferred to the 
                                        individual only if the 
                                        individual notifies the 
                                        supplier not later than 1 month 
                                        after the supplier makes such 
                                        offer that the individual 
                                        agrees to accept transfer of 
                                        the title to the Group 3 
                                        Support Surface. Unless the 
                                        individual accepts transfer of 
                                        title to the Group 3 Support 
                                        Surface in the manner set forth 
                                        in this subclause, the 
                                        individual shall be deemed to 
                                        have rejected transfer of 
                                        title. If the individual agrees 
                                        to accept the transfer of the 
                                        title to the Group 3 Support 
                                        Surface, the supplier shall 
                                        transfer such title to the 
                                        individual on the first day 
                                        that begins after the 13th 
                                        continuous month during which 
                                        payment is made for the rental 
                                        of the Group 3 Support Surface 
                                        under clause (i).
                                            ``(bb) Special rule.--If, 
                                        on the effective date of this 
                                        subclause, an individual's 
                                        rental period for a Group 3 
                                        Support Surface has exceeded 10 
                                        continuous months, but the 
                                        first day that begins after the 
                                        13th continuous month during 
                                        which payment is made for the 
                                        rental under clause (i) has not 
                                        been reached, the supplier 
                                        shall, within 1 month following 
                                        such effective date, offer the 
                                        individual the option to accept 
                                        or reject transfer of title to 
                                        a Group 3 Support Surface. Such 
                                        title shall be transferred to 
                                        the individual only if the 
                                        individual notifies the 
                                        supplier not later than 1 month 
                                        after the supplier makes such 
                                        offer that the individual 
                                        agrees to accept transfer of 
                                        title to the Group 3 Support 
                                        Surface. Unless the individual 
                                        accepts transfer of title to 
                                        the Group 3 Support Surface in 
                                        the manner set forth in this 
                                        subclause, the individual shall 
                                        be deemed to have rejected 
                                        transfer of title. If the 
                                        individual agrees to accept the 
                                        transfer of the title to the 
                                        Group 3 Support Surface, the 
                                        supplier shall transfer such 
                                        title to the individual on the 
                                        first day that begins after the 
                                        13th continuous month during 
                                        which payment is made for the 
                                        rental of the Group 3 Support 
                                        Surface under clause (i) unless 
                                        that day has passed, in which 
                                        case the supplier shall 
                                        transfer such title to the 
                                        individual not later than 1 
                                        month after notification that 
                                        the individual accepts transfer 
                                        of title.
                                            ``(cc) Treatment of 
                                        subsequent resupply within 
                                        period of reasonable useful 
                                        lifetime of group 3 support 
                                        surface in case of need.--If an 
                                        individual rejects transfer of 
                                        title to a Group 3 Support 
                                        Surface under this subclause 
                                        and the individual requires 
                                        such Support Surface at any 
                                        subsequent time during the 
                                        period of the reasonable useful 
                                        lifetime of such equipment (as 
                                        defined by the Secretary) 
                                        beginning with the first month 
                                        for which payment is made for 
                                        the rental of such equipment 
                                        under clause (i), the supplier 
                                        shall supply the equipment 
                                        without charge to the 
                                        individual or the program under 
                                        this title during the remainder 
                                        of such period, other than 
                                        payment for maintenance and 
                                        servicing during such period 
                                        which would otherwise have been 
                                        paid if the individual had 
                                        accepted title to such 
                                        equipment. The previous 
                                        sentence shall not affect the 
                                        payment of amounts under this 
                                        part for such equipment after 
                                        the end of such period of the 
                                        reasonable useful lifetime of 
                                        the equipment.
                                            ``(dd) Payments.--
                                        Maintenance and servicing 
                                        payments shall be made in 
                                        accordance with clause (iv), in 
                                        the case of a supplier that 
                                        transfers title to the Group 3 
                                        Support Surface under this 
                                        subclause, after such transfer 
                                        and, in the case of an 
                                        individual who rejects transfer 
                                        of title under this subclause, 
                                        after the end of the period of 
                                        medical need during which 
                                        payment is made under clause 
                                        (i).''; and
            (2) in clause (iv), by inserting ``or, in the case of an 
        individual who rejects transfer of title to a Group 3 Support 
        Surface under clause (ii), after the end of the period of 
        medical need during which payment is made under clause (i),'' 
        after ``under clause (ii)''.
    (b) Effective Date.--The amendments made by this section shall 
apply with respect to durable medical equipment not later than January 
1, 2011.

SEC. 1142. EXTENSION OF PAYMENT RULE FOR BRACHYTHERAPY.

     Section 1833(t)(16)(C) of the Social Security Act (42 U.S.C. 
1395l(t)(16)(C)), as amended by section 142 of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275), is amended by striking, the first place it appears, ``January 1, 
2010'' and inserting ``January 1, 2012''.

SEC. 1143. HOME INFUSION THERAPY REPORT TO CONGRESS.

    Not later than July 1, 2011, the Medicare Payment Advisory 
Commission shall submit to Congress a report on the following:
            (1) The scope of coverage for home infusion therapy in the 
        fee-for-service Medicare program under title XVIII of the 
        Social Security Act, Medicare Advantage under part C of such 
        title, the veteran's health care program under chapter 17 of 
        title 38, United States Code, and among private payers, 
        including an analysis of the scope of services provided by home 
        infusion therapy providers to their patients in such programs.
            (2) The benefits and costs of providing such coverage under 
        the Medicare program, including a calculation of the potential 
        savings achieved through avoided or shortened hospital and 
        nursing home stays as a result of Medicare coverage of home 
        infusion therapy.
            (3) An assessment of sources of data on the costs of home 
        infusion therapy that might be used to construct payment 
        mechanisms in the Medicare program.
            (4) Recommendations, if any, on the structure of a payment 
        system under the Medicare program for home infusion therapy, 
        including an analysis of the payment methodologies used under 
        Medicare Advantage plans and private health plans for the 
        provision of home infusion therapy and their applicability to 
        the Medicare program.

SEC. 1144. REQUIRE AMBULATORY SURGICAL CENTERS (ASCS) TO SUBMIT COST 
              DATA AND OTHER DATA.

    (a) Cost Reporting.--
            (1) In general.--Section 1833(i) of the Social Security Act 
        (42 U.S.C. 1395l(i)) is amended by adding at the end the 
        following new paragraph:
    ``(8) The Secretary shall require, as a condition of the agreement 
described in section 1832(a)(2)(F)(i), the submission of such cost 
report as the Secretary may specify, taking into account the 
requirements for such reports under section 1815 in the case of a 
hospital.''.
            (2) Development of cost report.--Not later than 3 years 
        after the date of the enactment of this Act, the Secretary of 
        Health and Human Services shall develop a cost report form for 
        use under section 1833(i)(8) of the Social Security Act, as 
        added by paragraph (1).
            (3) Audit requirement.--The Secretary shall provide for 
        periodic auditing of cost reports submitted under section 
        1833(i)(8) of the Social Security Act, as added by paragraph 
        (1).
            (4) Effective date.--The amendment made by paragraph (1) 
        shall apply to agreements applicable to cost reporting periods 
        beginning 18 months after the date the Secretary develops the 
        cost report form under paragraph (2).
    (b) Additional Data on Quality.--
            (1) In general.--Section 1833(i)(7) of such Act (42 U.S.C. 
        1395l(i)(7)) is amended--
                    (A) in subparagraph (B), by inserting ``subject to 
                subparagraph (C),'' after ``may otherwise provide,''; 
                and
                    (B) by adding at the end the following new 
                subparagraph:
    ``(C) Under subparagraph (B) the Secretary shall require the 
reporting of such additional data relating to quality of services 
furnished in an ambulatory surgical facility, including data on health 
care associated infections, as the Secretary may specify.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall to reporting for years beginning with 2012.

SEC. 1145. TREATMENT OF CERTAIN CANCER HOSPITALS.

    Section 1833(t) of the Social Security Act (42 U.S.C. 1395l(t)) is 
amended by adding at the end the following new paragraph:
            ``(18) Authorization of adjustment for cancer hospitals.--
                    ``(A) Study.--The Secretary shall conduct a study 
                to determine if, under the system under this 
                subsection, costs incurred by hospitals described in 
                section 1886(d)(1)(B)(v) with respect to ambulatory 
                payment classification groups exceed those costs 
                incurred by other hospitals furnishing services under 
                this subsection (as determined appropriate by the 
                Secretary).
                    ``(B) Authorization of adjustment.--Insofar as the 
                Secretary determines under subparagraph (A) that costs 
                incurred by hospitals described in section 
                1886(d)(1)(B)(v) exceed those costs incurred by other 
                hospitals furnishing services under this subsection, 
                the Secretary shall provide for an appropriate 
                adjustment under paragraph (2)(E) to reflect those 
                higher costs effective for services furnished on or 
                after January 1, 2011.''.

SEC. 1146. PAYMENT FOR IMAGING SERVICES.

    (a) Adjustment in Practice Expense to Reflect a Presumed Level of 
Utilization.--Section 1848 of the Social Security Act (42 U.S.C. 1395w-
4) is amended--
            (1) in subsection (b)(4)--
                    (A) in subparagraph (B), by striking ``subparagraph 
                (A)'' and inserting ``this paragraph''; and
                    (B) by adding at the end the following new 
                subparagraph:
                    ``(C) Adjustment in practice expense to reflect a 
                presumed level of utilization.--Consistent with the 
                methodology for computing the number of practice 
                expense relative value units under subsection 
                (c)(2)(C)(ii) with respect to advanced diagnostic 
                imaging services (as defined in section 1834(e)(1)(B)) 
                furnished on or after January 1, 2011, the Secretary 
                shall adjust such number of units so it reflects a 
                presumed rate of utilization of imaging equipment of 75 
                percent.''; and
            (2) in subsection (c)(2)(B)(v)), by adding at the end the 
        following new subclause:
                                    ``(III) Change in presumed 
                                utilization level of certain advanced 
                                diagnostic imaging services.--Effective 
                                for fee schedules established beginning 
                                with 2011, reduced expenditures 
                                attributable to the presumed 
                                utilization of 75 percent under 
                                subsection (b)(4)(C) instead of a 
                                presumed utilization of imaging 
                                equipment of 50 percent.''.
    (b) Adjustment in Technical Component ``discount'' on Single-
session Imaging to Consecutive Body Parts.--Section 1848 of such Act 
(42 U.S.C. 1395w-4) is further amended--
            (1) in subsection (b)(4), by adding at the end the 
        following new subparagraph:
                    ``(D) Adjustment in technical component discount on 
                single-session imaging involving consecutive body 
                parts.--For services furnished on or after January 1, 
                2011, the Secretary shall increase the reduction in 
                expenditures attributable to the multiple procedure 
                payment reduction applicable to the technical component 
                for imaging under the final rule published by the 
                Secretary in the Federal Register on November 21, 2005 
                (part 405 of title 42, Code of Federal Regulations) 
                from 25 percent to 50 percent.''; and
            (2) in subsection (c)(2)(B)(v), by adding at the end the 
        following new subclause:
                                    ``(III) Additional reduced payment 
                                for multiple imaging procedures.--
                                Effective for fee schedules established 
                                beginning with 2011, reduced 
                                expenditures attributable to the 
                                increase in the multiple procedure 
                                payment reduction from 25 percent to 50 
                                percent as described in subsection 
                                (b)(4)(D).''.

SEC. 1147. DURABLE MEDICAL EQUIPMENT PROGRAM IMPROVEMENTS.

    (a) Waiver of Surety Bond Requirement.--Section 1834(a)(16) of the 
Social Security Act (42 U.S.C. 1395m(a)(16)) is amended by adding at 
the end the following sentence: ``The requirement for a surety bond 
described in subparagraph (B) shall not apply in the case of a pharmacy 
or supplier that exclusively furnishes eyeglasses or contact lenses 
described in section 1861(s)(8) if the pharmacy or supply has been 
enrolled under section 1866(j) as a supplier of durable medical 
equipment, prosthetics, orthotics, and supplies and has been issued 
(which may include renewal of) a supplier number (as described in the 
first sentence of this paragraph) for at least 5 years, and if a final 
adverse action (as defined in section 424.57(a) of title 42, Code of 
Federal Regulations) has never been imposed for such pharmacy or 
supplier.''.
    (b) Ensuring Supply of Oxygen Equipment .--
            (1) In general.--Section 1834(a)(5)(F) of the Social 
        Security Act (42 U.S.C. 1395m(a)(5)(F)) is amended--
                    (A) in clause (ii), by striking ``After the'' and 
                inserting ``Except as provided in clause (iii), after 
                the''; and
                    (B) by adding at the end the following new clause:
                            ``(iii) Continuation of supply.--In the 
                        case of a supplier furnishing such equipment to 
                        an individual under this subsection as of the 
                        27th month of the 36 months described in clause 
                        (i), the supplier furnishing such equipment as 
                        of such month shall continue to furnish such 
                        equipment to such individual (either directly 
                        or though arrangements with other suppliers of 
                        such equipment) during any subsequent period of 
                        medical need for the remainder of the 
                        reasonable useful lifetime of the equipment, as 
                        determined by the Secretary, regardless of the 
                        location of the individual, unless another 
                        supplier has accepted responsibility for 
                        continuing to furnish such equipment during the 
                        remainder of such period.''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall take effect as of the date of the enactment of this Act 
        and shall apply to the furnishing of equipment to individuals 
        for whom the 27th month of a continuous period of use of oxygen 
        equipment described in section 1834(a)(5)(F) of the Social 
        Security Act occurs on or after July 1, 2010.
    (c) Treatment of Current Accreditation Applications.--Section 
1834(a)(20)(F) of such Act (42 U.S.C. 1395m(a)(20)(F)) is amended--
            (1) in clause (i)--
                    (A) by striking ``clause (ii)'' and inserting 
                ``clauses (ii) and (iii)''; and
                    (B) by striking ``and'' at the end;
            (2) by striking the period at the end of clause (ii)(II) 
        and by inserting a semicolon;
            (3) by inserting after clause (ii) the following new 
        clauses:
                            ``(iii) the requirement for accreditation 
                        described in clause (i) shall not apply for 
                        purposes of supplying diabetic testing 
                        supplies, canes, and crutches in the case of a 
                        pharmacy that is enrolled under section 1866(j) 
                        as a supplier of durable medical equipment, 
                        prosthetics, orthotics, and supplies; and
                            ``(iv) a supplier that has submitted an 
                        application for accreditation before August 1, 
                        2009, shall retain the supplier's provider or 
                        supplier number until an independent 
                        accreditation organization determines if such 
                        supplier complies with requirements under this 
                        paragraph.''; and
            (4) by adding at the end the following new sentence: 
        ``Nothing in clauses (iii) and (iv) shall be construed as 
        affecting the application of an accreditation requirement for 
        suppliers to qualify for bidding in a competitive acquisition 
        area under section 1847,''.
    (d) Restoring 36-month Oxygen Rental Period in Case of Supplier 
Bankruptcy for Certain Individuals.--Section 1834(a)(5)(F) of such Act 
(42 U.S.C. 1395m(a)(5)(F)), as amended by subsection (b), is further 
amended by adding at the end the following new clause:
                            ``(iv) Exception for bankruptcy.--If a 
                        supplier who furnishes oxygen and oxygen 
                        equipment to an individual is declared bankrupt 
                        and its assets are liquidated and at the time 
                        of such declaration and liquidation more than 
                        24 months of rental payments have been made, 
                        such individual may begin a new 36-month rental 
                        period under this subparagraph with another 
                        supplier of oxygen.''.

SEC. 1148. MEDPAC STUDY AND REPORT ON BONE MASS MEASUREMENT.

    (a) In General.--The Medicare Payment Advisory Commission shall 
conduct a study regarding bone mass measurement, including computed 
tomography, duel-energy x-ray absorptriometry, and vertebral fracture 
assessment. The study shall focus on the following:
            (1) An assessment of the adequacy of Medicare payment rates 
        for such services, taking into account costs of acquiring the 
        necessary equipment, professional work time, and practice 
        expense costs.
            (2) The impact of Medicare payment changes since 2006 on 
        beneficiary access to bone mass measurement benefits in general 
        and in rural and minority communities specifically.
            (3) A review of the clinically appropriate and recommended 
        use among Medicare beneficiaries and how usage rates among such 
        beneficiaries compares to such recommendations.
            (4) In conjunction with the findings under (3), 
        recommendations, if necessary, regarding methods for reaching 
        appropriate use of bone mass measurement studies among Medicare 
        beneficiaries.
    (b) Report.--The Commission shall submit a report to the Congress, 
not later than 9 months after the date of the enactment of this Act, 
containing a description of the results of the study conducted under 
subsection (a) and the conclusions and recommendations, if any, 
regarding each of the issues described in paragraphs (1), (2) (3) and 
(4) of such subsection.

SEC. 1149. TIMELY ACCESS TO POST-MASTECTOMY ITEMS.

    (a) In General.--Section 1834(h)(1) of the Social Security Act (42 
U.S.C. 1395m) is amended--
            (1) by redesignating subparagraph (H) as subparagraph (I); 
        and
            (2) by inserting after subparagraph (G) the following new 
        subparagraph:
                    ``(H) Special payment rule for post-mastectomy 
                external breast prosthesis garments.--Payment for post-
                mastectomy external breast prosthesis garments shall be 
                made regardless of whether such items are supplied to 
                the beneficiary prior to or after the mastectomy 
                procedure or other breast cancer surgical procedure. 
                The Secretary shall develop policies to ensure 
                appropriate beneficiary access and utilization 
                safeguards for such items supplied to a beneficiary 
                prior to the mastectomy or other breast cancer surgical 
                procedure.''
    (b) Effective Date.--This amendment shall apply not later than 
January 1, 2011.

SEC. 1149A. PAYMENT FOR BIOSIMILAR BIOLOGICAL PRODUCTS.

    (a) In General.--Section 1847A of the Social Security Act (42 
U.S.C. 1395w-3a) is amended--
            (1) in subsection (b)(1)--
                    (A) in subparagraph (A), by striking ``or'' at the 
                end;
                    (B) in subparagraph (B), by striking the period at 
                the end and inserting ``; or''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(C) in the case of one or more interchangeable 
                biological products (as defined in subsection 
                (c)(6)(I)) and their reference biological product (as 
                defined in subsection (c)(6)(J)), which shall be 
                included in the same billing and payment code, the sum 
                of--
                            ``(i) the average sales price as determined 
                        using the methodology described in paragraph 
                        (6) applied to such interchangeable and 
                        reference products for all National Drug Codes 
                        assigned to such products in the same manner as 
                        such paragraph (6) is applied to multiple 
                        source drugs; and
                            ``(ii) 6 percent of the amount determined 
                        under clause (i);
                    ``(D) in the case of a biosimilar biological 
                product (as defined in subsection (c)(6)(H)), the sum 
                of--
                            ``(i) the average sales price as determined 
                        using the methodology described in paragraph 
                        (4) applied to such biosimilar biological 
                        product for all National Drug Codes assigned to 
                        such product in the same manner as such 
                        paragraph (4) is applied to a single source 
                        drug; and
                            ``(ii) 6 percent of the amount determined 
                        under paragraph (4) or the amount determined 
                        under subparagraph (C)(ii), as the case may be, 
                        for the reference biological product (as 
                        defined in subsection (c)(6)(J)); or
                    ``(E) in the case of a reference biological product 
                for both an interchangeable biological product and a 
                biosimilar product, the amount determined in 
                subparagraph (C).''; and
            (2) in subsection (c)(6)--
                    (A) by amending subparagraph (D)(i) to read as 
                follows:
                            ``(i) a biological, including a reference 
                        biological product for a biosimilar product, 
                        but excluding--
                                    ``(I) a biosimilar biological 
                                product;
                                    ``(II) an interchangeable 
                                biological product;
                                    ``(III) a reference biological 
                                product for an interchangeable 
                                biological product; and
                                    ``(IV) a reference biological 
                                product for both an interchangeable 
                                biological product and a biosimilar 
                                product; or''; and
                    (B) by adding at the end the following new 
                subparagraphs:
                    ``(H) Biosimilar biological product.--The term 
                `biosimilar biological product' means a biological 
                product licensed as a biosimilar biological product 
                under section 351(k) of the Public Health Service Act.
                    ``(I) Interchangeable biological product.--The term 
                `interchangeable biological product' means a biological 
                product licensed as an interchangeable biological 
                product under section 351(k) of the Public Health 
                Service Act
                    ``(J) Reference biological product.--The term 
                `reference biological product' means the biological 
                product that is referred to in the application for a 
                biosimilar or interchangeable biological product 
                licensed under section 351(k) of the Public Health 
                Service Act.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to payments for biosimilar biological products, interchangeable 
biological products, and reference biological products beginning with 
the first day of the second calendar quarter after the date of the 
enactment of this Act.

SEC. 1149B. STUDY AND REPORT ON DME COMPETITIVE BIDDING PROCESS.

    (a) Study.--The Comptroller General of the United States shall 
conduct a study to evaluate the potential establishment of a program 
under Medicare under title XVIII of the Social Security Act to acquire 
durable medical equipment and supplies through a competitive bidding 
process among manufacturers of such equipment and supplies. Such study 
shall address the following:
            (1) Identification of types of durable medical equipment 
        and supplies that would be appropriate for bidding under such a 
        program.
            (2) Recommendations on how to structure such an acquisition 
        program in order to promote fiscal responsibility while also 
        ensuring beneficiary access to high quality equipment and 
        supplies.
            (3) Recommendations on how such a program could be phased-
        in and on what geographic level would bidding be most 
        appropriate.
            (4) In addition to price, recommendations on criteria that 
        could be factored into the bidding process.
            (5) Recommendations on how suppliers could be compensated 
        for furnishing and servicing equipment and supplies acquired 
        under such a program.
            (6) Comparison of such a program to the current competitive 
        bidding program under Medicare for durable medical equipment, 
        as well as any other similar Federal acquisition programs, such 
        as the General Services Administration's vehicle purchasing 
        program.
            (7) Any other consideration relevant to the acquisition, 
        supply, and service of durable medical equipment and supplies 
        that is deemed appropriate by the Comptroller General.
    (b) Report.--Not later than 12 months after the date of the 
enactment of this Act, the Comptroller General of the United States 
shall submit to Congress a report on the findings of the study under 
subsection (a).

        Subtitle C--Provisions Related to Medicare Parts A and B

SEC. 1151. REDUCING POTENTIALLY PREVENTABLE HOSPITAL READMISSIONS.

    (a) Hospitals.--
            (1) In general.--Section 1886 of the Social Security Act 
        (42 U.S.C. 1395ww), as amended by section 1103(a), is amended 
        by adding at the end the following new subsection:
    ``(p) Adjustment to Hospital Payments for Excess Readmissions.--
            ``(1) In general.--With respect to payment for discharges 
        from an applicable hospital (as defined in paragraph (5)(C)) 
        occurring during a fiscal year beginning on or after October 1, 
        2011, in order to account for excess readmissions in the 
        hospital, the Secretary shall reduce the payments that would 
        otherwise be made to such hospital under subsection (d) (or 
        section 1814(b)(3), as the case may be) for such a discharge by 
        an amount equal to the product of--
                    ``(A) the base operating DRG payment amount (as 
                defined in paragraph (2)) for the discharge; and
                    ``(B) the adjustment factor (described in paragraph 
                (3)(A)) for the hospital for the fiscal year.
            ``(2) Base operating drg payment amount.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), for purposes of this subsection, the 
                term `base operating DRG payment amount' means, with 
                respect to a hospital for a fiscal year, the payment 
                amount that would otherwise be made under subsection 
                (d) for a discharge if this subsection did not apply, 
                reduced by any portion of such amount that is 
                attributable to payments under subparagraphs (B) and 
                (F) of paragraph (5).
                    ``(B) Adjustments.--For purposes of subparagraph 
                (A), in the case of a hospital that is paid under 
                section 1814(b)(3), the term `base operating DRG 
                payment amount' means the payment amount under such 
                section.
            ``(3) Adjustment factor.--
                    ``(A) In general.--For purposes of paragraph (1), 
                the adjustment factor under this paragraph for an 
                applicable hospital for a fiscal year is equal to the 
                greater of--
                            ``(i) the ratio described in subparagraph 
                        (B) for the hospital for the applicable period 
                        (as defined in paragraph (5)(D)) for such 
                        fiscal year; or
                            ``(ii) the floor adjustment factor 
                        specified in subparagraph (C).
                    ``(B) Ratio.--The ratio described in this 
                subparagraph for a hospital for an applicable period is 
                equal to 1 minus the ratio of--
                            ``(i) the aggregate payments for excess 
                        readmissions (as defined in paragraph (4)(A)) 
                        with respect to an applicable hospital for the 
                        applicable period; and
                            ``(ii) the aggregate payments for all 
                        discharges (as defined in paragraph (4)(B)) 
                        with respect to such applicable hospital for 
                        such applicable period.
                    ``(C) Floor adjustment factor.--For purposes of 
                subparagraph (A), the floor adjustment factor specified 
                in this subparagraph for--
                            ``(i) fiscal year 2012 is 0.99;
                            ``(ii) fiscal year 2013 is 0.98;
                            ``(iii) fiscal year 2014 is 0.97; or
                            ``(iv) a subsequent fiscal year is 0.95.
            ``(4) Aggregate payments, excess readmission ratio 
        defined.--For purposes of this subsection:
                    ``(A) Aggregate payments for excess readmissions.--
                The term `aggregate payments for excess readmissions' 
                means, for a hospital for a fiscal year, the sum, for 
                applicable conditions (as defined in paragraph (5)(A)), 
                of the product, for each applicable condition, of--
                            ``(i) the base operating DRG payment amount 
                        for such hospital for such fiscal year for such 
                        condition;
                            ``(ii) the number of admissions for such 
                        condition for such hospital for such fiscal 
                        year; and
                            ``(iii) the excess readmissions ratio (as 
                        defined in subparagraph (C)) for such hospital 
                        for the applicable period for such fiscal year 
                        minus 1.
                    ``(B) Aggregate payments for all discharges.--The 
                term `aggregate payments for all discharges' means, for 
                a hospital for a fiscal year, the sum of the base 
                operating DRG payment amounts for all discharges for 
                all conditions from such hospital for such fiscal year.
                    ``(C) Excess readmission ratio.--
                            ``(i) In general.--Subject to clauses (ii) 
                        and (iii), the term `excess readmissions ratio' 
                        means, with respect to an applicable condition 
                        for a hospital for an applicable period, the 
                        ratio (but not less than 1.0) of--
                                    ``(I) the risk adjusted 
                                readmissions based on actual 
                                readmissions, as determined consistent 
                                with a readmission measure methodology 
                                that has been endorsed under paragraph 
                                (5)(A)(ii)(I), for an applicable 
                                hospital for such condition with 
                                respect to the applicable period; to
                                    ``(II) the risk adjusted expected 
                                readmissions (as determined consistent 
                                with such a methodology) for such 
                                hospital for such condition with 
                                respect to such applicable period.
                            ``(ii) Exclusion of certain readmissions.--
                        For purposes of clause (i), with respect to a 
                        hospital, excess readmissions shall not include 
                        readmissions for an applicable condition for 
                        which there are fewer than a minimum number (as 
                        determined by the Secretary) of discharges for 
                        such applicable condition for the applicable 
                        period and such hospital.
                            ``(iii) Adjustment.--In order to promote a 
                        reduction over time in the overall rate of 
                        readmissions for applicable conditions, the 
                        Secretary may provide, beginning with 
                        discharges for fiscal year 2014, for the 
                        determination of the excess readmissions ratio 
                        under subparagraph (C) to be based on a ranking 
                        of hospitals by readmission ratios (from lower 
                        to higher readmission ratios) normalized to a 
                        benchmark that is lower than the 50th 
                        percentile.
            ``(5) Definitions.--For purposes of this subsection:
                    ``(A) Applicable condition.--The term `applicable 
                condition' means, subject to subparagraph (B), a 
                condition or procedure selected by the Secretary among 
                conditions and procedures for which--
                            ``(i) readmissions (as defined in 
                        subparagraph (E)) that represent conditions or 
                        procedures that are high volume or high 
                        expenditures under this title (or other 
                        criteria specified by the Secretary); and
                            ``(ii) measures of such readmissions--
                                    ``(I) have been endorsed by the 
                                entity with a contract under section 
                                1890(a); and
                                    ``(II) such endorsed measures have 
                                appropriate exclusions for readmissions 
                                that are unrelated to the prior 
                                discharge (such as a planned 
                                readmission or transfer to another 
                                applicable hospital).
                    ``(B) Expansion of applicable conditions.--
                Beginning with fiscal year 2013, the Secretary shall 
                expand the applicable conditions beyond the 3 
                conditions for which measures have been endorsed as 
                described in subparagraph (A)(ii)(I) as of the date of 
                the enactment of this subsection to the additional 4 
                conditions that have been so identified by the Medicare 
                Payment Advisory Commission in its report to Congress 
                in June 2007 and to other conditions and procedures 
                which may include an all-condition measure of 
                readmissions, as determined appropriate by the 
                Secretary. In expanding such applicable conditions, the 
                Secretary shall seek the endorsement described in 
                subparagraph (A)(ii)(I) but may apply such measures 
                without such an endorsement.
                    ``(C) Applicable hospital.--The term `applicable 
                hospital' means a subsection (d) hospital or a hospital 
                that is paid under section 1814(b)(3).
                    ``(D) Applicable period.--The term `applicable 
                period' means, with respect to a fiscal year, such 
                period as the Secretary shall specify for purposes of 
                determining excess readmissions.
                    ``(E) Readmission.--The term `readmission' means, 
                in the case of an individual who is discharged from an 
                applicable hospital, the admission of the individual to 
                the same or another applicable hospital within a time 
                period specified by the Secretary from the date of such 
                discharge. Insofar as the discharge relates to an 
                applicable condition for which there is an endorsed 
                measure described in subparagraph (A)(ii)(I), such time 
                period (such as 30 days) shall be consistent with the 
                time period specified for such measure.
            ``(6) Limitations on review.--There shall be no 
        administrative or judicial review under section 1869, section 
        1878, or otherwise of--
                    ``(A) the determination of base operating DRG 
                payment amounts;
                    ``(B) the methodology for determining the 
                adjustment factor under paragraph (3), including excess 
                readmissions ratio under paragraph (4)(C), aggregate 
                payments for excess readmissions under paragraph 
                (4)(A), and aggregate payments for all discharges under 
                paragraph (4)(B), and applicable periods and applicable 
                conditions under paragraph (5);
                    ``(C) the measures of readmissions as described in 
                paragraph (5)(A)(ii); and
                    ``(D) the determination of a targeted hospital 
                under paragraph (8)(B)(i), the increase in payment 
                under paragraph (8)(B)(ii), the aggregate cap under 
                paragraph (8)(C)(i), the hospital-specific limit under 
                paragraph (8)(C)(ii), and the form of payment made by 
                the Secretary under paragraph (8)(D).
            ``(7) Monitoring inappropriate changes in admissions 
        practices.--The Secretary shall monitor the activities of 
        applicable hospitals to determine if such hospitals have taken 
        steps to avoid patients at risk in order to reduce the 
        likelihood of increasing readmissions for applicable conditions 
        or taken other inappropriate steps involving readmissions or 
        transfers. If the Secretary determines that such a hospital has 
        taken such a step, after notice to the hospital and opportunity 
        for the hospital to undertake action to alleviate such steps, 
        the Secretary may impose an appropriate sanction.
            ``(8) Assistance to certain hospitals.--
                    ``(A) In general.--For purposes of providing funds 
                to applicable hospitals to take steps described in 
                subparagraph (E) to address factors that may impact 
                readmissions of individuals who are discharged from 
                such a hospital, for fiscal years beginning on or after 
                October 1, 2011, the Secretary shall make a payment 
                adjustment for a hospital described in subparagraph 
                (B), with respect to each such fiscal year, by a 
                percent estimated by the Secretary to be consistent 
                with subparagraph (C). The Secretary shall provide 
                priority to hospitals that serve Medicare beneficiaries 
                at highest risk for readmission or for a poor 
                transition from such a hospital to a post-hospital site 
                of care.
                    ``(B) Targeted hospitals.--Subparagraph (A) shall 
                apply to an applicable hospital that--
                            ``(i) had (or, in the case of an 1814(b)(3) 
                        hospital, otherwise would have had) a 
                        disproportionate patient percentage (as defined 
                        in section 1886(d)(5)(F)) of at least 30 
                        percent, using the latest available data as 
                        estimated by the Secretary; and
                            ``(ii) provides assurances satisfactory to 
                        the Secretary that the increase in payment 
                        under this paragraph shall be used for purposes 
                        described in subparagraph (E).
                    ``(C) Caps.--
                            ``(i) Aggregate cap.--The aggregate amount 
                        of the payment adjustment under this paragraph 
                        for a fiscal year shall not exceed 5 percent of 
                        the estimated difference in the spending that 
                        would occur for such fiscal year with and 
                        without application of the adjustment factor 
                        described in paragraph (3) and applied pursuant 
                        to paragraph (1).
                            ``(ii) Hospital-specific limit.--The 
                        aggregate amount of the payment adjustment for 
                        a hospital under this paragraph shall not 
                        exceed the estimated difference in spending 
                        that would occur for such fiscal year for such 
                        hospital with and without application of the 
                        adjustment factor described in paragraph (3) 
                        and applied pursuant to paragraph (1).
                    ``(D) Form of payment.--The Secretary may make the 
                additional payments under this paragraph on a lump sum 
                basis, a periodic basis, a claim by claim basis, or 
                otherwise.
                    ``(E) Use of additional payment.--
                            ``(i) In general.--Funding under this 
                        paragraph shall be used by targeted hospitals 
                        for activities designed to address the patient 
                        noncompliance issues that result in higher than 
                        normal readmission rates, including 
                        transitional care services described in clause 
                        (ii) and any or all of the other activities 
                        described in clause (iii).
                            ``(ii) Transitional care services.--The 
                        transitional care services described in this 
                        clause are transitional care services furnished 
                        by a qualified transitional care provider, such 
                        as a nurse or other health professional, who 
                        meets relevant experience and training 
                        requirements as specified by the Secretary that 
                        support a beneficiary under this section 
                        beginning on the date of an individual's 
                        admission to a hospital for inpatient hospital 
                        services and ending at the latest on the last 
                        day of the 90-day period beginning on the date 
                        of the individual's discharge from the 
                        applicable hospital. The Secretary shall 
                        determine and update services to be included in 
                        transitional care services under this clause as 
                        appropriate, based on evidence of their 
                        effectiveness in reducing hospital readmissions 
                        and improving health outcomes. Such services 
                        shall include the following:
                                    ``(I) Conduct of an assessment 
                                prior to discharge, which assessment 
                                may include an assessment of the 
                                individual's physical and mental 
                                condition, cognitive and functional 
                                capacities, medication regimen and 
                                adherence, social and environmental 
                                needs, and primary caregiver needs and 
                                resources.
                                    ``(II) Development of a evidence-
                                based plan of transitional care for the 
                                individual developed after consultation 
                                with the individual and the 
                                individual's primary caregiver and 
                                other health team members, as 
                                appropriate. Such plan shall include a 
                                list of current therapies prescribed, 
                                treatment goals and may include other 
                                items or elements as determined by the 
                                Secretary, such as identifying list of 
                                potential health risks and future 
                                services for both the individual and 
                                any primary caregiver.
                            ``(iii) Other activities.--The other 
                        activities described in this clause are the 
                        following:
                                    ``(I) Providing other care 
                                coordination services not described 
                                under clause (ii).
                                    ``(II) Hiring translators and 
                                interpreters.
                                    ``(III) Increasing services offered 
                                by discharge planners.
                                    ``(IV) Ensuring that individuals 
                                receive a summary of care and 
                                medication orders upon discharge.
                                    ``(V) Developing a quality 
                                improvement plan to assess and remedy 
                                preventable readmission rates.
                                    ``(VI) Assigning appropriate 
                                follow-up care for discharged 
                                individuals.
                                    ``(VII) Doing other activities as 
                                determined appropriate by the 
                                Secretary.
                    ``(F) GAO report on use of funds.--Not later than 3 
                years after the date on which funds are first made 
                available under this paragraph, the Comptroller General 
                of the United States shall submit to Congress a report 
                on the use of such funds. Such report shall consider 
                information on the effective uses of such funds, how 
                the uses of such funds affected hospital readmission 
                rates (including at 6 months post-discharge), health 
                outcomes and quality, reductions in expenditures under 
                this title and the experiences of beneficiaries, 
                primary caregivers, and providers, as well as any 
                appropriate recommendations.''.
    (b) Application to Critical Access Hospitals.--Section 1814(l) of 
the Social Security Act (42 U.S.C. 1395f(l)) is amended--
            (1) in paragraph (5)--
                    (A) by striking ``and'' at the end of subparagraph 
                (C);
                    (B) by striking the period at the end of 
                subparagraph (D) and inserting ``; and'';
                    (C) by inserting at the end the following new 
                subparagraph:
            ``(E) the methodology for determining the adjustment factor 
        under paragraph (5), including the determination of aggregate 
        payments for actual and expected readmissions, applicable 
        periods, applicable conditions and measures of readmissions.''; 
        and
                    (D) by redesignating such paragraph as paragraph 
                (6); and
            (2) by inserting after paragraph (4) the following new 
        paragraph:
    ``(5) The adjustment factor described in section 1886(p)(3) shall 
apply to payments with respect to a critical access hospital with 
respect to a cost reporting period beginning in fiscal year 2012 and 
each subsequent fiscal year (after application of paragraph (4) of this 
subsection) in a manner similar to the manner in which such section 
applies with respect to a fiscal year to an applicable hospital as 
described in section 1886(p)(2).''.
    (c) Post Acute Care Providers.--
            (1) Interim policy.--
                    (A) In general.--With respect to a readmission to 
                an applicable hospital or a critical access hospital 
                (as described in section 1814(l) of the Social Security 
                Act) from a post acute care provider (as defined in 
                paragraph (3)) and such a readmission is not governed 
                by section 412.531 of title 42, Code of Federal 
                Regulations, if the claim submitted by such a post-
                acute care provider under title XVIII of the Social 
                Security Act indicates that the individual was 
                readmitted to a hospital from such a post-acute care 
                provider or admitted from home and under the care of a 
                home health agency within 30 days of an initial 
                discharge from an applicable hospital or critical 
                access hospital, the payment under such title on such 
                claim shall be the applicable percent specified in 
                subparagraph (B) of the payment that would otherwise be 
                made under the respective payment system under such 
                title for such post-acute care provider if this 
                subsection did not apply. In applying the previous 
                sentence, the Secretary shall exclude a period of 1 day 
                from the date the individual is first admitted to or 
                under the care of the post-acute care provider.
                    (B) Applicable percent defined.--For purposes of 
                subparagraph (A), the applicable percent is--
                            (i) for fiscal or rate year 2012 is 0.996;
                            (ii) for fiscal or rate year 2013 is 0.993; 
                        and
                            (iii) for fiscal or rate year 2014 is 0.99.
                    (C) Effective date.--Subparagraph (1) shall apply 
                to discharges or services furnished (as the case may be 
                with respect to the applicable post acute care 
                provider) on or after the first day of the fiscal year 
                or rate year, beginning on or after October 1, 2011, 
                with respect to the applicable post acute care 
                provider.
            (2) Development and application of performance measures.--
                    (A) In general.--The Secretary of Health and Human 
                Services shall develop appropriate measures of 
                readmission rates for post acute care providers. The 
                Secretary shall seek endorsement of such measures by 
                the entity with a contract under section 1890(a) of the 
                Social Security Act but may adopt and apply such 
                measures under this paragraph without such an 
                endorsement. The Secretary shall expand such measures 
                in a manner similar to the manner in which applicable 
                conditions are expanded under paragraph (5)(B) of 
                section 1886(p) of the Social Security Act, as added by 
                subsection (a).
                    (B) Implementation.--The Secretary shall apply, on 
                or after October 1, 2014, with respect to post acute 
                care providers, policies similar to the policies 
                applied with respect to applicable hospitals and 
                critical access hospitals under the amendments made by 
                subsection (a). The provisions of paragraph (1) shall 
                apply with respect to any period on or after October 1, 
                2014, and before such application date described in the 
                previous sentence in the same manner as such provisions 
                apply with respect to fiscal or rate year 2014.
                    (C) Monitoring and penalties.--The provisions of 
                paragraph (7) of such section 1886(p) shall apply to 
                providers under this paragraph in the same manner as 
                they apply to hospitals under such section.
            (3) Definitions.--For purposes of this subsection:
                    (A) Post acute care provider.--The term ``post 
                acute care provider'' means--
                            (i) a skilled nursing facility (as defined 
                        in section 1819(a) of the Social Security Act);
                            (ii) an inpatient rehabilitation facility 
                        (described in section 1886(h)(1)(A) of such 
                        Act);
                            (iii) a home health agency (as defined in 
                        section 1861(o) of such Act); and
                            (iv) a long term care hospital (as defined 
                        in section 1861(ccc) of such Act).
                    (B) Other terms .--The terms ``applicable 
                condition'', ``applicable hospital'', and 
                ``readmission'' have the meanings given such terms in 
                section 1886(p)(5) of the Social Security Act, as added 
                by subsection (a)(1).
    (d) Physicians.--
            (1) Study.--The Secretary of Health and Human Services 
        shall conduct a study to determine how the readmissions policy 
        described in the previous subsections could be applied to 
        physicians.
            (2) Considerations.--In conducting the study, the Secretary 
        shall consider approaches such as--
                    (A) creating a new code (or codes) and payment 
                amount (or amounts) under the fee schedule in section 
                1848 of the Social Security Act (in a budget neutral 
                manner) for services furnished by an appropriate 
                physician who sees an individual within the first week 
                after discharge from a hospital or critical access 
                hospital;
                    (B) developing measures of rates of readmission for 
                individuals treated by physicians;
                    (C) applying a payment reduction for physicians who 
                treat the patient during the initial admission that 
                results in a readmission; and
                    (D) methods for attributing payments or payment 
                reductions to the appropriate physician or physicians.
            (3) Report.--The Secretary shall issue a public report on 
        such study not later than the date that is one year after the 
        date of the enactment of this Act.
    (e) Funding.--For purposes of carrying out the provisions of this 
section, in addition to funds otherwise available, out of any funds in 
the Treasury not otherwise appropriated, there are appropriated to the 
Secretary of Health and Human Services for the Center for Medicare & 
Medicaid Services Program Management Account $25,000,000 for each 
fiscal year beginning with 2010. Amounts appropriated under this 
subsection for a fiscal year shall be available until expended.

SEC. 1152. POST ACUTE CARE SERVICES PAYMENT REFORM PLAN AND BUNDLING 
              PILOT PROGRAM.

    (a) Plan.--
            (1) In general.--The Secretary of Health and Human Services 
        (in this section referred to as the ``Secretary'') shall 
        develop a detailed plan to reform payment for post acute care 
        (PAC) services under the Medicare program under title XVIII of 
        the Social Security Act (in this section referred to as the 
        ``Medicare program)''. The goals of such payment reform are 
        to--
                    (A) improve the coordination, quality, and 
                efficiency of such services; and
                    (B) improve outcomes for individuals such as 
                reducing the need for readmission to hospitals from 
                providers of such services.
            (2) Bundling post acute services.--The plan described in 
        paragraph (1) shall include detailed specifications for a 
        bundled payment for post acute services (in this section 
        referred to as the ``post acute care bundle''), and may include 
        other approaches determined appropriate by the Secretary.
            (3) Post acute services.--For purposes of this section, the 
        term ``post acute services'' means services for which payment 
        may be made under the Medicare program that are furnished by 
        skilled nursing facilities, inpatient rehabilitation 
        facilities, long term care hospitals, hospital based outpatient 
        rehabilitation facilities and home health agencies to an 
        individual after discharge of such individual from a hospital, 
        and such other services determined appropriate by the 
        Secretary.
    (b) Details.--The plan described in subsection (a)(1) shall include 
consideration of the following issues:
            (1) The nature of payments under a post acute care bundle, 
        including the type of provider or entity to whom payment should 
        be made, the scope of activities and services included in the 
        bundle, whether payment for physicians' services should be 
        included in the bundle, and the period covered by the bundle.
            (2) Whether the payment should be consolidated with the 
        payment under the inpatient prospective system under section 
        1886 of the Social Security Act (in this section referred to as 
        MS-DRGs) or a separate payment should be established for such 
        bundle, and if a separate payment is established, whether it 
        should be made only upon use of post acute care services or for 
        every discharge.
            (3) Whether the bundle should be applied across all 
        categories of providers of inpatient services (including 
        critical access hospitals) and post acute care services or 
        whether it should be limited to certain categories of 
        providers, services, or discharges, such as high volume or high 
        cost MS-DRGs.
            (4) The extent to which payment rates could be established 
        to achieve offsets for efficiencies that could be expected to 
        be achieved with a bundle payment, whether such rates should be 
        established on a national basis or for different geographic 
        areas, should vary according to discharge, case mix, outliers, 
        and geographic differences in wages or other appropriate 
        adjustments, and how to update such rates.
            (5) The nature of protections needed for individuals under 
        a system of bundled payments to ensure that individuals receive 
        quality care, are furnished the level and amount of services 
        needed as determined by an appropriate assessment instrument, 
        are offered choice of provider, and the extent to which 
        transitional care services would improve quality of care for 
        individuals and the functioning of a bundled post-acute system.
            (6) The nature of relationships that may be required 
        between hospitals and providers of post acute care services to 
        facilitate bundled payments, including the application of 
        gainsharing, anti-referral, anti-kickback, and anti-trust laws.
            (7) Quality measures that would be appropriate for 
        reporting by hospitals and post acute providers (such as 
        measures that assess changes in functional status and quality 
        measures appropriate for each type of post acute services 
        provider including how the reporting of such quality measures 
        could be coordinated with other reporting of such quality 
        measures by such providers otherwise required).
            (8) How cost-sharing for a post acute care bundle should be 
        treated relative to current rules for cost-sharing for 
        inpatient hospital, home health, skilled nursing facility, and 
        other services.
            (9) How other programmatic issues should be treated in a 
        post acute care bundle, including rules specific to various 
        types of post-acute providers such as the post-acute transfer 
        policy, three-day hospital stay to qualify for services 
        furnished by skilled nursing facilities, and the coordination 
        of payments and care under the Medicare program and the 
        Medicaid program.
            (10) Such other issues as the Secretary deems appropriate.
    (c) Consultations and Analysis.--
            (1) Consultation with stakeholders.--In developing the plan 
        under subsection (a)(1), the Secretary shall consult with 
        relevant stakeholders and shall consider experience with such 
        research studies and demonstrations that the Secretary 
        determines appropriate.
            (2) Analysis and data collection.--In developing such plan, 
        the Secretary shall--
                    (A) analyze the issues described in subsection (b) 
                and other issues that the Secretary determines 
                appropriate;
                    (B) analyze the impacts (including geographic 
                impacts) of post acute service reform approaches, 
                including bundling of such services on individuals, 
                hospitals, post acute care providers, and physicians;
                    (C) use existing data (such as data submitted on 
                claims) and collect such data as the Secretary 
                determines are appropriate to develop such plan 
                required in this section; and
                    (D) if patient functional status measures are 
                appropriate for the analysis, to the extent practical, 
                build upon the CARE tool being developed pursuant to 
                section 5008 of the Deficit Reduction Act of 2005.
    (d) Administration.--
            (1) Funding.--For purposes of carrying out the provisions 
        of this section, in addition to funds otherwise available, out 
        of any funds in the Treasury not otherwise appropriated, there 
        are appropriated to the Secretary for the Center for Medicare & 
        Medicaid Services Program Management Account $15,000,000 for 
        each of the fiscal years 2010 through 2012. Amounts 
        appropriated under this paragraph for a fiscal year shall be 
        available until expended.
            (2) Expedited data collection.--Chapter 35 of title 44, 
        United States Code shall not apply to this section.
    (e) Public Reports.--
            (1) Interim reports.--The Secretary shall issue interim 
        public reports on a periodic basis on the plan described in 
        subsection (a)(1), the issues described in subsection (b), and 
        impact analyses as the Secretary determines appropriate.
            (2) Final report.--Not later than the date that is 3 years 
        after the date of the enactment of this Act, the Secretary 
        shall issue a final public report on such plan, including 
        analysis of issues described in subsection (b) and impact 
        analyses.
    (f) Conversion of Acute Care Episode Demonstration to Pilot Program 
and Expansion to Include Post Acute Services.--
            (1) In general.--Part E of title XVIII of the Social 
        Security Act is amended by inserting after section 1866C the 
        following new section:

 ``conversion of acute care episode demonstration to pilot program and 
                expansion to include post acute services

    ``Sec. 1866D.  (a) Conversion and Expansion.--
            ``(1) In general.--By not later than January 1, 2011, the 
        Secretary shall, for the purpose of promoting the use of 
        bundled payments to promote efficient, coordinated, and high 
        quality delivery of care--
                    ``(A) convert the acute care episode demonstration 
                program conducted under section 1866C to a pilot 
                program; and
                    ``(B) subject to subsection (c), expand such 
                program as so converted to include post acute services 
                and such other services the Secretary determines to be 
                appropriate, which may include transitional services.
            ``(2) Bundled payment structures.--
                    ``(A) In general.--In carrying out paragraph (1), 
                the Secretary may apply bundled payments with respect 
                to--
                            ``(i) hospitals and physicians;
                            ``(ii) hospitals and post-acute care 
                        providers;
                            ``(iii) hospitals, physicians, and post-
                        acute care providers; or
                            ``(iv) combinations of post-acute 
                        providers.
                    ``(B) Further application.--
                            ``(i) In general.--In carrying out 
                        paragraph (1), the Secretary shall apply 
                        bundled payments in a manner so as to include 
                        collaborative care networks and continuing care 
                        hospitals.
                            ``(ii) Collaborative care network 
                        defined.--For purposes of this subparagraph, 
                        the term `collaborative care network' means a 
                        consortium of health care providers that 
                        provides a comprehensive range of coordinated 
                        and integrated health care services to low-
                        income patient populations (including the 
                        uninsured) which may include coordinated and 
                        comprehensive care by safety net providers to 
                        reduce any unnecessary use of items and 
                        services furnished in emergency departments, 
                        manage chronic conditions, improve quality and 
                        efficiency of care, increase preventive 
                        services, and promote adherence to post-acute 
                        and follow-up care plans.
                            ``(iii) Continuing care hospital defined.--
                        For purposes of this subparagraph, the term 
                        `continuing care hospital' means an entity that 
                        has demonstrated the ability to meet patient 
                        care and patient safety standards and that 
                        provides under common management the medical 
                        and rehabilitation services provided in 
                        inpatient rehabilitation hospitals and units 
                        (as defined in section 1886(d)(1)(B)(ii)), 
                        long-term care hospitals (as defined in section 
                        1886(d)(1)(B)(iv)(I)), and skilled nursing 
                        facilities (as defined in section 1819(a)) that 
                        are located in a hospital described in section 
                        1886(d).
    ``(b) Scope.--The Secretary shall set specific goals for the number 
of acute and post-acute bundling test sites under the pilot program to 
ensure that over time the pilot program is of sufficient size and scope 
to--
            ``(1) test the approaches under the pilot program in a 
        variety of settings, including urban, rural, and underserved 
        areas;
            ``(2) include geographic areas and additional conditions 
        that account for significant program spending, as defined by 
        the Secretary; and
            ``(3) subject to subsection (d), disseminate the pilot 
        program rapidly on a national basis.
To the extent that the Secretary finds inpatient and post acute care 
bundling to be successful in improving quality and reducing costs, the 
Secretary shall implement such mechanisms and reforms under the pilot 
program on as large a geographic scale as practical and economical, 
consistent with subsection (e). Nothing in this subsection shall be 
construed as limiting the number of hospital and physician groups or 
the number of hospital and post-acute provider groups that may 
participate in the pilot program.
    ``(c) Limitation.--The Secretary shall only expand the pilot 
program under subsection (a) if the Secretary finds that--
            ``(1) the demonstration program under section 1866C and 
        pilot program under this section maintain or increase the 
        quality of care received by individuals enrolled under this 
        title; and
            ``(2) such demonstration program and pilot program reduce 
        program expenditures and, based on the certification under 
        subsection (d), that the expansion of such pilot program would 
        result in estimated spending that would be less than what 
        spending would otherwise be in the absence of this section.
    ``(d) Certification.--For purposes of subsection (c), the Chief 
Actuary of the Centers for Medicare & Medicaid Services shall certify 
whether expansion of the pilot program under this section would result 
in estimated spending that would be less than what spending would 
otherwise be in the absence of this section.
    ``(e) Voluntary Participation.--Nothing in this paragraph shall be 
construed as requiring the participation of an entity in the pilot 
program under this section.
    ``(f) Evaluation on Cost and Quality of Care.--The Secretary shall 
conduct an evaluation of the pilot program under subsection (a) to 
study the effect of such program on costs and quality of care. The 
findings of such evaluation shall be included in the final report 
required under section 1152(e)(2) of the Affordable Health Care for 
America Act.
    ``(g) Study of Additional Bundling and Episode-based Payment for 
Physicians' Services.--
            ``(1) In general.--The Secretary shall provide for a study 
        of and development of a plan for testing additional ways to 
        increase bundling of payments for physicians in connection with 
        an episode of care, such as in connection with outpatient 
        hospital services or services rendered in physicians' offices, 
        other than those provided under the pilot program.
            ``(2) Application.--The Secretary may implement such a plan 
        through a demonstration program.''.
            (2) Conforming amendment.--Section 1866C(b) of the Social 
        Security Act (42 U.S.C. 1395cc-3(b)) is amended by striking 
        ``The Secretary'' and inserting ``Subject to section 1866D, the 
        Secretary''.

SEC. 1153. HOME HEALTH PAYMENT UPDATE FOR 2010.

    Section 1895(b)(3)(B)(ii) of the Social Security Act (42 U.S.C. 
1395fff(b)(3)(B)(ii)) is amended--
            (1) in subclause (IV), by striking ``and'';
            (2) by redesignating subclause (V) as subclause (VII); and
            (3) by inserting after subclause (IV) the following new 
        subclauses:
                                    ``(V) 2007, 2008, and 2009, subject 
                                to clause (v), the home health market 
                                basket percentage increase;
                                    ``(VI) 2010, subject to clause (v), 
                                0 percent; and''.

SEC. 1154. PAYMENT ADJUSTMENTS FOR HOME HEALTH CARE.

    (a) Acceleration of Adjustment for Case Mix Changes.--Section 
1895(b)(3)(B) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(B)) 
is amended--
            (1) in clause (iv), by striking ``Insofar as'' and 
        inserting ``Subject to clause (vi), insofar as''; and
            (2) by adding at the end the following new clause:
                            ``(vi) Special rule for case mix changes 
                        for 2011.--
                                    ``(I) In general.--With respect to 
                                the case mix adjustments established in 
                                section 484.220(a) of title 42, Code of 
                                Federal Regulations, the Secretary 
                                shall apply, in 2010, the adjustment 
                                established in paragraph (3) of such 
                                section for 2011, in addition to 
                                applying the adjustment established in 
                                paragraph (2) for 2010.
                                    ``(II) Construction.--Nothing in 
                                this clause shall be construed as 
                                limiting the amount of adjustment for 
                                case mix for 2010 or 2011 if more 
                                recent data indicate an appropriate 
                                adjustment that is greater than the 
                                amount established in the section 
                                described in subclause (I).''.
    (b) Rebasing Home Health Prospective Payment Amount.--Section 
1895(b)(3)(A) of the Social Security Act (42 U.S.C. 1395fff(b)(3)(A)) 
is amended--
            (1) in clause (i)--
                    (A) in subclause (III), by inserting ``and before 
                2011'' after ``after the period described in subclause 
                (II)''; and
                    (B) by inserting after subclause (III) the 
                following new subclauses:
                                    ``(IV) Subject to clause (iii)(I), 
                                for 2011, such amount (or amounts) 
                                shall be adjusted by a uniform 
                                percentage determined to be appropriate 
                                by the Secretary based on analysis of 
                                factors such as changes in the average 
                                number and types of visits in an 
                                episode, the change in intensity of 
                                visits in an episode, growth in cost 
                                per episode, and other factors that the 
                                Secretary considers to be relevant.
                                    ``(V) Subject to clause (iii)(II), 
                                for a year after 2011, such a amount 
                                (or amounts) shall be equal to the 
                                amount (or amounts) determined under 
                                this clause for the previous year, 
                                updated under subparagraph (B).''; and
            (2) by adding at the end the following new clause:
                            ``(iii) Special rule in case of inability 
                        to effect timely rebasing.--
                                    ``(I) Application of proxy amount 
                                for 2011.--If the Secretary is not able 
                                to compute the amount (or amounts) 
                                under clause (i)(IV) so as to permit, 
                                on a timely basis, the application of 
                                such clause for 2011, the Secretary 
                                shall substitute for such amount (or 
                                amounts) 95 percent of the amount (or 
                                amounts) that would otherwise be 
                                specified under clause (i)(III) if it 
                                applied for 2011.
                                    ``(II) Adjustment for subsequent 
                                years based on data.--If the Secretary 
                                applies subclause (I), the Secretary 
                                before July 1, 2011, shall compare the 
                                amount (or amounts) applied under such 
                                subclause with the amount (or amounts) 
                                that should have been applied under 
                                clause (i)(IV). The Secretary shall 
                                decrease or increase the prospective 
                                payment amount (or amounts) under 
                                clause (i)(V) for 2012 (or, at the 
                                Secretary's discretion, over a period 
                                of several years beginning with 2012) 
                                by the amount (if any) by which the 
                                amount (or amounts) applied under 
                                subclause (I) is greater or less, 
                                respectively, than the amount (or 
                                amounts) that should have been applied 
                                under clause (i)(IV).''.

SEC. 1155. INCORPORATING PRODUCTIVITY IMPROVEMENTS INTO MARKET BASKET 
              UPDATE FOR HOME HEALTH SERVICES.

    (a) In General.--Section 1895(b)(3)(B) of the Social Security Act 
(42 U.S.C. 1395fff(b)(3)(B)) is amended--
            (1) in clause (iii), by inserting ``(including being 
        subject to the productivity adjustment described in section 
        1886(b)(3)(B)(iii)(II))'' after ``in the same manner''; and
            (2) in clause (v)(I), by inserting ``(but not below 0)'' 
        after ``reduced''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to home health market basket percentage increases for years 
beginning with 2011.

SEC. 1155A. MEDPAC STUDY ON VARIATION IN HOME HEALTH MARGINS.

    (a) In General.--The Medicare Payment Advisory Commission shall 
conduct a study regarding variation in performance of home health 
agencies in an effort to explain variation in Medicare margins for such 
agencies. Such study shall include an examination of at least the 
following issues:
            (1) The demographic characteristics of individuals served 
        and the geographic distribution associated with transportation 
        costs.
            (2) The characteristics of such agencies, such as whether 
        such agencies operate 24 hours each day, provide charity care, 
        or are part of an integrated health system.
            (3) The socio-economic status of individuals served, such 
        as the proportion of such individuals who are dually eligible 
        for Medicare and Medicaid benefits.
            (4) The presence of severe and or chronic disease or 
        disability in individuals served, as evidenced by multiple 
        discontinuous home health episodes with a high number of visits 
        per episode.
            (5) The differences in services provided, such as therapy 
        and non-therapy services.
    (b) Report.--Not later than June 1, 2011, the Commission shall 
submit a report to the Congress on the results of the study conducted 
under subsection (a) and shall include in the report the Commission's 
conclusions and recommendations, if appropriate, regarding each of the 
issues described in paragraphs (1), (2) and (3) of such subsection.

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.

    (a) In General.--Notwithstanding section 484.55(a)(2) of title 42 
of the Code of Federal Regulations or any other provision of law, a 
home health agency may determine the most appropriate skilled therapist 
to make the initial assessment visit for an individual who is referred 
(and may be eligible) for home health services under title XVIII of the 
Social Security Act but who does not require skilled nursing care as 
long as the skilled service (for which that therapist is qualified to 
provide the service) is included as part of the plan of care for home 
health services for such individual.
    (b) Rule of Construction.--Nothing in subsection (a) shall be 
construed to provide for initial eligibility for coverage of home 
health services under title XVIII of the Social Security Act on the 
basis of a need for occupational therapy.

SEC. 1156. LIMITATION ON MEDICARE EXCEPTIONS TO THE PROHIBITION ON 
              CERTAIN PHYSICIAN REFERRALS MADE TO HOSPITALS.

    (a) In General.--Section 1877 of the Social Security Act (42 U.S.C. 
1395nn) is amended--
            (1) in subsection (d)(2)--
                    (A) in subparagraph (A), by striking ``and'' at the 
                end;
                    (B) in subparagraph (B), by striking the period at 
                the end and inserting ``; and''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(C) in the case where the entity is a hospital, 
                the hospital meets the requirements of paragraph 
                (3)(D).'';
            (2) in subsection (d)(3)--
                    (A) in subparagraph (B), by striking ``and'' at the 
                end;
                    (B) in subparagraph (C), by striking the period at 
                the end and inserting ``; and''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(D) the hospital meets the requirements described 
                in subsection (i)(1).'';
            (3) by amending subsection (f) to read as follows:
    ``(f) Reporting and Disclosure Requirements.--
            ``(1) In general.--Each entity providing covered items or 
        services for which payment may be made under this title shall 
        provide the Secretary with the information concerning the 
        entity's ownership, investment, and compensation arrangements, 
        including--
                    ``(A) the covered items and services provided by 
                the entity, and
                    ``(B) the names and unique physician identification 
                numbers of all physicians with an ownership or 
                investment interest (as described in subsection 
                (a)(2)(A)), or with a compensation arrangement (as 
                described in subsection (a)(2)(B)), in the entity, or 
                whose immediate relatives have such an ownership or 
                investment interest or who have such a compensation 
                relationship with the entity.
        Such information shall be provided in such form, manner, and at 
        such times as the Secretary shall specify. The requirement of 
        this subsection shall not apply to designated health services 
        provided outside the United States or to entities which the 
        Secretary determines provide services for which payment may be 
        made under this title very infrequently.
            ``(2) Requirements for hospitals with physician ownership 
        or investment.--In the case of a hospital that meets the 
        requirements described in subsection (i)(1), the hospital 
        shall--
                    ``(A) submit to the Secretary an initial report, 
                and periodic updates at a frequency determined by the 
                Secretary, containing a detailed description of the 
                identity of each physician owner and physician investor 
                and any other owners or investors of the hospital;
                    ``(B) require that any referring physician owner or 
                investor discloses to the individual being referred, by 
                a time that permits the individual to make a meaningful 
                decision regarding the receipt of services, as 
                determined by the Secretary, the ownership or 
                investment interest, as applicable, of such referring 
                physician in the hospital; and
                    ``(C) disclose the fact that the hospital is 
                partially or wholly owned by one or more physicians or 
                has one or more physician investors--
                            ``(i) on any public website for the 
                        hospital; and
                            ``(ii) in any public advertising for the 
                        hospital.
        The information to be reported or disclosed under this 
        paragraph shall be provided in such form, manner, and at such 
        times as the Secretary shall specify. The requirements of this 
        paragraph shall not apply to designated health services 
        furnished outside the United States or to entities which the 
        Secretary determines provide services for which payment may be 
        made under this title very infrequently.
            ``(3) Publication of information.--The Secretary shall 
        publish, and periodically update, the information submitted by 
        hospitals under paragraph (2)(A) on the public Internet website 
        of the Centers for Medicare & Medicaid Services.'';
            (4) by amending subsection (g)(5) to read as follows:
            ``(5) Failure to report or disclose information.--
                    ``(A) Reporting.--Any person who is required, but 
                fails, to meet a reporting requirement of paragraphs 
                (1) and (2)(A) of subsection (f) is subject to a civil 
                money penalty of not more than $10,000 for each day for 
                which reporting is required to have been made.
                    ``(B) Disclosure.--Any physician who is required, 
                but fails, to meet a disclosure requirement of 
                subsection (f)(2)(B) or a hospital that is required, 
                but fails, to meet a disclosure requirement of 
                subsection (f)(2)(C) is subject to a civil money 
                penalty of not more than $10,000 for each case in which 
                disclosure is required to have been made.
                    ``(C) Application.--The provisions of section 1128A 
                (other than the first sentence of subsection (a) and 
                other than subsection (b)) shall apply to a civil money 
                penalty under subparagraphs (A) and (B) in the same 
                manner as such provisions apply to a penalty or 
                proceeding under section 1128A(a).''; and
            (5) by adding at the end the following new subsection:
    ``(i) Requirements to Qualify for Rural Provider and Hospital 
Ownership Exceptions to Self-referral Prohibition.--
            ``(1) Requirements described.--For purposes of subsection 
        (d)(3)(D), the requirements described in this paragraph are as 
        follows:
                    ``(A) Provider agreement.--The hospital had--
                            ``(i) physician ownership or investment on 
                        January 1, 2009; and
                            ``(ii) a provider agreement under section 
                        1866 in effect on such date.
                    ``(B) Prohibition on physician ownership or 
                investment.--The percentage of the total value of the 
                ownership or investment interests held in the hospital, 
                or in an entity whose assets include the hospital, by 
                physician owners or investors in the aggregate does not 
                exceed such percentage as of the date of enactment of 
                this subsection.
                    ``(C) Prohibition on expansion of facility 
                capacity.--Except as provided in paragraph (2), the 
                number of operating rooms, procedure rooms, or beds of 
                the hospital at any time on or after the date of the 
                enactment of this subsection are no greater than the 
                number of operating rooms, procedure rooms, or beds, 
                respectively, as of such date.
                    ``(D) Ensuring bona fide ownership and 
                investment.--
                            ``(i) Any ownership or investment interests 
                        that the hospital offers to a physician are not 
                        offered on more favorable terms than the terms 
                        offered to a person who is not in a position to 
                        refer patients or otherwise generate business 
                        for the hospital.
                            ``(ii) The hospital (or any investors in 
                        the hospital) does not directly or indirectly 
                        provide loans or financing for any physician 
                        owner or investor in the hospital.
                            ``(iii) The hospital (or any investors in 
                        the hospital) does not directly or indirectly 
                        guarantee a loan, make a payment toward a loan, 
                        or otherwise subsidize a loan, for any 
                        physician owner or investor or group of 
                        physician owners or investors that is related 
                        to acquiring any ownership or investment 
                        interest in the hospital.
                            ``(iv) Ownership or investment returns are 
                        distributed to each owner or investor in the 
                        hospital in an amount that is directly 
                        proportional to the ownership or investment 
                        interest of such owner or investor in the 
                        hospital.
                            ``(v) The investment interest of the owner 
                        or investor is directly proportional to the 
                        owner's or investor's capital contributions 
                        made at the time the ownership or investment 
                        interest is obtained.
                            ``(vi) Physician owners and investors do 
                        not receive, directly or indirectly, any 
                        guaranteed receipt of or right to purchase 
                        other business interests related to the 
                        hospital, including the purchase or lease of 
                        any property under the control of other owners 
                        or investors in the hospital or located near 
                        the premises of the hospital.
                            ``(vii) The hospital does not offer a 
                        physician owner or investor the opportunity to 
                        purchase or lease any property under the 
                        control of the hospital or any other owner or 
                        investor in the hospital on more favorable 
                        terms than the terms offered to a person that 
                        is not a physician owner or investor.
                            ``(viii) The hospital does not condition 
                        any physician ownership or investment interests 
                        either directly or indirectly on the physician 
                        owner or investor making or influencing 
                        referrals to the hospital or otherwise 
                        generating business for the hospital.
                    ``(E) Patient safety.--In the case of a hospital 
                that does not offer emergency services, the hospital 
                has the capacity to--
                            ``(i) provide assessment and initial 
                        treatment for medical emergencies; and
                            ``(ii) if the hospital lacks additional 
                        capabilities required to treat the emergency 
                        involved, refer and transfer the patient with 
                        the medical emergency to a hospital with the 
                        required capability.
                    ``(F) Limitation on application to certain 
                converted facilities.--The hospital was not converted 
                from an ambulatory surgical center to a hospital on or 
                after the date of enactment of this subsection.
            ``(2) Exception to prohibition on expansion of facility 
        capacity.--
                    ``(A) Process.--
                            ``(i) Establishment.--The Secretary shall 
                        establish and implement a process under which a 
                        hospital may apply for an exception from the 
                        requirement under paragraph (1)(C).
                            ``(ii) Opportunity for community input.--
                        The process under clause (i) shall provide 
                        persons and entities in the community in which 
                        the hospital applying for an exception is 
                        located with the opportunity to provide input 
                        with respect to the application.
                            ``(iii) Timing for implementation.--The 
                        Secretary shall implement the process under 
                        clause (i) on the date that is one month after 
                        the promulgation of regulations described in 
                        clause (iv).
                            ``(iv) Regulations.--Not later than the 
                        first day of the month beginning 18 months 
                        after the date of the enactment of this 
                        subsection, the Secretary shall promulgate 
                        regulations to carry out the process under 
                        clause (i). The Secretary may issue such 
                        regulations as interim final regulations.
                    ``(B) Frequency.--The process described in 
                subparagraph (A) shall permit a hospital to apply for 
                an exception up to once every 2 years.
                    ``(C) Permitted increase.--
                            ``(i) In general.--Subject to clause (ii) 
                        and subparagraph (D), a hospital granted an 
                        exception under the process described in 
                        subparagraph (A) may increase the number of 
                        operating rooms, procedure rooms, or beds of 
                        the hospital above the baseline number of 
                        operating rooms, procedure rooms, or beds, 
                        respectively, of the hospital (or, if the 
                        hospital has been granted a previous exception 
                        under this paragraph, above the number of 
                        operating rooms, procedure rooms, or beds, 
                        respectively, of the hospital after the 
                        application of the most recent increase under 
                        such an exception).
                            ``(ii) 100 percent increase limitation.--
                        The Secretary shall not permit an increase in 
                        the number of operating rooms, procedure rooms, 
                        or beds of a hospital under clause (i) to the 
                        extent such increase would result in the number 
                        of operating rooms, procedure rooms, or beds of 
                        the hospital exceeding 200 percent of the 
                        baseline number of operating rooms, procedure 
                        rooms, or beds of the hospital.
                            ``(iii) Baseline number of operating rooms, 
                        procedure rooms, or beds.--In this paragraph, 
                        the term `baseline number of operating rooms, 
                        procedure rooms, or beds' means the number of 
                        operating rooms, procedure rooms, or beds of a 
                        hospital as of the date of enactment of this 
                        subsection.
                    ``(D) Increase limited to facilities on the main 
                campus of the hospital.--Any increase in the number of 
                operating rooms, procedure rooms, or beds of a hospital 
                pursuant to this paragraph may only occur in facilities 
                on the main campus of the hospital.
                    ``(E) Conditions for approval of an increase in 
                facility capacity.--The Secretary may grant an 
                exception under the process described in subparagraph 
                (A) only to a hospital--
                            ``(i) that is located in a county in which 
                        the percentage increase in the population 
                        during the most recent 5-year period for which 
                        data are available is estimated to be at least 
                        150 percent of the percentage increase in the 
                        population growth of the State in which the 
                        hospital is located during that period, as 
                        estimated by Bureau of the Census and available 
                        to the Secretary;
                            ``(ii) whose annual percent of total 
                        inpatient admissions that represent inpatient 
                        admissions under the program under title XIX is 
                        estimated to be equal to or greater than the 
                        average percent with respect to such admissions 
                        for all hospitals located in the county in 
                        which the hospital is located;
                            ``(iii) that does not discriminate against 
                        beneficiaries of Federal health care programs 
                        and does not permit physicians practicing at 
                        the hospital to discriminate against such 
                        beneficiaries;
                            ``(iv) that is located in a State in which 
                        the average bed capacity in the State is 
                        estimated to be less than the national average 
                        bed capacity;
                            ``(v) that has an average bed occupancy 
                        rate that is estimated to be greater than the 
                        average bed occupancy rate in the State in 
                        which the hospital is located; and
                            ``(vi) that meets other conditions as 
                        determined by the Secretary.
                    ``(F) Procedure rooms.--In this subsection, the 
                term `procedure rooms' includes rooms in which 
                catheterizations, angiographies, angiograms, and 
                endoscopies are furnished, but such term shall not 
                include emergency rooms or departments (except for 
                rooms in which catheterizations, angiographies, 
                angiograms, and endoscopies are furnished).
                    ``(G) Publication of final decisions.--Not later 
                than 120 days after receiving a complete application 
                under this paragraph, the Secretary shall publish on 
                the public Internet website of the Centers for Medicare 
                & Medicaid Services the final decision with respect to 
                such application.
                    ``(H) Limitation on review.--There shall be no 
                administrative or judicial review under section 1869, 
                section 1878, or otherwise of the exception process 
                under this paragraph, including the establishment of 
                such process, and any determination made under such 
                process.
            ``(3) Physician owner or investor defined.--For purposes of 
        this subsection and subsection (f)(2), the term `physician 
        owner or investor' means a physician (or an immediate family 
        member of such physician) with a direct or an indirect 
        ownership or investment interest in the hospital.
            ``(4) Patient safety requirement.--In the case of a 
        hospital to which the requirements of paragraph (1) apply, 
        insofar as the hospital admits a patient and does not have any 
        physician available on the premises 24 hours per day, 7 days 
        per week, before admitting the patient--
                    ``(A) the hospital shall disclose such fact to the 
                patient; and
                    ``(B) following such disclosure, the hospital shall 
                receive from the patient a signed acknowledgment that 
                the patient understands such fact.
            ``(5) Clarification.--Nothing in this subsection shall be 
        construed as preventing the Secretary from terminating a 
        hospital's provider agreement if the hospital is not in 
        compliance with regulations pursuant to section 1866.''.
    (b) Verifying Compliance.--The Secretary of Health and Human 
Services shall establish policies and procedures to verify compliance 
with the requirements described in subsections (i)(1) and (i)(4) of 
section 1877 of the Social Security Act, as added by subsection (a)(5). 
The Secretary may use unannounced site reviews of hospitals and audits 
to verify compliance with such requirements.
    (c) Implementation.--
            (1) Funding.--For purposes of carrying out the amendments 
        made by subsection (a) and the provisions of subsection (b), in 
        addition to funds otherwise available, out of any funds in the 
        Treasury not otherwise appropriated there are appropriated to 
        the Secretary of Health and Human Services for the Centers for 
        Medicare & Medicaid Services Program Management Account 
        $5,000,000 for each fiscal year beginning with fiscal year 
        2010. Amounts appropriated under this paragraph for a fiscal 
        year shall be available until expended.
            (2) Administration.--Chapter 35 of title 44, United States 
        Code, shall not apply to the amendments made by subsection (a) 
        and the provisions of subsection (b).

SEC. 1157. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC ADJUSTMENT FACTORS 
              UNDER MEDICARE.

    (a) In General.--The Secretary of Health and Human Services shall 
enter into a contract with the Institute of Medicine of the National 
Academy of Science to conduct a comprehensive empirical study, and 
provide recommendations as appropriate, on the accuracy of the 
geographic adjustment factors established under sections 1848(e) and 
1886(d)(3)(E) of the Social Security Act (42 U.S.C. 1395w-4(e), 
1395ww(d)(3)(E)).
    (b) Matters Included.--Such study shall include an evaluation and 
assessment of the following with respect to such adjustment factors:
            (1) Empirical validity of the adjustment factors.
            (2) Methodology used to determine the adjustment factors.
            (3) Measures used for the adjustment factors, taking into 
        account--
                    (A) timeliness of data and frequency of revisions 
                to such data;
                    (B) sources of data and the degree to which such 
                data are representative of costs; and
                    (C) operational costs of providers who participate 
                in Medicare.
    (c) Evaluation.--Such study shall, within the context of the United 
States health care marketplace, evaluate and consider the following:
            (1) The effect of the adjustment factors on the level and 
        distribution of the health care workforce and resources, 
        including--
                    (A) recruitment and retention that takes into 
                account workforce mobility between urban and rural 
                areas;
                    (B) ability of hospitals and other facilities to 
                maintain an adequate and skilled workforce; and
                    (C) patient access to providers and needed medical 
                technologies.
            (2) The effect of the adjustment factors on population 
        health and quality of care.
            (3) The effect of the adjustment factors on the ability of 
        providers to furnish efficient, high value care.
    (d) Report.--The contract under subsection (a) shall provide for 
the Institute of Medicine to submit, not later than 1 year after the 
date of the enactment of this Act, to the Secretary and the Congress a 
report containing results and recommendations of the study conducted 
under this section.
    (e) Funding.--There are authorized to be appropriated to carry out 
this section such sums as may be necessary.

SEC. 1158. REVISION OF MEDICARE PAYMENT SYSTEMS TO ADDRESS GEOGRAPHIC 
              INEQUITIES.

    (a) Revision of Medicare Payment Systems.--Taking into account the 
recommendations described in the report under section 1157, and 
notwithstanding the geographic adjustments that would otherwise apply 
under section 1848(e) and section 1886(d)(3)(E) of the Social Security 
Act (42 U.S.C. 1395w-4(e), 1395ww(d)(3)(E)), the Secretary of Health 
and Human Services shall include in proposed rules applicable to the 
rulemaking cycle for payment systems for physicians' services and 
inpatient hospital services under sections 1848 and section 1886(d) of 
such Act, respectively, proposals (as the Secretary determines to be 
appropriate) to revise the geographic adjustment factors used in such 
systems. Such proposals' rules shall be contained in the next 
rulemaking cycle following the submission to the Secretary of the 
report described in section 1157.
    (b) Payment Adjustments.--
            (1) Funding for improvements.--For years before 2014, the 
        Secretary shall ensure that the additional expenditures 
        resulting from the implementation of the provisions of this 
        section, as estimated by the Secretary, do not exceed 
        $8,000,000,000, and do not exceed half of such amount in any 
        payment year.
            (2) Hold harmless.--In carrying out this subsection--
                    (A) for payment years before 2014, the Secretary 
                shall not reduce the geographic adjustment below the 
                factor that applied for such payment system in the 
                payment year before such changes; and
                    (B) for payment years beginning with 2014, the 
                Secretary shall implement the geographic adjustment in 
                a manner that does not result in any net change in 
                aggregate expenditures under title XVIII of the Social 
                Security Act from the amount of such expenditures that 
                the Secretary estimates would have occurred if no 
                geographic adjustment had occurred under this section.
    (c) Medicare Improvement Fund.--
            (1) Amounts in the Medicare Improvement Fund under section 
        1898 of the Social Security Act, as amended by paragraph (2), 
        shall be available to the Secretary to make changes to the 
        geographic adjustments factors as described in subsections (a) 
        and (b) with respect to services furnished before January 1, 
        2014.   No more than one-half of such amounts shall be 
        available with respect to services furnished in any one payment 
        year.
            (2) Section 1898(b) of the Social Security Act (42 U.S.C. 
        1395iii(b)) is amended--
                    (A) by amending paragraph (1)(A) to read as 
                follows:
                    ``(A) the period beginning with fiscal year 2011 
                and ending with fiscal year 2019, $8,000,000,000; 
                and''; and
                    (B) by adding at the end the following new 
                paragraph:
            ``(5) Adjustment for underfunding.--For fiscal year 2014 or 
        a subsequent fiscal year specified by the Secretary, the amount 
        available to the fund under subsection (a) shall be increased 
        by the Secretary's estimate of the amount (based on data on 
        actual expenditures) by which--
                    ``(A) the additional expenditures resulting from 
                the implementation of subsection (a) of section 1158 of 
                the Affordable Health Care for America Act for the 
                period before fiscal year 2014, is less than
                    ``(B) the maximum amount of funds available under 
                subsection (a) of such section for funding for such 
                expenditures.''.

SEC. 1159. INSTITUTE OF MEDICINE STUDY OF GEOGRAPHIC VARIATION IN 
              HEALTH CARE SPENDING AND PROMOTING HIGH-VALUE HEALTH 
              CARE.

    (a) In General.--The Secretary of Health and Human Services (in 
this section and the succeeding section referred to as the 
``Secretary'') shall enter into an agreement with the Institute of 
Medicine of the National Academies (referred to in this section as the 
``Institute'') to conduct a study on geographic variation and growth in 
volume and intensity of services in per capita health care spending 
among the Medicare, Medicaid, privately insured and uninsured 
populations. Such study may draw on recent relevant reports of the 
Institute and shall include each of the following:
            (1) An evaluation of the extent and range of such variation 
        using various units of geographic measurement, including micro 
        areas within larger areas.
            (2) An evaluation of the extent to which geographic 
        variation can be attributed to differences in input prices; 
        health status; practice patterns; access to medical services; 
        supply of medical services; socio-economic factors, including 
        race, ethnicity, gender, age, income and educational status; 
        and provider and payer organizational models.
            (3) An evaluation of the extent to which variations in 
        spending are correlated with patient access to care, insurance 
        status, distribution of health care resources, health care 
        outcomes, and consensus-based measures of health care quality.
            (4) An evaluation of the extent to which variation can be 
        attributed to physician and practitioner discretion in making 
        treatment decisions, and the degree to which discretionary 
        treatment decisions are made that could be characterized as 
        different from the best available medical evidence.
            (5) An evaluation of the extent to which variation can be 
        attributed to patient preferences and patient compliance with 
        treatment protocols.
            (6) An assessment of the degree to which variation cannot 
        be explained by empirical evidence.
            (7) For Medicare beneficiaries, An evaluation of the extent 
        to which variations in spending are correlated with insurance 
        status prior to enrollment in the Medicare program under title 
        XVIII of the Social Security Act, and institutionalization 
        status; whether beneficiaries are dually eligible for the 
        Medicare program and Medicaid under title XIX of such Act; and 
        whether beneficiaries are enrolled in fee-for-service Medicare 
        or Medicare Advantage.
            (8) An evaluation of such other factors as the Institute 
        deems appropriate.
The Institute shall conduct public hearings and provide an opportunity 
for comments prior to completion of the reports under subsection (e).
    (b) Recommendations.--Taking into account the findings under 
subsection (a) and the changes to the payment systems made by this Act, 
the Institute shall recommend changes to payment for items and services 
under parts A and B of title XVIII of the Social Security Act, for 
addressing variation in Medicare per capita spending for items and 
services (not including add-ons for graduate medical education, 
disproportionate share payments, and health information technology, as 
specified in sections 1886(d)(5)(F), 1886(d)(5)(B), 1886(h), 1848(o), 
and 1886(n), respectively, of such Act) by promoting high-value care 
(as defined in subsection (f)), with particular attention to high-
volume, high-cost conditions. In making such recommendations, the 
Institute shall consider each of the following:
            (1) Measurement and reporting on quality and population 
        health.
            (2) Reducing fragmented and duplicative care.
            (3) Promoting the practice of evidence-based medicine.
            (4) Empowering patients to make value-based care decisions.
            (5) Leveraging the use of health information technology.
            (6) The role of financial and other incentives affecting 
        provision of care.
            (7) Variation in input costs.
            (8) The characteristics of the patient population, 
        including socio-economic factors (including race, ethnicity, 
        gender, age, income and educational status), and whether the 
        beneficiaries are dually eligible for the Medicare program 
        under title XVIII of the Social Security Act and Medicaid under 
        title XIX of such Act.
            (9) Other topics the Institute deems appropriate.
In making such recommendations, the Institute shall consider an 
appropriate phase-in that takes into account the impact of payment 
changes on providers and facilities and preserves access to care for 
Medicare beneficiaries.
    (c) Specific Considerations.--In making the recommendations under 
subsection (b), the Institute shall specifically address whether 
payment systems under title XVIII of the Social Security Act for 
physicians and hospitals should be further modified to incentivize 
high-value care. In so doing, the Institute shall consider the adoption 
of a value index based on a composite of appropriate measures of 
quality and cost that would adjust provider payments on a regional or 
provider-level basis. If the Institute finds that application of such a 
value index would significantly incentivize providers to furnish high-
value care, it shall make specific recommendations on how such an index 
would be designed and implemented. In so doing, it should identify 
specific measures of quality and cost appropriate for use in such an 
index, and include a thorough analysis (including on a geographic 
basis) of how payments and spending under such title would be affected 
by such an index.
    (d) Additional Considerations.--The Institute shall consider the 
experience of governmental and community-based programs that promote 
high-value care.
    (e) Reports.--
            (1) Not later than April 15, 2011, the Institute shall 
        submit to the Secretary and each House of Congress a report 
        containing findings and recommendations of the study conducted 
        under this section.
            (2) Following submission of the report under paragraph (1), 
        the Institute shall use the data collected and analyzed in this 
        section to issue a subsequent report, or series of reports, on 
        how best to address geographic variation or efforts to promote 
        high-value care for items and services reimbursed by private 
        insurance or other programs. Such reports shall include a 
        comparison to the Institute's findings and recommendations 
        regarding the Medicare program. Such reports, and any 
        recommendations, would not be subject to the procedures 
        outlined in section 1160.
    (f) High-value Care Defined.--For purposes of this section, the 
term ``high-value care'' means the efficient delivery of high quality, 
evidence-based, patient-centered care.
    (g) Appropriations.--There is appropriated from amounts in the 
general fund of the Treasury not otherwise appropriated $10,000,000 to 
carry out this section. Such sums are authorized to remain available 
until expended.

SEC. 1160. IMPLEMENTATION, AND CONGRESSIONAL REVIEW, OF PROPOSAL TO 
              REVISE MEDICARE PAYMENTS TO PROMOTE HIGH VALUE HEALTH 
              CARE.

    (a) Preparation and Submission of Implementation Plans.--
            (1) Final implementation plan.--Not later than 240 days 
        after the date of receipt by the Secretary and each House of 
        Congress of the report under section 1159(e)(1), the Secretary 
        shall submit to each House of Congress a final implementation 
        plan describing proposed changes to payment for items and 
        services under parts A and B of title XVIII of the Social 
        Security Act (which may include payment for inpatient and 
        outpatient hospital services for services furnished in PPS and 
        PPS-exempt hospitals, physicians' services, dialysis facility 
        services, skilled nursing facility services, home health 
        services, hospice care, clinical laboratory services, durable 
        medical equipment, and other items and services, but which 
        shall exclude add-on payments for graduate medical education, 
        disproportionate share payments, and health information 
        technology, as specified in sections 1886(d)(5)(F), 
        1886(d)(5)(B), 1886(h), 1848(o), and 1886(n), respectively, of 
        the Social Security Act) taking into consideration, as 
        appropriate, the recommendations of the report submitted under 
        section 1159(e)(1) and the changes to the payment systems made 
        by this Act. To the extent such implementation plan requires a 
        substantial change to the payment system, it shall include a 
        transition phase-in that takes into consideration possible 
        disruption to provider participation in the Medicare program 
        under title XVIII of the Social Security Act and preserves 
        access to care for Medicare beneficiaries.
            (2) Preliminary implementation plan.--Not later than 90 
        days after the date the Institute of Medicine submits to each 
        House of Congress the report under section 1159(e)(1), the 
        Secretary shall submit to each House of Congress a preliminary 
        version of the implementation plan provided for under paragraph 
        (1)(A).
            (3) No increase in budget expenditures.--The Secretary 
        shall include with the submission of the final implementation 
        plan under paragraph (1) a certification by the Chief Actuary 
        of the Centers for Medicare & Medicaid Services that over the 
        initial 10-year period in which the plan is implemented, the 
        aggregate level of net expenditures under the Medicare program 
        under title XVIII of the Social Security Act will not exceed 
        the aggregate level of such expenditures that would have 
        occurred if the plan were not implemented.
            (4) Waivers required.--To the extent the final 
        implementation plan under paragraph (1) proposes changes that 
        are not otherwise permitted under title XVIII of the Social 
        Security Act, the Secretary shall specify in the plan the 
        specific waivers required under such title to implement such 
        changes. Except as provided in subsection (c), the Secretary is 
        authorized to waive the requirements so specified in order to 
        implement such changes.
            (5) Assessment of impact.--In addition, both the 
        preliminary and final implementation plans under this 
        subsection shall include a detailed assessment of the effects 
        of the proposed payment changes by provider or supplier type 
        and State relative to the payments that would otherwise apply.
    (b) Review by MedPAC and GAO.--Not later than 45 days after the 
date the preliminary implementation plan is received by each House of 
Congress under subsection (a)(2), the Medicare Payment Advisory 
Committee and the Comptroller General of the United States shall each 
evaluate such plan and submit to each House of Congress a report 
containing its analysis and recommendations regarding implementation of 
the plan, including an analysis of the effects of the proposed changes 
in the plan on payments and projected spending.
    (c) Implementation.--
            (1) In general.--The Secretary shall include, in applicable 
        proposed rules for the next rulemaking cycle beginning after 
        the Congressional action deadline, appropriate proposals to 
        revise payments under title XVIII of the Social Security Act in 
        accordance with the final implementation plan submitted under 
        subsection (a)(1), and the waivers specified in subsection 
        (a)(4) to the extent required to carry out such plan are 
        effective, unless a joint resolution (described in subsection 
        (d)(5)(A)) with respect to such plan is enacted by not later 
        than such deadline. If such a joint resolution is enacted, the 
        Secretary is not authorized to implement such plan and the 
        waiver authority provided under subsection (a)(4) shall no 
        longer be effective.
            (2) Congressional action deadline.--For purposes of this 
        section, the term ``Congressional action deadline'' means, with 
        respect to a final implementation plan under subsection (a)(1), 
        May 31, 2012, or, if later, the date that is 145 days after the 
        date of receipt of such plan by each House of Congress under 
        subsection (a).
    (d) Congressional Procedures.--
            (1) Introduction.--On the day on which the final 
        implementation plan is received by the House of Representatives 
        and the Senate under subsection (a), a joint resolution 
        specified in paragraph (5)(A) shall be introduced in the House 
        of Representatives by the majority leader and minority leader 
        of the House of Representatives and in the Senate by the 
        majority leader and minority leader of the Senate. If either 
        House is not in session on the day on which such a plan is 
        received, the joint resolution with respect to such plan shall 
        be introduced in that House, as provided in the preceding 
        sentence, on the first day thereafter on which that House is in 
        session.
            (2) Consideration in the house of representatives.--
                    (A) Reporting and discharge.--Any committee of the 
                House of Representatives to which a joint resolution 
                introduced under paragraph (1) is referred shall report 
                such joint resolution to the House not later than 50 
                legislative days after the applicable date of 
                introduction of the joint resolution. If a committee 
                fails to report such joint resolution within that 
                period, a motion to discharge the committee from 
                further consideration of the joint resolution shall be 
                in order. Such a motion shall be in order only at a 
                time designated by the Speaker in the legislative 
                schedule within two legislative days after the day on 
                which the proponent announces an intention to offer the 
                motion. Notice may not be given on an anticipatory 
                basis. Such a motion shall not be in order after the 
                last committee authorized to consider the joint 
                resolution reports it to the House or after the House 
                has disposed of a motion to discharge the joint 
                resolution. The previous question shall be considered 
                as ordered on the motion to its adoption without 
                intervening motion except 20 minutes of debate equally 
                divided and controlled by the proponent and an 
                opponent. A motion to reconsider the vote by which the 
                motion is disposed of shall not be in order.
                    (B) Proceeding to consideration.--After each 
                committee authorized to consider a joint resolution 
                reports such joint resolution to the House of 
                Representatives or has been discharged from its 
                consideration, a motion to proceed to consider such 
                joint resolution shall be in order. Such a motion shall 
                be in order only at a time designated by the Speaker in 
                the legislative schedule within two legislative days 
                after the day on which the proponent announces an 
                intention to offer the motion. Notice may not be given 
                on an anticipatory basis. Such a motion shall not be in 
                order after the House of Representatives has disposed 
                of a motion to proceed on the joint resolution. The 
                previous question shall be considered as ordered on the 
                motion to its adoption without intervening motion. A 
                motion to reconsider the vote by which the motion is 
                disposed of shall not be in order.
                    (C) Consideration.--The joint resolution shall be 
                considered in the House and shall be considered as 
                read. All points of order against a joint resolution 
                and against its consideration are waived. The previous 
                question shall be considered as ordered on the joint 
                resolution to its passage without intervening motion 
                except two hours of debate equally divided and 
                controlled by the proponent and an opponent. A motion 
                to reconsider the vote on passage of a joint resolution 
                shall not be in order.
            (3) Consideration in the senate.--
                    (A) Reporting and discharge.--Any committee of the 
                Senate to which a joint resolution introduced under 
                paragraph (1) is referred shall report such joint 
                resolution to the Senate within 50 legislative days. If 
                a committee fails to report such joint resolution at 
                the close of the 15th legislative day after its receipt 
                by the Senate, such committee shall be automatically 
                discharged from further consideration of such joint 
                resolution and such joint resolution or joint 
                resolutions shall be placed on the calendar. A vote on 
                final passage of such joint resolution shall be taken 
                in the Senate on or before the close of the second 
                legislative day after such joint resolution is reported 
                by the committee or committees of the Senate to which 
                it was referred, or after such committee or committees 
                have been discharged from further consideration of such 
                joint resolution.
                    (B) Proceeding to consideration.--A motion in the 
                Senate to proceed to the consideration of a joint 
                resolution shall be privileged and not debatable. An 
                amendment to such a motion shall not be in order, nor 
                shall it be in order to move to reconsider the vote by 
                which such a motion is agreed to or disagreed to.
                    (C) Consideration.--
                            (i) Debate in the Senate on a joint 
                        resolution, and all debatable motions and 
                        appeals in connection therewith, shall be 
                        limited to not more than 20 hours. The time 
                        shall be equally divided between, and 
                        controlled by, the majority leader and the 
                        minority leader or their designees.
                            (ii) Debate in the Senate on any debatable 
                        motion or appeal in connection with a joint 
                        resolution shall be limited to not more than 1 
                        hour, to be equally divided between, and 
                        controlled by, the mover and the manager of the 
                        resolution, except that in the event the 
                        manager of the joint resolution is in favor of 
                        any such motion or appeal, the time in 
                        opposition thereto shall be controlled by the 
                        minority leader or a designee. Such leaders, or 
                        either of them, may, from time under their 
                        control on the passage of a joint resolution, 
                        allot additional time to any Senator during the 
                        consideration of any debatable motion or 
                        appeal.
                            (iii) A motion in the Senate to further 
                        limit debate is not debatable. A motion to 
                        recommit a joint resolution is not in order.
            (4) Rules relating to senate and house of 
        representatives.--
                    (A) Coordination with action by other house.--If, 
                before the passage by one House of a joint resolution 
                of that House, that House receives from the other House 
                a joint resolution, then the following procedures shall 
                apply:
                            (i) The joint resolution of the other House 
                        shall not be referred to a committee.
                            (ii) With respect to the joint resolution 
                        of the House receiving the resolution, the 
                        procedure in that House shall be the same as if 
                        no such joint resolution had been received from 
                        the other House; but the vote on passage shall 
                        be on the joint resolution of the other House.
                    (B) Treatment of companion measures.--If, following 
                passage of a joint resolution in the Senate, the Senate 
                then receives the companion measure from the House of 
                Representatives, the companion measure shall not be 
                debatable.
                    (C) Rules of house of representatives and senate.--
                This paragraph and the preceding paragraphs are enacted 
                by Congress--
                            (i) as an exercise of the rulemaking power 
                        of the Senate and House of Representatives, 
                        respectively, and as such it is deemed a part 
                        of the rules of each House, respectively, but 
                        applicable only with respect to the procedure 
                        to be followed in that House in the case of a 
                        joint resolution, and it supersedes other rules 
                        only to the extent that it is inconsistent with 
                        such rules; and
                            (ii) with full recognition of the 
                        constitutional right of either House to change 
                        the rules (so far as relating to the procedure 
                        of that House) at any time, in the same manner, 
                        and to the same extent as in the case of any 
                        other rule of that House.
            (5) Definitions.--In this section:
                    (A) Joint resolution.--The term ``joint 
                resolution'' means only a joint resolution--
                            (i) which does not have a preamble;
                            (ii) the title of which is as follows: 
                        ``Joint resolution disapproving a Medicare 
                        final implementation plan of the Secretary of 
                        Health and Human Services submitted under 
                        section 1160(a) of the Affordable Health Care 
                        for America Act''; and
                            (iii) the sole matter after the resolving 
                        clause of which is as follows: ``That the 
                        Congress disapproves the final implementation 
                        plan of the Secretary of Health and Human 
                        Services transmitted to the Congress on--------
                        --.'', the blank space being filled with the 
                        appropriate date.
                    (B) Legislative day.--The term ``legislative day'' 
                means any calendar day excluding any day on which that 
                House was not in session.
            (6) Budgetary treatment.--For the purposes of consideration 
        of a joint resolution, the Chairmen of the House of 
        Representatives and Senate Committees on the Budget shall 
        exclude from the evaluation of the budgetary effects of the 
        measure, any such effects that are directly attributable to 
        disapproving a Medicare final implementation plan of the 
        Secretary submitted under subsection (a).

                 Subtitle D--Medicare Advantage Reforms

                   PART 1--PAYMENT AND ADMINISTRATION

SEC. 1161. PHASE-IN OF PAYMENT BASED ON FEE-FOR-SERVICE COSTS; QUALITY 
              BONUS PAYMENTS.

    (a) Phase-in of Payment Based on Fee-for-service Costs.--Section 
1853 of the Social Security Act (42 U.S.C. 1395w-23) is amended--
            (1) in subsection (j)(1)(A)--
                    (A) by striking ``beginning with 2007'' and 
                inserting ``for 2007, 2008, 2009, and 2010''; and
                    (B) by inserting after ``(k)(1)'' the following: 
                ``, or, beginning with 2011, \1/12\ of the blended 
                benchmark amount determined under subsection (n)(1)''; 
                and
            (2) by adding at the end the following new subsection:
    ``(n) Determination of Blended Benchmark Amount.--
            ``(1) In general.--For purposes of subsection (j), subject 
        to paragraphs (3) and (4), the term `blended benchmark amount' 
        means for an area--
                    ``(A) for 2011 the sum of--
                            ``(i) \2/3\ of the applicable amount (as 
                        defined in subsection (k)) for the area and 
                        year; and
                            ``(ii) \1/3\ of the amount specified in 
                        paragraph (2) for the area and year;
                    ``(B) for 2012 the sum of--
                            ``(i) \1/3\ of the applicable amount for 
                        the area and year; and
                            ``(ii) \2/3\ of the amount specified in 
                        paragraph (2) for the area and year; and
                    ``(C) for a subsequent year the amount specified in 
                paragraph (2) for the area and year.
            ``(2) Specified amount.--The amount specified in this 
        paragraph for an area and year is the amount specified in 
        subsection (c)(1)(D)(i) for the area and year adjusted (in a 
        manner specified by the Secretary) to take into account the 
        phase-out in the indirect costs of medical education from 
        capitation rates described in subsection (k)(4).
            ``(3) Fee-for-service payment floor.--In no case shall the 
        blended benchmark amount for an area and year be less than the 
        amount specified in paragraph (2).
            ``(4) Exception for pace plans.--This subsection shall not 
        apply to payments to a PACE program under section 1894.''.
    (b) Quality Bonus Payments.--Section 1853 of the Social Security 
Act (42 U.S.C. 1395w-23), as amended by subsection (a), is amended--
            (1) in subsection (j), by inserting ``subject to subsection 
        (o),'' after ``For purposes of this part,''; and
            (2) by adding at the end the following new subsection:
    ``(o) Quality Based Payment Adjustment.--
            ``(1) In general.--In the case of a qualifying plan in a 
        qualifying county with respect to a year beginning with 2011, 
        the blended benchmark amount under subsection (n)(1) shall be 
        increased--
                    ``(A) for 2011, by 1.5 percent;
                    ``(B) for 2012, by 3.0 percent; and
                    ``(C) for a subsequent year, by 5.0 percent.
            ``(2) Qualifying plan and qualifying county defined.--For 
        purposes of this subsection:
                    ``(A) Qualifying plan.--The term `qualifying plan' 
                means, for a year and subject to paragraph (4), a plan 
                that, in a preceding year specified by the Secretary, 
                had a quality ranking (based on the quality ranking 
                system established by the Centers for Medicare & 
                Medicaid Services for Medicare Advantage plans) of 4 
                stars or higher.
                    ``(B) Qualifying county.--The term `qualifying 
                county' means, for a year, a county--
                            ``(i) that ranked within the lowest third 
                        of counties in the amount specified in 
                        subsection (n)(2) for a year specified by the 
                        Secretary; and
                            ``(ii) for which, as of June of a year 
                        specified by the Secretary, of the Medicare 
                        Advantage eligible individuals residing in the 
                        county at least 20 percent of such individuals 
                        were enrolled in Medicare Advantage plans.
            ``(3) Determinations of quality.--
                    ``(A) Quality performance.--The Secretary shall 
                provide for the computation of a quality performance 
                score for each Medicare Advantage plan to be applied 
                for each year.
                    ``(B) Computation of score.--
                            ``(i) Quality performance sore.--For years 
                        before a year specified by the Secretary, the 
                        quality performance score for a Medicare 
                        Advantage plan shall be computed based on a 
                        blend (as designated by the Secretary) of the 
                        plan's performance on--
                                    ``(I) HEDIS effectiveness of care 
                                quality measures;
                                    ``(II) CAHPS quality measures; and
                                    ``(III) such other measures of 
                                clinical quality as the Secretary may 
                                specify.
                        Such measures shall be risk-adjusted as the 
                        Secretary deems appropriate.
                            ``(ii) Establishment of outcome-based 
                        measures.--By not later than for a year 
                        specified by the Secretary, the Secretary shall 
                        implement reporting requirements for quality 
                        under this section on measures selected under 
                        clause (iii) that reflect the outcomes of care 
                        experienced by individuals enrolled in Medicare 
                        Advantage plans (in addition to measures 
                        described in clause (i)). Such measures may 
                        include--
                                    ``(I) measures of rates of 
                                admission and readmission to a 
                                hospital;
                                    ``(II) measures of prevention 
                                quality, such as those established by 
                                the Agency for Healthcare Research and 
                                Quality (that include hospital 
                                admission rates for specified 
                                conditions);
                                    ``(III) measures of patient 
                                mortality and morbidity following 
                                surgery;
                                    ``(IV) measures of health 
                                functioning (such as limitations on 
                                activities of daily living) and 
                                survival for patients with chronic 
                                diseases;
                                    ``(V) measures of patient safety; 
                                and
                                    ``(VI) other measure of outcomes 
                                and patient quality of life as 
                                determined by the Secretary.
                        Such measures shall be risk-adjusted as the 
                        Secretary deems appropriate. In determining the 
                        quality measures to be used under this clause, 
                        the Secretary shall take into consideration the 
                        recommendations of the Medicare Payment 
                        Advisory Commission in its report to Congress 
                        under section 168 of the Medicare Improvements 
                        for Patients and Providers Act of 2008 (Public 
                        Law 110-275) and shall provide preference to 
                        measures collected on and comparable to 
                        measures used in measuring quality under parts 
                        A and B.
                            ``(iii) Rules for selection of measures.--
                        The Secretary shall select measures for 
                        purposes of clause (ii) consistent with the 
                        following:
                                    ``(I) The Secretary shall provide 
                                preference to clinical quality measures 
                                that have been endorsed by the entity 
                                with a contract with the Secretary 
                                under section 1890(a).
                                    ``(II) Prior to any measure being 
                                selected under this clause, the 
                                Secretary shall publish in the Federal 
                                Register such measure and provide for a 
                                period of public comment on such 
                                measure.
                            ``(iv) Transitional use of blend.--For 
                        payments for years specified by the Secretary, 
                        the Secretary may compute the quality 
                        performance score for a Medicare Advantage plan 
                        based on a blend of the measures specified in 
                        clause (i) and the measures described in clause 
                        (ii) and selected under clause (iii).
                            ``(v) Use of quality outcomes measures.--
                        For payments beginning with a year specified by 
                        the Secretary (beginning after the years 
                        specified for section (iv)), the preponderance 
                        of measures used under this paragraph shall be 
                        quality outcomes measures described in clause 
                        (ii) and selected under clause (iii).
                    ``(C) Reporting of data.--Each Medicare Advantage 
                organization shall provide for the reporting to the 
                Secretary of quality performance data described in this 
                paragraph (in order to determine a quality performance 
                score under this paragraph) in such time and manner as 
                the Secretary shall specify.
            ``(4) Notification.--The Secretary, in the annual 
        announcement required under subsection (b)(1)(B) in 2010 and 
        each succeeding year, shall notify the Medicare Advantage 
        organization that is offering a qualifying plan in a qualifying 
        county of such identification for the year. The Secretary shall 
        provide for publication on the website for the Medicare program 
        of the information described in the previous sentence.
            ``(5) Authority to disqualify deficient plans.--The 
        Secretary may determine that a Medicare Advantage plan is not a 
        qualifying plan if the Secretary has identified deficiencies in 
        the plan's compliance with rules for Medicare Advantage plans 
        under this part.''.

SEC. 1162. AUTHORITY FOR SECRETARIAL CODING INTENSITY ADJUSTMENT 
              AUTHORITY.

    Section 1853(a)(1)(C)(ii) of the Social Security Act (42 U.S.C. 
1395w-23(a)(1)(C)(ii) is amended--
            (1) in the matter before subclause (I), by striking 
        ``through 2010'' and inserting ``and each subsequent year''; 
        and
            (2) in subclause (II)--
                    (A) by inserting ``periodically'' before ``conduct 
                an analysis'';
                    (B) by inserting ``on a timely basis'' after ``are 
                incorporated''; and
                    (C) by striking ``only for 2008, 2009, and 2010'' 
                and inserting ``for 2008 and subsequent years''.

SEC. 1163. SIMPLIFICATION OF ANNUAL BENEFICIARY ELECTION PERIODS.

    (a) 2 Week Processing Period for Annual Enrollment Period (AEP).--
Paragraph (3)(B) of section 1851(e) of the Social Security Act (42 
U.S.C. 1395w-21(e)) is amended--
            (1) by striking ``and'' at the end of clause (iii);
            (2) in clause (iv)--
                    (A) by striking ``and succeeding years'' and 
                inserting ``, 2008, 2009, and 2010''; and
                    (B) by striking the period at the end and inserting 
                ``; and''; and
            (3) by adding at the end the following new clause:
                            ``(v) with respect to 2011 and succeeding 
                        years, the period beginning on November 1 and 
                        ending on December 15 of the year before such 
                        year.''.
    (b) Elimination of 3-month Additional Open Enrollment Period 
(OEP).--Effective for plan years beginning with 2011, paragraph (2) of 
such section is amended by striking subparagraph (C).

SEC. 1164. EXTENSION OF REASONABLE COST CONTRACTS.

    Section 1876(h)(5)(C) of the Social Security Act (42 U.S.C. 
1395mm(h)(5)(C)) is amended--
            (1) in clause (ii), by striking ``January 1, 2010'' and 
        inserting ``January 1, 2012''; and
            (2) in clause (iii), by striking ``the service area for the 
        year'' and inserting ``the portion of the plan's service area 
        for the year that is within the service area of a reasonable 
        cost reimbursement contract''.

SEC. 1165. LIMITATION OF WAIVER AUTHORITY FOR EMPLOYER GROUP PLANS.

    (a) In General.--The first sentence of each of paragraphs (1) and 
(2) of section 1857(i) of the Social Security Act (42 U.S.C. 1395w-
27(i)) is amended by inserting before the period at the end the 
following: ``, but only if 90 percent of the Medicare Advantage 
eligible individuals enrolled under such plan reside in a county in 
which the MA organization offers an MA local plan''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply for plan years beginning on or after January 1, 2011, and shall 
not apply to plans which were in effect as of December 31, 2010.

SEC. 1166. IMPROVING RISK ADJUSTMENT FOR PAYMENTS.

    (a) Report to Congress.--Not later than 1 year after the date of 
the enactment of this Act, the Secretary of Health and Human Services 
shall submit to Congress a report that evaluates the adequacy of the 
risk adjustment system under section 1853(a)(1)(C) of the Social 
Security Act (42 U.S.C. 1395-23(a)(1)(C)) in predicting costs for 
beneficiaries with chronic or co-morbid conditions, beneficiaries 
dually-eligible for Medicare and Medicaid, and non-Medicaid eligible 
low-income beneficiaries; and the need and feasibility of including 
further gradations of diseases or conditions and multiple years of 
beneficiary data.
    (b) Improvements to Risk Adjustment.--Not later than January 1, 
2012, the Secretary shall implement necessary improvements to the risk 
adjustment system under section 1853(a)(1)(C) of the Social Security 
Act (42 U.S.C. 1395-23(a)(1)(C)), taking into account the evaluation 
under subsection (a).

SEC. 1167. ELIMINATION OF MA REGIONAL PLAN STABILIZATION FUND.

    (a) In General.--Section 1858 of the Social Security Act (42 U.S.C. 
1395w-27a) is amended by striking subsection (e).
    (b) Transition.--Any amount contained in the MA Regional Plan 
Stabilization Fund as of the date of the enactment of this Act shall be 
transferred to the Federal Supplementary Medical Insurance Trust Fund.

SEC. 1168. STUDY REGARDING THE EFFECTS OF CALCULATING MEDICARE 
              ADVANTAGE PAYMENT RATES ON A REGIONAL AVERAGE OF MEDICARE 
              FEE FOR SERVICE RATES.

    (a) In General.--The Administrator of the Centers for Medicare and 
Medicaid Services shall conduct a study to determine the potential 
effects of calculating Medicare Advantage payment rates on a more 
aggregated geographic basis (such as metropolitan statistical areas or 
other regional delineations) rather than using county boundaries. In 
conducting such study, the Administrator shall consider the effect of 
such alternative geographic basis on the following:
            (1) The quality of care received by Medicare Advantage 
        enrollees.
            (2) The networks of Medicare Advantage plans, including any 
        implications for providers contracting with Medicare Advantage 
        plans.
            (3) The predictability of benchmark amounts for Medicare 
        advantage plans.
    (b) Consultations.--In conducting the study, the Administrator 
shall consult with the following:
            (1) Experts in health care financing.
            (2) Representatives of foundations and other nonprofit 
        entities that have conducted or supported research on Medicare 
        financing issues.
            (3) Representatives from Medicare Advantage plans.
            (4) Such other entities or people as determined by the 
        Secretary.
    (c) Report.--Not later than one year after the date of the 
enactment of this Act, the Administrator shall transmit a report to the 
Congress on the study conducted under this section. The report shall 
contain a detailed statement of findings and conclusions of the study, 
together with its recommendations for such legislation and 
administrative actions as the Administrator considers appropriate.

             PART 2--BENEFICIARY PROTECTIONS AND ANTI-FRAUD

SEC. 1171. LIMITATION ON COST-SHARING FOR INDIVIDUAL HEALTH SERVICES.

    (a) In General.--Section 1852(a)(1) of the Social Security Act (42 
U.S.C. 1395w-22(a)(1)) is amended--
            (1) in subparagraph (A), by inserting before the period at 
        the end the following: ``with cost-sharing that is no greater 
        (and may be less) than the cost-sharing that would otherwise be 
        imposed under such program option'';
            (2) in subparagraph (B)(i), by striking ``or an actuarially 
        equivalent level of cost-sharing as determined in this part''; 
        and
            (3) by amending clause (ii) of subparagraph (B) to read as 
        follows:
                            ``(ii) Permitting use of flat copayment or 
                        per diem rate.--Nothing in clause (i) shall be 
                        construed as prohibiting a Medicare Advantage 
                        plan from using a flat copayment or per diem 
                        rate, in lieu of the cost-sharing that would be 
                        imposed under part A or B, so long as the 
                        amount of the cost-sharing imposed does not 
                        exceed the amount of the cost-sharing that 
                        would be imposed under the respective part if 
                        the individual were not enrolled in a plan 
                        under this part.''.
    (b) Limitation for Dual Eligibles and Qualified Medicare 
Beneficiaries.--Section 1852(a)(7) of such Act is amended to read as 
follows:
            ``(7) Limitation on cost-sharing for dual eligibles and 
        qualified medicare beneficiaries.--In the case of a individual 
        who is a full-benefit dual eligible individual (as defined in 
        section 1935(c)(6)) or a qualified medicare beneficiary (as 
        defined in section 1905(p)(1)) who is enrolled in a Medicare 
        Advantage plan, the plan may not impose cost-sharing that 
        exceeds the amount of cost-sharing that would be permitted with 
        respect to the individual under this title and title XIX if the 
        individual were not enrolled with such plan.''.
    (c) Effective Dates.--
            (1) The amendments made by subsection (a) shall apply to 
        plan years beginning on or after January 1, 2011.
            (2) The amendments made by subsection (b) shall apply to 
        plan years beginning on or after January 1, 2011.

SEC. 1172. CONTINUOUS OPEN ENROLLMENT FOR ENROLLEES IN PLANS WITH 
              ENROLLMENT SUSPENSION.

    Section 1851(e)(4) of the Social Security Act (42 U.S.C. 
1395w(e)(4)) is amended--
            (1) in subparagraph (C), by striking at the end ``or'';
            (2) in subparagraph (D)--
                    (A) by inserting ``, taking into account the health 
                or well-being of the individual'' before the period; 
                and
                    (B) by redesignating such subparagraph as 
                subparagraph (E); and
            (3) by inserting after subparagraph (C) the following new 
        subparagraph:
                    ``(D) the individual is enrolled in an MA plan and 
                enrollment in the plan is suspended under paragraph 
                (2)(B) or (3)(C) of section 1857(g) because of a 
                failure of the plan to meet applicable requirements; 
                or''.

SEC. 1173. INFORMATION FOR BENEFICIARIES ON MA PLAN ADMINISTRATIVE 
              COSTS.

    (a) Disclosure of Medical Loss Ratios and Other Expense Data.--
Section 1851 of the Social Security Act (42 U.S.C. 1395w-21), as 
previously amended by this subtitle, is amended by adding at the end 
the following new subsection:
    ``(p) Publication of Medical Loss Ratios and Other Cost-related 
Information.--
            ``(1) In general.--The Secretary shall publish, not later 
        than November 1 of each year (beginning with 2011), for each MA 
        plan contract, the medical loss ratio of the plan in the 
        previous year.
            ``(2) Submission of data.--
                    ``(A) In general.--Each MA organization shall 
                submit to the Secretary, in a form and manner specified 
                by the Secretary, data necessary for the Secretary to 
                publish the medical loss ratio on a timely basis.
                    ``(B) Data for 2010 and 2011.--The data submitted 
                under subparagraph (A) for 2010 and for 2011 shall be 
                consistent in content with the data reported as part of 
                the MA plan bid in June 2009 for 2010.
                    ``(C) Use of standardized elements and 
                definitions.--The data to be submitted under 
                subparagraph (A) relating to medical loss ratio for a 
                year, beginning with 2012, shall be submitted based on 
                the standardized elements and definitions developed 
                under paragraph (3).
            ``(3) Development of data reporting standards.--
                    ``(A) In general.--The Secretary shall develop and 
                implement standardized data elements and definitions 
                for reporting under this subsection, for contract years 
                beginning with 2012, of data necessary for the 
                calculation of the medical loss ratio for MA plans. Not 
                later than December 31, 2010, the Secretary shall 
                publish a report describing the elements and 
                definitions so developed.
                    ``(B) Consultation.--The Secretary shall consult 
                with the Health Choices Commissioner, representatives 
                of MA organizations, experts on health plan accounting 
                systems, and representatives of the National 
                Association of Insurance Commissioners, in the 
                development of such data elements and definitions.
            ``(4) Medical loss ratio to be defined.--For purposes of 
        this part, the term `medical loss ratio' has the meaning given 
        such term by the Secretary, taking into account the meaning 
        given such term by the Health Choices Commissioner under 
        section 116 of the Affordable Health Care for America Act.''.
    (b) Minimum Medical Loss Ratio.--Section 1857(e) of the Social 
Security Act (42 U.S.C. 1395w-27(e)) is amended by adding at the end 
the following new paragraph:
            ``(4) Requirement for minimum medical loss ratio.--If the 
        Secretary determines for a contract year (beginning with 2014) 
        that an MA plan has failed to have a medical loss ratio (as 
        defined in section 1851(p)(4)) of at least .85--
                    ``(A) the Secretary shall require the Medicare 
                Advantage organization offering the plan to give 
                enrollees a rebate (in the second succeeding contract 
                year) of premiums under this part (or part B or part D, 
                if applicable) by such amount as would provide for a 
                benefits ratio of at least .85;
                    ``(B) for 3 consecutive contract years, the 
                Secretary shall not permit the enrollment of new 
                enrollees under the plan for coverage during the second 
                succeeding contract year; and
                    ``(C) the Secretary shall terminate the plan 
                contract if the plan fails to have such a medical loss 
                ratio for 5 consecutive contract years.''.

SEC. 1174. STRENGTHENING AUDIT AUTHORITY.

    (a) For Part C Payments Risk Adjustment.--Section 1857(d)(1) of the 
Social Security Act (42 U.S.C. 1395w-27(d)(1)) is amended by inserting 
after ``section 1858(c))'' the following: ``, and data submitted with 
respect to risk adjustment under section 1853(a)(3)''.
    (b) Enforcement of Audits and Deficiencies.--
            (1) In general.--Section 1857(e) of such Act, as amended by 
        section 1173, is amended by adding at the end the following new 
        paragraph:
            ``(5) Enforcement of audits and deficiencies.--
                    ``(A) Information in contract.--The Secretary shall 
                require that each contract with an MA organization 
                under this section shall include terms that inform the 
                organization of the provisions in subsection (d).
                    ``(B) Enforcement authority.--The Secretary is 
                authorized, in connection with conducting audits and 
                other activities under subsection (d), to take such 
                actions, including pursuit of financial recoveries, 
                necessary to address deficiencies identified in such 
                audits or other activities.''.
            (2) Application under part d.--For provision applying the 
        amendment made by paragraph (1) to prescription drug plans 
        under part D, see section 1860D-12(b)(3)(D) of the Social 
        Security Act.
    (c) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act and shall apply to 
audits and activities conducted for contract years beginning on or 
after January 1, 2011.

SEC. 1175. AUTHORITY TO DENY PLAN BIDS.

    (a) In General.--Section 1854(a)(5) of the Social Security Act (42 
U.S.C. 1395w-24(a)(5)) is amended by adding at the end the following 
new subparagraph:
                    ``(C) Rejection of bids.--Nothing in this section 
                shall be construed as requiring the Secretary to accept 
                any or every bid by an MA organization under this 
                subsection.''.
    (b) Application Under Part D.--Section 1860D-11(d) of such Act (42 
U.S.C. 1395w-111(d)) is amended by adding at the end the following new 
paragraph:
            ``(3) Rejection of bids.--Paragraph (5)(C) of section 
        1854(a) shall apply with respect to bids under this section in 
        the same manner as it applies to bids by an MA organization 
        under such section.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to bids for contract years beginning on or after January 1, 2011.

SEC. 1175A. STATE AUTHORITY TO ENFORCE STANDARDIZED MARKETING 
              REQUIREMENTS.

    Section 1856(b)(3) of the Social Security Act (42 U.S.C. 1395w-
26(b)(3)) is amended--
            (1) by striking ``The standards'' and inserting ``(A) in 
        general.--The standards'' with appropriate indentation that is 
        the same as for the subparagraph (B) added by paragraph (2); 
        and
            (2) by adding at the end the following new subparagraph:
                    ``(B) Enforcement of federal standards permitted.--
                            ``(i) In general.--Subject to the 
                        subsequent provision of this subparagraph, 
                        nothing in this title shall be construed to 
                        prohibit a State from conducting a market 
                        conduct examination or from imposing civil 
                        monetary penalties, in accordance with laws and 
                        procedures of the State, against Medicare 
                        Advantage organizations, PDP sponsors, or 
                        agents or brokers of such organizations or 
                        sponsors for violations of the marketing 
                        requirements under subsections (h)(4), (h)(6), 
                        and (j) of section 1851 and section 
                        1857(g)(1)(E).
                            ``(ii) Additional remedies resulting from 
                        federal-state cooperation.--
                                    ``(I) State recommendation.--A 
                                State may recommend to the Secretary 
                                the imposition of an intermediate 
                                sanction not described in clause (i) 
                                (such as those available under section 
                                1857(g)) against a Medicare Advantage 
                                organization, PDP sponsor, or agent or 
                                broker of such an organization or 
                                sponsor for a violation described in 
                                such clause.
                                    ``(II) Response to 
                                recommendation.--Not later than 30 days 
                                after receipt of a recommendation under 
                                subclause (I) from a State, with 
                                respect to a violation described in 
                                clause (i), the Secretary shall respond 
                                in writing to the State indicating the 
                                progress of any investigation involving 
                                such violation, whether the Secretary 
                                intends to pursue the recommendation 
                                from the State, and in the case the 
                                Secretary does not intend to pursue 
                                such recommendation, the reason for 
                                such decision.
                            ``(iii) Non-duplication of penalties.--In 
                        the case that an action has been initiated 
                        against a Medicare Advantage organization, PDP 
                        sponsor, or agent or broker of such an 
                        organization or sponsor for a violation of a 
                        marketing requirement under subsection (h)(4), 
                        (h)(6), or (j) of section 1851 or section 
                        1857(g)(1)(E)--
                                    ``(I) in the case such action has 
                                been initiated by the Secretary, no 
                                State may bring an action under such 
                                applicable subsection or section 
                                against such organization, sponsor, 
                                agent, or broker with respect to such 
                                violation during the pendency period of 
                                the action initiated by the Secretary 
                                and, if a penalty is imposed pursuant 
                                to such action, after such period; and
                                    ``(II) in the case such action has 
                                been initiated by a State, the 
                                Secretary may not bring an action under 
                                such applicable subsection or section 
                                against such organization, sponsor, 
                                agent, or broker with respect to such 
                                violation during the pendency period of 
                                the action initiated by the Secretary 
                                and, if a penalty is imposed pursuant 
                                to such action, after such period.
                        Nothing in this clause shall be construed as 
                        limiting the ability of the Secretary to impose 
                        any sanction other than a civil monetary 
                        penalty under section 1857 against a Medicare 
                        Advantage organization, PDP sponsor, or agent 
                        or broker of such an organization or sponsor 
                        for a violation described in clause (i).
                            ``(iv) Construction.--Nothing in this 
                        subparagraph shall be construed as affecting 
                        any State authority to regulate brokers 
                        described in this paragraph or any other 
                        conduct of a Medicare Advantage organization or 
                        PDP sponsor.''.

                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.

    Section 1859(f)(4) of the Social Security Act (42 U.S.C. 1395w-
28(f)(4)) is amended by adding at the end the following new 
subparagraph:
                    ``(C) The plan does not enroll an individual on or 
                after January 1, 2011, other than--
                            ``(i) during an annual, coordinated open 
                        enrollment period; or
                            ``(ii) during a special election period 
                        consisting of the period for which the 
                        individual has a chronic condition that 
                        qualifies the individual as an individual 
                        described in subsection (b)(6)(B)(iii) for such 
                        plan and ending on the date on which the 
                        individual enrolls in such a plan on the basis 
                        of such condition.
                If an individual is enrolled in such a plan on the 
                basis of a chronic condition and becomes eligible for 
                another such plan on the basis of another chronic 
                condition, the other plan may enroll the individual on 
                the basis of such other chronic condition during a 
                special enrollment period described in clause (ii). An 
                individual is eligible to apply such clause only once 
                on the basis of any specific chronic condition.''.

SEC. 1177. EXTENSION OF AUTHORITY OF SPECIAL NEEDS PLANS TO RESTRICT 
              ENROLLMENT; SERVICE AREA MORATORIUM FOR CERTAIN SNPS.

    (a) In General.--Section 1859(f)(1) of the Social Security Act (42 
U.S.C. 1395w-28(f)(1)) is amended by striking ``January 1, 2011'' and 
inserting ``January 1, 2013 (or January 1, 2016, in the case of a plan 
described in section 1177(b)(1) of the Affordable Health Care for 
America Act)''.
    (b) Extension of Certain Plans.--
            (1) Plans described.--For purposes of Section 1859(f)(1) of 
        the Social Security Act (42 U.S.C. 1395w-28(f)(1)), a plan 
        described in this paragraph is a Medicare Advantage dual 
        eligible special needs plan that--
                    (A) whose sponsoring Medicare Advantage 
                organization, as of the date enactment of the 
                Affordable Health Care for America Act, has a contract 
                with a State Medicaid Agency that participated in the 
                ``Demonstrations Serving Those Dually-Eligible for 
                Medicare and Medicaid'' under the Medicare program; and
                    (B) that has been approved by the Centers for 
                Medicare & Medicaid Services as a dual eligible special 
                needs plan and that offers integrated Medicare and 
                Medicaid services under a contract with the State 
                Medicaid agency.
            (2) Analysis; report.--
                    (A) Analysis.--The Secretary of Health and Human 
                Services shall provide, through a contract with an 
                independent health services evaluation organization, 
                for an analysis of the plans described in paragraph (1) 
                with regard to the impact of such plans on cost, 
                quality of care, patient satisfaction, and other 
                subjects specified by the Secretary. Such report also 
                will identify statutory changes needed to simplify 
                access to needed services, improve coordination of 
                benefits and services and ensure protection for dual 
                eligibles as appropriate.
                    (B) Report.--Not later than December 31, 2011, the 
                Secretary shall submit to the Congress a report on the 
                analysis under subparagraph (A) and shall include in 
                such report such recommendations with regard to the 
                treatment of such plans as the Secretary deems 
                appropriate.
    (c) Extension of Service Area Moratorium for Certain SNPs.--Section 
164(c)(2) of the Medicare Improvements for Patients and Providers Act 
of 2008 is amended by striking ``December 31, 2010'' and inserting 
``December 31, 2012''.

SEC. 1178. EXTENSION OF MEDICARE SENIOR HOUSING PLANS.

    Section 1859 of the Social Security Act (42 U.S.C. 1395w-28) is 
amended by adding at the end the following new subsection:
    ``(g) Special Rules for Senior Housing Facility Plans.--
            ``(1) In general.--Notwithstanding any other provision of 
        this part, in the case of a Medicare Advantage senior housing 
        facility plan described in paragraph (2) and for periods before 
        January 1, 2013--
                    ``(A) the service area of such plan may be limited 
                to a senior housing facility in a geographic area;
                    ``(B) the service area of such plan may not be 
                expanded; and
                    ``(C) additional senior housing facilities may not 
                be serviced by such plan.
            ``(2) Medicare advantage senior housing facility plan 
        described.--For purposes of this subsection, a Medicare 
        Advantage senior housing facility plan is a Medicare Advantage 
        plan that--
                    ``(A)(i) restricts enrollment of individuals under 
                this part to individuals who reside in a continuing 
                care retirement community (as defined in section 
                1852(l)(4)(B));
                    ``(ii) provides primary care services onsite and 
                has a ratio of accessible providers to beneficiaries 
                that the Secretary determines is adequate, taking into 
                consideration the number of residents onsite, the 
                health needs of those residents, and the accessibility 
                of providers offsite; and
                    ``(iii) provides transportation services for 
                beneficiaries to providers outside of the facility; and
                    ``(B) is offered by a Medicare Advantage 
                organization that has offered at least 1 plan described 
                in subparagraph (A) for at least 1 year prior to 
                January 1, 2010, under a demonstration project 
                established by the Secretary.''.

              Subtitle E--Improvements to Medicare Part D

SEC. 1181. ELIMINATION OF COVERAGE GAP.

    (a) Immediate Reduction in Coverage Gap in 2010.--Section 1860D-
2(b) of the Social Security Act (42 U.S.C. 1395w-102(b)) is amended--
            (1) in paragraph (3)(A), by striking ``paragraph (4)'' and 
        inserting ``paragraphs (4) and (7)''; and
            (2) by adding at the end the following new paragraph:
            ``(7) Increase in initial coverage limit in 2010.--
                    ``(A) In general.--For plan years beginning during 
                2010, the initial coverage limit described in paragraph 
                (3)(B) otherwise applicable shall be increased by $500.
                    ``(B) Application.--In applying subparagraph (A)--
                            ``(i) except as otherwise provided in this 
                        subparagraph, there shall be no change in the 
                        premiums, bids, or any other parameters under 
                        this part or part C;
                            ``(ii) costs that would be treated as 
                        incurred costs for purposes of applying 
                        paragraph (4) but for the application of 
                        subparagraph (A) shall continue to be treated 
                        as incurred costs;
                            ``(iii) the Secretary shall establish 
                        procedures, which may include a reconciliation 
                        process, to fully reimburse PDP sponsors with 
                        respect to prescription drug plans and MA 
                        organizations with respect to MA-PD plans for 
                        the reduction in beneficiary cost sharing 
                        associated with the application of subparagraph 
                        (A);
                            ``(iv) the Secretary shall develop an 
                        estimate of the additional increased costs 
                        attributable to the application of this 
                        paragraph for increased drug utilization and 
                        financing and administrative costs and shall 
                        use such estimate to adjust payments to PDP 
                        sponsors with respect to prescription drug 
                        plans under this part and MA organizations with 
                        respect to MA-PD plans under part C; and
                            ``(v) the Secretary shall establish 
                        procedures for retroactive reimbursement of 
                        part D eligible individuals who are covered 
                        under such a plan for costs which are incurred 
                        before the date of initial implementation of 
                        subparagraph (A) and which would be reimbursed 
                        under such a plan if such implementation 
                        occurred as of January 1, 2010.''.
    (b) Additional Closure in Gap Beginning in 2011.--Section 1860D-
2(b) of such Act (42 U.S.C. 1395w-102(b)) as amended by subsection (a), 
is further amended--
            (1) in paragraph (3)(A), by striking ``and (7)'' and 
        inserting ``, (7), and (8)'' ;
            (2) in paragraph (4)(B)(i), by inserting ``subject to 
        paragraph (8)'' after ``purposes of this part''; and
            (3) by adding at the end the following new paragraph:
            ``(8) Phased-in elimination of coverage gap.--
                    ``(A) In general.--For each year beginning with 
                2011, the Secretary shall consistent with this 
                paragraph progressively increase the initial coverage 
                limit (described in subsection (b)(3)) and decrease the 
                annual out-of-pocket threshold from the amounts 
                otherwise computed until, beginning in 2019, there is a 
                continuation of coverage from the initial coverage 
                limit for expenditures incurred through the total 
                amount of expenditures at which benefits are available 
                under paragraph (4).
                    ``(B) Increase in initial coverage limit.--
                            ``(i) In general.--For a year beginning 
                        with 2011, subject to clause (ii), the initial 
                        coverage limit otherwise computed without 
                        regard to this paragraph shall be increased by 
                        the cumulative ICL phase-in percentage (as 
                        defined in clause (iii) for the year) times the 
                        out-of-pocket gap amount (as defined in 
                        subparagraph (D)) for the year.
                            ``(ii) Maintenance of 2010 initial coverage 
                        limit level.--If for a year the initial 
                        coverage limit otherwise computed under this 
                        paragraph would be less than the initial 
                        coverage limit applied during 2010, taking into 
                        account paragraph (7), the initial coverage 
                        limit for that year shall be such initial 
                        coverage limit as so applied during 2010.
                            ``(iii) Cumulative phase-in percentage.--
                                    ``(I) In general.--For purposes of 
                                this paragraph, subject to subclause 
                                (II), the term `cumulative ICL phase-in 
                                percentage' means for a year the sum of 
                                the annual ICL phase-in percentage (as 
                                defined in clause (iv)) for the year 
                                and the annual ICL phase-in percentages 
                                for each previous year beginning with 
                                2011.
                                    ``(II) Limitation.--If the sum of 
                                the cumulative ICL phase-in percentage 
                                and the cumulative OPT phase-in 
                                percentage (as defined in subparagraph 
                                (C)(iii)) for a year would otherwise 
                                exceed 100 percent, each such 
                                percentage shall be reduced in a 
                                proportional amount so the sum does not 
                                exceed 100 percent.
                            ``(iv) Annual icl phase-in percentage.--For 
                        purposes of this paragraph, the term `annual 
                        ICL phase-in percentage' means--
                                    ``(I) for 2011, 8.25 percent;
                                    ``(II) for 2012, 2013, and 2014, 
                                4.5 percent;
                                    ``(III) for 2015 and 2016, 6 
                                percent;
                                    ``(IV) for 2017, 7.5 percent;
                                    ``(V) for 2018, 8 percent; and
                                    ``(VI) for 2019, 8 percent, or such 
                                other percent as may be necessary to 
                                provide for a full continuation of 
                                coverage as described in subparagraph 
                                (A) in that year.
                    ``(C) Decrease in annual out-of-pocket threshold.--
                            ``(i) In general.--For a year beginning 
                        with 2011, subject to clause (ii), the annual 
                        out-of-pocket threshold otherwise computed 
                        without regard to this paragraph shall be 
                        decreased by the cumulative OPT phase-in 
                        percentage (as defined in clause (iii) for the 
                        year) of the out-of-pocket gap amount for the 
                        year multiplied by 1.75.
                            ``(ii) Maintenance.--The Secretary shall 
                        adjust the annual out-of-pocket threshold for a 
                        year to the extent necessary to ensure that the 
                        sum of the initial coverage limit described in 
                        subparagraph (A) and the out-of-pocket gap 
                        amount (defined in subparagraph (D)), as 
                        determined for the year pursuant to the 
                        provisions of this paragraph for such year, 
                        does not exceed such sum that would have 
                        applied if this paragraph did not apply.
                            ``(iii) Cumulative opt phase-in 
                        percentage.--For purposes of this paragraph, 
                        subject to subparagraph (B)(iii)(II), the term 
                        `cumulative OPT phase-in percentage' means for 
                        a year the sum of the annual OPT phase-in 
                        percentage (as defined in clause (iv)) for the 
                        year and the annual OPT phase-in percentages 
                        for each previous year beginning with 2011.
                            ``(iv) Annual opt phase-in percentage.--For 
                        purposes of this paragraph, the term `annual 
                        OPT phase-in percentage' means--
                                    ``(I) for 2011, 0 percent;
                                    ``(II) for 2012, 2013, and 2014, 
                                4.5 percent;
                                    ``(III) for 2015 and 2016, 6 
                                percent;
                                    ``(IV) for 2017, 7.5 percent; and
                                    ``(V) for 2018 and 2019, 8 percent.
                    ``(D) Out-of-pocket gap amount.--For purposes of 
                this paragraph, the term `out-of-pocket gap amount' 
                means for a year the amount by which--
                            ``(i) the annual out-of-pocket threshold 
                        specified in paragraph (4)(B) for the year (as 
                        determined as if this paragraph did not apply), 
                        exceeds
                            ``(ii) the sum of--
                                    ``(I) the annual deductible under 
                                paragraph (1) for the year; and
                                    ``(II) \1/4\ of the amount by which 
                                the initial coverage limit under 
                                paragraph (3) for the year (as 
                                determined as if this paragraph did not 
                                apply) exceeds such annual deductible.
                    ``(E) Relation to aahca transitional increase.--
                Except as otherwise specifically provided, this 
                paragraph shall be applied as if no increase had been 
                made in the initial coverage limit under paragraph 
                (7).''.
    (c) Requiring Drug Manufacturers to Provide Drug Rebates for Rebate 
Eligible Individuals.--
            (1) In general.--Section 1860D-2 of the Social Security Act 
        (42 U.S.C. 1395w-102) is amended--
                    (A) in subsection (e)(1), in the matter before 
                subparagraph (A), by inserting ``and subsection (f)'' 
                after ``this subsection''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(f) Prescription Drug Rebate Agreement for Rebate Eligible 
Individuals.--
            ``(1) Requirement.--
                    ``(A) In general.--For plan years beginning on or 
                after January 1, 2011, in this part, the term `covered 
                part D drug' does not include any drug or biological 
                product that is manufactured by a manufacturer that has 
                not entered into and have in effect a rebate agreement 
                described in paragraph (2).
                    ``(B) 2010 plan year requirement.--Any drug or 
                biological product manufactured by a manufacturer that 
                declines to enter into a rebate agreement described in 
                paragraph (2) for the period beginning on January 1, 
                2010, and ending on December 31, 2010, shall not be 
                included as a `covered part D drug ` for the subsequent 
                plan year.
            ``(2) Rebate agreement.--A rebate agreement under this 
        subsection shall require the manufacturer to provide to the 
        Secretary a rebate for each rebate period (as defined in 
        paragraph (6)(B)) ending after December 31, 2009, in the amount 
        specified in paragraph (3) for any covered part D drug of the 
        manufacturer dispensed after December 31, 2009, to any rebate 
        eligible individual (as defined in paragraph (6)(A)) for which 
        payment was made by a PDP sponsor under part D or a MA 
        organization under part C for such period, including payments 
        passed through the low-income and reinsurance subsidies under 
        sections 1860D-14 and 1860D-15(b), respectively. Such rebate 
        shall be paid by the manufacturer to the Secretary not later 
        than 30 days after the date of receipt of the information 
        described in section 1860D-12(b)(7), including as such section 
        is applied under section 1857(f)(3), or 30 days after the 
        receipt of information under subparagraph (D) of paragraph (3), 
        as determined by the Secretary. Insofar as not inconsistent 
        with this subsection, the Secretary shall establish terms and 
        conditions of such agreement relating to compliance, penalties, 
        and program evaluations, investigations, and audits that are 
        similar to the terms and conditions for rebate agreements under 
        paragraphs (3) and (4) of section 1927(b).
            ``(3) Rebate for rebate eligible medicare drug plan 
        enrollees.--
                    ``(A) In general.--The amount of the rebate 
                specified under this paragraph for a manufacturer for a 
                rebate period, with respect to each dosage form and 
                strength of any covered part D drug provided by such 
                manufacturer and dispensed to a rebate eligible 
                individual, shall be equal to the product of--
                            ``(i) the total number of units of such 
                        dosage form and strength of the drug so 
                        provided and dispensed for which payment was 
                        made by a PDP sponsor under part D or a MA 
                        organization under part C for the rebate 
                        period, including payments passed through the 
                        low-income and reinsurance subsidies under 
                        sections 1860D-14 and 1860D-15(b), 
                        respectively; and
                            ``(ii) the amount (if any) by which--
                                    ``(I) the Medicaid rebate amount 
                                (as defined in subparagraph (B)) for 
                                such form, strength, and period, 
                                exceeds
                                    ``(II) the average Medicare drug 
                                program rebate eligible rebate amount 
                                (as defined in subparagraph (C)) for 
                                such form, strength, and period.
                    ``(B) Medicaid rebate amount.--For purposes of this 
                paragraph, the term `Medicaid rebate amount' means, 
                with respect to each dosage form and strength of a 
                covered part D drug provided by the manufacturer for a 
                rebate period--
                            ``(i) in the case of a single source drug 
                        or an innovator multiple source drug, the 
                        amount specified in paragraph (1)(A)(ii) of 
                        section 1927(c) plus the amount, if any, 
                        specified in paragraph (2)(A)(ii) of such 
                        section, for such form, strength, and period; 
                        or
                            ``(ii) in the case of any other covered 
                        outpatient drug, the amount specified in 
                        paragraph (3)(A)(i) of such section for such 
                        form, strength, and period.
                    ``(C) Average medicare drug program rebate eligible 
                rebate amount.--For purposes of this subsection, the 
                term `average Medicare drug program rebate eligible 
                rebate amount' means, with respect to each dosage form 
                and strength of a covered part D drug provided by a 
                manufacturer for a rebate period, the sum, for all PDP 
                sponsors under part D and MA organizations 
                administering a MA-PD plan under part C, of--
                            ``(i) the product, for each such sponsor or 
                        organization, of--
                                    ``(I) the sum of all rebates, 
                                discounts, or other price concessions 
                                (not taking into account any rebate 
                                provided under paragraph (2) for such 
                                dosage form and strength of the drug 
                                dispensed, calculated on a per-unit 
                                basis, but only to the extent that any 
                                such rebate, discount, or other price 
                                concession applies equally to drugs 
                                dispensed to rebate eligible Medicare 
                                drug plan enrollees and drugs dispensed 
                                to PDP and MA-PD enrollees who are not 
                                rebate eligible individuals; and
                                    ``(II) the number of the units of 
                                such dosage and strength of the drug 
                                dispensed during the rebate period to 
                                rebate eligible individuals enrolled in 
                                the prescription drug plans 
                                administered by the PDP sponsor or the 
                                MA-PD plans administered by the MA 
                                organization; divided by
                            ``(ii) the total number of units of such 
                        dosage and strength of the drug dispensed 
                        during the rebate period to rebate eligible 
                        individuals enrolled in all prescription drug 
                        plans administered by PDP sponsors and all MA-
                        PD plans administered by MA organizations.
                    ``(D) Use of estimates.--The Secretary may 
                establish a methodology for estimating the average 
                Medicare drug program rebate eligible rebate amounts 
                for each rebate period based on bid and utilization 
                information under this part and may use these estimates 
                as the basis for determining the rebates under this 
                section. If the Secretary elects to estimate the 
                average Medicare drug program rebate eligible rebate 
                amounts, the Secretary shall establish a reconciliation 
                process for adjusting manufacturer rebate payments not 
                later than 3 months after the date that manufacturers 
                receive the information collected under section 1860D-
                12(b)(7)(B).
            ``(4) Length of agreement.--The provisions of paragraph (4) 
        of section 1927(b) (other than clauses (iv) and (v) of 
        subparagraph (B)) shall apply to rebate agreements under this 
        subsection in the same manner as such paragraph applies to a 
        rebate agreement under such section.
            ``(5) Other terms and conditions.--The Secretary shall 
        establish other terms and conditions of the rebate agreement 
        under this subsection, including terms and conditions related 
        to compliance, that are consistent with this subsection.
            ``(6) Definitions.--In this subsection and section 1860D-
        12(b)(7):
                    ``(A) Rebate eligible individual.--The term `rebate 
                eligible individual'--
                            ``(i) means a full-benefit dual eligible 
                        individual (as defined in section 1935(c)(6)); 
                        and
                            ``(ii) includes, for drugs dispensed after 
                        December 31, 2014, a subsidy eligible 
                        individual (as defined in section 1860D-
                        14(a)(3)(A)).
                    ``(B) Rebate period.--The term `rebate period' has 
                the meaning given such term in section 1927(k)(8).
            ``(7) Waiver.--Chapter 35 of title 44, United States Code, 
        shall not apply to the requirements under this subsection for 
        the period beginning on January 1, 2010, and ending on December 
        31, 2010.''.
            (2) Reporting requirement for the determination and payment 
        of rebates by manufactures related to rebate for rebate 
        eligible medicare drug plan enrollees.--
                    (A) Requirements for pdp sponsors.--Section 1860D-
                12(b) of the Social Security Act (42 U.S.C. 1395w-
                112(b)) is amended by adding at the end the following 
                new paragraph:
            ``(7) Reporting requirement for the determination and 
        payment of rebates by manufacturers related to rebate for 
        rebate eligible medicare drug plan enrollees.--
                    ``(A) In general.--For purposes of the rebate under 
                section 1860D-2(f) for contract years beginning on or 
                after January 1, 2011, each contract entered into with 
                a PDP sponsor under this part with respect to a 
                prescription drug plan shall require that the sponsor 
                comply with subparagraphs (B) and (C).
                    ``(B) Report form and contents.--Not later than a 
                date specified by the Secretary, a PDP sponsor of a 
                prescription drug plan under this part shall report to 
                each manufacturer--
                            ``(i) information (by National Drug Code 
                        number) on the total number of units of each 
                        dosage, form, and strength of each drug of such 
                        manufacturer dispensed to rebate eligible 
                        Medicare drug plan enrollees under any 
                        prescription drug plan operated by the PDP 
                        sponsor during the rebate period;
                            ``(ii) information on the price discounts, 
                        price concessions, and rebates for such drugs 
                        for such form, strength, and period;
                            ``(iii) information on the extent to which 
                        such price discounts, price concessions, and 
                        rebates apply equally to rebate eligible 
                        Medicare drug plan enrollees and PDP enrollees 
                        who are not rebate eligible Medicare drug plan 
                        enrollees; and
                            ``(iv) any additional information that the 
                        Secretary determines is necessary to enable the 
                        Secretary to calculate the average Medicare 
                        drug program rebate eligible rebate amount (as 
                        defined in paragraph (3)(C) of such section), 
                        and to determine the amount of the rebate 
                        required under this section, for such form, 
                        strength, and period.
                Such report shall be in a form consistent with a 
                standard reporting format established by the Secretary.
                    ``(C) Submission to secretary.--Each PDP sponsor 
                shall promptly transmit a copy of the information 
                reported under subparagraph (B) to the Secretary for 
                the purpose of audit oversight and evaluation.
                    ``(D) Confidentiality of information.--The 
                provisions of subparagraph (D) of section 1927(b)(3), 
                relating to confidentiality of information, shall apply 
                to information reported by PDP sponsors under this 
                paragraph in the same manner that such provisions apply 
                to information disclosed by manufacturers or 
                wholesalers under such section, except--
                            ``(i) that any reference to `this section' 
                        in clause (i) of such subparagraph shall be 
                        treated as being a reference to this section;
                            ``(ii) the reference to the Director of the 
                        Congressional Budget Office in clause (iii) of 
                        such subparagraph shall be treated as including 
                        a reference to the Medicare Payment Advisory 
                        Commission; and
                            ``(iii) clause (iv) of such subparagraph 
                        shall not apply.
                    ``(E) Oversight.--Information reported under this 
                paragraph may be used by the Inspector General of the 
                Department of Health and Human Services for the 
                statutorily authorized purposes of audit, 
                investigation, and evaluations.
                    ``(F) Penalties for failure to provide timely 
                information and provision of false information.--In the 
                case of a PDP sponsor--
                            ``(i) that fails to provide information 
                        required under subparagraph (B) on a timely 
                        basis, the sponsor is subject to a civil money 
                        penalty in the amount of $10,000 for each day 
                        in which such information has not been 
                        provided; or
                            ``(ii) that knowingly (as defined in 
                        section 1128A(i)) provides false information 
                        under such subparagraph, the sponsor is subject 
                        to a civil money penalty in an amount not to 
                        exceed $100,000 for each item of false 
                        information.
                Such civil money penalties are in addition to other 
                penalties as may be prescribed by law. The provisions 
                of section 1128A (other than subsections (a) and (b)) 
                shall apply to a civil money penalty under this 
                subparagraph in the same manner as such provisions 
                apply to a penalty or proceeding under section 
                1128A(a).''.
                    (B) Application to ma organizations.--Section 
                1857(f)(3) of the Social Security Act (42 U.S.C. 1395w-
                27(f)(3)) is amended by adding at the end the 
                following:
                    ``(D) Reporting requirement related to rebate for 
                rebate eligible medicare drug plan enrollees.--Section 
                1860D-12(b)(7).''.
            (3) Deposit of rebates into medicare prescription drug 
        account.--Section 1860D-16(c) of such Act (42 U.S.C. 1395w-
        116(c)) is amended by adding at the end the following new 
        paragraph:
            ``(6) Rebate for rebate eligible medicare drug plan 
        enrollees.--Amounts paid under a rebate agreement under section 
        1860D-2(f) shall be deposited into the Account and shall be 
        used to pay for all or part of the gradual elimination of the 
        coverage gap under section 1860D-2(b)(7).''.

SEC. 1182. DISCOUNTS FOR CERTAIN PART D DRUGS IN ORIGINAL COVERAGE GAP.

    Section 1860D-2 of the Social Security Act (42 U.S.C. 1395w-102), 
as amended by section 1181, is amended--
            (1) in subsection (b)(4)(C)(ii), by inserting ``subject to 
        subsection (g)(2)(C),'' after ``(ii)'';
            (2) in subsection (e)(1), in the matter before subparagraph 
        (A), by striking ``subsection (f)'' and inserting ``subsections 
        (f) and (g)'' after ``this subsection''; and
            (3) by adding at the end the following new subsection:
    ``(g) Requirement for Manufacturer Discount Agreement for Certain 
Qualifying Drugs.--
            ``(1) In general.--In this part, the term `covered part D 
        drug' does not include any drug or biological product that is 
        manufactured by a manufacturer that has not entered into and 
        have in effect for all qualifying drugs (as defined in 
        paragraph (5)(A)) a discount agreement described in paragraph 
        (2).
            ``(2) Discount agreement.--
                    ``(A) Periodic discounts.--A discount agreement 
                under this paragraph shall require the manufacturer 
                involved to provide, to each PDP sponsor with respect 
                to a prescription drug plan or each MA organization 
                with respect to each MA-PD plan, a discount in an 
                amount specified in paragraph (3) for qualifying drugs 
                (as defined in paragraph (5)(A)) of the manufacturer 
                dispensed to a qualifying enrollee after January 1, 
                2010, insofar as the individual is in the original gap 
                in coverage (as defined in paragraph (5)(E)).
                    ``(B) Discount agreement.--Insofar as not 
                inconsistent with this subsection, the Secretary shall 
                establish terms and conditions of such agreement, 
                including terms and conditions relating to compliance, 
                similar to the terms and conditions for rebate 
                agreements under paragraphs (2), (3), and (4) of 
                section 1927(b), except that--
                            ``(i) discounts shall be applied under this 
                        subsection to prescription drug plans and MA-PD 
                        plans instead of State plans under title XIX;
                            ``(ii) PDP sponsors and MA organizations 
                        shall be responsible, instead of States, for 
                        provision of necessary utilization information 
                        to drug manufacturers; and
                            ``(iii) sponsors and MA organizations shall 
                        be responsible for reporting information on 
                        drug-component negotiated price.
                    ``(C) Counting discount toward true out-of-pocket 
                costs.--Under the discount agreement, in applying 
                subsection (b)(4), with regard to subparagraph (C)(i) 
                of such subsection, if a qualified enrollee purchases 
                the qualified drug insofar as the enrollee is in an 
                actual gap of coverage (as defined in paragraph 
                (5)(D)), the amount of the discount under the agreement 
                shall be treated and counted as costs incurred by the 
                plan enrollee.
            ``(3) Discount amount.--The amount of the discount 
        specified in this paragraph for a discount period for a plan is 
        equal to 50 percent of the amount of the drug-component 
        negotiated price (as defined in paragraph (5)(C)) for 
        qualifying drugs for the period involved.
            ``(4) Additional terms.--In the case of a discount provided 
        under this subsection with respect to a prescription drug plan 
        offered by a PDP sponsor or an MA-PD plan offered by an MA 
        organization, if a qualified enrollee purchases the qualified 
        drug--
                    ``(A) insofar as the enrollee is in an actual gap 
                of coverage (as defined in paragraph (5)(D)), the 
                sponsor or plan shall provide the discount to the 
                enrollee at the time the enrollee pays for the drug; 
                and
                    ``(B) insofar as the enrollee is in the portion of 
                the original gap in coverage (as defined in paragraph 
                (5)(E)) that is not in the actual gap in coverage, the 
                discount shall not be applied against the negotiated 
                price (as defined in subsection (d)(1)(B)) for the 
                purpose of calculating the beneficiary payment.
            ``(5) Definitions.--In this subsection:
                    ``(A) Qualifying drug.--The term `qualifying drug' 
                means, with respect to a prescription drug plan or MA-
                PD plan, a drug or biological product that--
                            ``(i)(I) is a drug produced or distributed 
                        under an original new drug application approved 
                        by the Food and Drug Administration, including 
                        a drug product marketed by any cross-licensed 
                        producers or distributors operating under the 
                        new drug application;
                            ``(II) is a drug that was originally 
                        marketed under an original new drug application 
                        approved by the Food and Drug Administration; 
                        or
                            ``(III) is a biological product as approved 
                        under Section 351(a) of the Public Health 
                        Services Act;
                            ``(ii) is covered under the formulary of 
                        the plan or is treated as covered under the 
                        formulary of the plan as a result of a coverage 
                        determination or appeal under subsection (g) or 
                        (h) of section 1860D-4; and
                            ``(iii) is dispensed to an individual who 
                        is in the original gap in coverage.
                    ``(B) Qualifying enrollee.--The term `qualifying 
                enrollee' means an individual enrolled in a 
                prescription drug plan or MA-PD plan other than such an 
                individual who is a subsidy-eligible individual (as 
                defined in section 1860D-14(a)(3)).
                    ``(C) Drug-component negotiated price.--The term 
                `drug-component negotiated price' means, with respect 
                to a qualifying drug, the negotiated price (as defined 
                in section 423.100 of title 42, Code of Federal 
                Regulations, as in effect on the date of enactment of 
                this subsection), as determined without regard to any 
                dispensing fee, of the drug under the prescription drug 
                plan or MA-PD plan involved.
                    ``(D) Actual gap in coverage.--The term `actual gap 
                in coverage' means the gap in prescription drug 
                coverage that occurs between the initial coverage limit 
                (as modified under paragraph (7) and subparagraph (B) 
                of paragraph (8) of subsection (b)) and the annual out-
                of-pocket threshold (as modified under subparagraph (C) 
                of such subsection).
                    ``(E) Original gap in coverage.--The term `original 
                in gap coverage' means the gap in prescription drug 
                coverage that would occur between the initial coverage 
                limit (described in subsection (b)(3)) and the out-of-
                pocket threshold (as defined in subsection (b)(4)(B)) 
                if subsections (b)(7) and (b)(8) did not apply.
            ``(6) Special rule for 2010.--For the period beginning 
        January 1, 2010, and ending December 31, 2010, the Secretary 
        may--
                    ``(A) enter into agreements with manufacturers to 
                directly receive the discount amount described in 
                paragraph (3);
                    ``(B) collect the necessary information from 
                prescription drug plans and MA-PD plans to calculate 
                the discount amount described in such paragraph; and
                    ``(C) provide the discount described in such 
                paragraph to beneficiaries as close as practicable 
                after the point of sale.
            ``(7) Waiver.--Chapter 35 of title 44, United States Code, 
        shall not apply to the requirements under this subsection for 
        the period beginning on January 1, 2010, and ending on December 
        31, 2010.''.

SEC. 1183. REPEAL OF PROVISION RELATING TO SUBMISSION OF CLAIMS BY 
              PHARMACIES LOCATED IN OR CONTRACTING WITH LONG-TERM CARE 
              FACILITIES.

    (a) Part D Submission.--Section 1860D-12(b) of the Social Security 
Act (42 U.S.C. 1395w-112(b)), as amended by section 172(a)(1) of Public 
Law 110-275, is amended by striking paragraph (5) and redesignating 
paragraph (6) and paragraph (7), as added by section 1181(c)(2)(A), as 
paragraph (5) and paragraph (6), respectively.
    (b) Submission to MA-PD Plans.--Section 1857(f)(3) of the Social 
Security Act (42 U.S.C. 1395w-27(f)(3)), as added by section 171(b) of 
Public Law 110-275 and amended by section 172(a)(2) of such Public Law 
and section 1181 of this Act, is amended by striking subparagraph (B) 
and redesignating subparagraphs (C) and (D) as subparagraphs (B) and 
(C) respectively.
    (c) Effective Date.--The amendments made by this section shall 
apply for contract years beginning with 2010.

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.

    (a) In General.--Section 1860D-2(b)(4)(C) of the Social Security 
Act (42 U.S.C. 1395w-102(b)(4)(C)) is amended--
            (1) in clause (i), by striking ``and'' at the end;
            (2) in clause (ii)--
                    (A) by striking ``such costs shall be treated as 
                incurred only if'' and inserting ``and subject to 
                clause (iii), such costs shall be treated as incurred 
                only if'';
                    (B) by striking ``, under section 1860D-14, or 
                under a State Pharmaceutical Assistance Program''; and
                    (C) by striking the period at the end and inserting 
                ``; and''; and
            (3) by inserting after clause (ii) the following new 
        clause:
                            ``(iii) such costs shall be treated as 
                        incurred and shall not be considered to be 
                        reimbursed under clause (ii) if such costs are 
                        borne or paid--
                                    ``(I) under section 1860D-14;
                                    ``(II) under a State Pharmaceutical 
                                Assistance Program;
                                    ``(III) by the Indian Health 
                                Service, an Indian tribe or tribal 
                                organization, or an urban Indian 
                                organization (as defined in section 4 
                                of the Indian Health Care Improvement 
                                Act); or
                                    ``(IV) under an AIDS Drug 
                                Assistance Program under part B of 
                                title XXVI of the Public Health Service 
                                Act.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to costs incurred on or after January 1, 2011.

SEC. 1185. NO MID-YEAR FORMULARY CHANGES PERMITTED.

    (a) In General.--Section 1860D-4(b)(3)(E) of the Social Security 
Act (42 U.S.C. 1395w-104(b)(3)(E)) is amended--
            (1) in the heading, by inserting ``; certain formulary 
        changes only before initiating marketing for a plan year'' 
        after ``status of drug'';
            (2) by striking ``Any removal'' and inserting ``(i) 
        notice.--Any removal'' with the same indentation as the clause 
        added by paragraph (2);
            (3) by adding at the end the following new clause:
                            ``(ii) Certain changes in formulary only 
                        before initiating marketing for a plan year.--
                        Any removal of a covered part D drug from a 
                        formulary used by a PDP sponsor of a 
                        prescription drug plan (or MA organization of a 
                        MA-PD plan) or any other material change to the 
                        formulary so as to reduce the coverage (or 
                        increase the cost-sharing) of the drug under 
                        the plan for a plan year shall take effect by a 
                        date specified by the Secretary but no later 
                        than the start of plan marketing activities for 
                        the plan year. In addition to any exceptions to 
                        the previous sentence specified by the 
                        Secretary, the previous sentence shall not 
                        apply in the case that a drug is removed from 
                        the formulary of a plan because of a recall or 
                        withdrawal of the drug issued by the Food and 
                        Drug Administration, because the drug is 
                        replaced with a generic drug that is a 
                        therapeutic equivalent, or because of 
                        utilization management applied to--
                                    ``(I) a drug whose labeling 
                                includes a boxed warning required by 
                                the Food and Drug Administration under 
                                section 201.57(c)(1) of title 21, Code 
                                of Federal Regulations (or a successor 
                                regulation); or
                                    ``(II) a drug required under 
                                subsection (c)(2) of section 505-1 of 
                                the Federal Food, Drug, and Cosmetic 
                                Act to have a Risk Evaluation and 
                                Management Strategy that includes 
                                elements under subsection (f) of such 
                                section.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to contract years beginning on or after January 1, 2011.

SEC. 1186. NEGOTIATION OF LOWER COVERED PART D DRUG PRICES ON BEHALF OF 
              MEDICARE BENEFICIARIES.

    (a) Negotiation by Secretary.--Section 1860D-11 of the Social 
Security Act (42 U.S.C. 1395w-111) is amended by striking subsection 
(i) (relating to noninterference) and inserting the following:
    ``(i) Negotiation of Lower Drug Prices.--
            ``(1) In general.--Notwithstanding any other provision of 
        law, the Secretary shall negotiate with pharmaceutical 
        manufacturers the prices (including discounts, rebates, and 
        other price concessions) that may be charged to PDP sponsors 
        and MA organizations for covered part D drugs for part D 
        eligible individuals who are enrolled under a prescription drug 
        plan or under an MA-PD plan.
            ``(2) No change in rules for formularies.--
                    ``(A) In general.--Nothing in paragraph (1) shall 
                be construed to authorize the Secretary to establish or 
                require a particular formulary.
                    ``(B) Construction.--Subparagraph (A) shall not be 
                construed as affecting the Secretary's authority to 
                ensure appropriate and adequate access to covered part 
                D drugs under prescription drug plans and under MA-PD 
                plans, including compliance of such plans with 
                formulary requirements under section 1860D-4(b)(3).
            ``(3) Construction.--Nothing in this subsection shall be 
        construed as preventing the sponsor of a prescription drug 
        plan, or an organization offering an MA-PD plan, from obtaining 
        a discount or reduction of the price for a covered part D drug 
        below the price negotiated under paragraph (1).
            ``(4) Annual reports to congress.--Not later than June 1, 
        2011, and annually thereafter, the Secretary shall submit to 
        the Committees on Ways and Means, Energy and Commerce, and 
        Oversight and Government Reform of the House of Representatives 
        and the Committee on Finance of the Senate a report on 
        negotiations conducted by the Secretary to achieve lower prices 
        for Medicare beneficiaries, and the prices and price discounts 
        achieved by the Secretary as a result of such negotiations.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of the enactment of this Act and shall first 
apply to negotiations and prices for plan years beginning on January 1, 
2011.

SEC. 1187. ACCURATE DISPENSING IN LONG-TERM CARE FACILITIES.

    Section 1860D-4(c) of the Social Security Act (42 U.S.C. 1395w-
104(c)) is amended by adding at the end the following new paragraph:
            ``(3) Reduction of wasteful dispensing.--
                    ``(A) In general.--For plan years beginning on or 
                after January 1, 2012, a PDP sponsor offering a 
                prescription drug plan and MA organization offering a 
                MA-PD plan under part C shall have in place the 
                utilization management techniques established under 
                subparagraph (B).
                    ``(B) Requirements.--The Secretary shall establish 
                utilization management techniques, such as daily, 
                weekly, or automated dose dispensing, to apply to PDP 
                sponsors and MA organizations to reduce the quantities 
                of covered part D drugs dispensed to enrollees who are 
                residing in long-term care facilities in order to 
                reduce waste associated with unused medications.
                    ``(C) Consultation.--In establishing the 
                requirements under subparagraph (A), the Secretary 
                shall consult with the Administrator of the 
                Environmental Protection Agency, Administrator of the 
                Food and Drug Administration, Administrator of the Drug 
                Enforcement Administration, State Boards of Pharmacy, 
                pharmacy and physician organizations, and other 
                appropriate stakeholders to study and determine 
                additional methods for prescription drug plans to 
                reduce waste associated with unused prescription 
                drugs.''.

SEC. 1188. FREE GENERIC FILL.

    (a) In General.--Section 1128A(i)(6) of the Social Security Act (42 
U.S.C. 1320a-7a(i)(6)) is amended--
            (1) in subparagraph (C), by striking ``of 1996'' and all 
        that follows and inserting ``of 1996;'';
            (2) in the first subparagraph (D), by striking 
        ``promulgated'' and all that follows and inserting 
        ``promulgated;'';
            (3) by redesignating the second subparagraph (D) as a 
        subparagraph (E) and by striking the period at the end of such 
        subparagraph and inserting ``; and''; and
            (4) by adding at the end the following new subparagraph:
                    ``(F) with regard to a prescription drug plan 
                offered by a PDP sponsor or an MA-PD plan offered by an 
                MA organization, a reduction in or waiver of the 
                copayment amount under the plan given to an individual 
                to induce the individual to switch to a generic, 
                bioequivalent drug, or biosimilar.''.
    (b) Effective Date.--The amendments made by this subsection shall 
take effect on the date of the enactment of this Act and shall first 
apply with respect to remuneration offered, paid, solicited, or 
received on or after January 1, 2011.

SEC. 1189. STATE CERTIFICATION PRIOR TO WAIVER OF LICENSURE 
              REQUIREMENTS UNDER MEDICARE PRESCRIPTION DRUG PROGRAM.

    (a) In General.--Section 1860D-12(c) of the Social Security Act (42 
U.S.C. 1395w-112(c)) is amended--
            (1) in paragraph (1)(A), by striking ``In the case'' and 
        inserting ``Subject to paragraph (5), in the case''; and
            (2) by adding at the end the following new paragraph:
            ``(5) State certification required.--
                    ``(A) In general.--Except as provided in section 
                1860D-21(f)(4), the Secretary may only grant a waiver 
                under paragraph (1)(A) if the Secretary has received a 
                certification from the State insurance commissioner 
                that the prescription drug plan has a substantially 
                complete application pending in the State.
                    ``(B) Revocation of waiver upon finding of fraud 
                and abuse.--The Secretary shall revoke a waiver granted 
                under paragraph (1)(A) if the State insurance 
                commissioner submits a certification to the Secretary 
                that the recipient of such a waiver--
                            ``(i) has committed fraud or abuse with 
                        respect to such waiver;
                            ``(ii) has failed to make a good faith 
                        effort to satisfy State licensing requirements; 
                        or
                            ``(iii) was determined ineligible for 
                        licensure by the State.''.
    (b) Exception for PACE Programs.--Section 1860D-21(f) of such Act 
(42 U.S.C. 1395w-131(f)) is amended--
            (1) in paragraph (1), by striking ``paragraphs (2) and 
        (3)'' and inserting ``the succeeding paragraphs''; and
            (2) by adding at the end the following new paragraph:
            ``(4) Inapplicability of certain licensure waiver 
        requirements.--The provisions of paragraph (1) of section 
        1860D-12(c) (relating to waiver of licensure under certain 
        circumstances) shall apply without regard to paragraph (5) of 
        such section in the case of a PACE program that elects to 
        provide qualified prescription drug coverage to a part D 
        eligible individual who is enrolled under such program.''.
    (b) Effective Date.--The amendments made by this section shall 
apply with respect to plan years beginning on or after January 1, 2010.

             Subtitle F--Medicare Rural Access Protections

SEC. 1191. TELEHEALTH EXPANSION AND ENHANCEMENTS.

    (a) Additional Telehealth Site.--
            (1) In general.--Paragraph (4)(C)(ii) of section 1834(m) of 
        the Social Security Act (42 U.S.C. 1395m(m)) is amended by 
        adding at the end the following new subclause:
                                    ``(IX) A renal dialysis facility.''
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to services furnished on or after January 1, 2011.
    (b) Telehealth Advisory Committee.--
            (1) Establishment.--Section 1868 of the Social Security Act 
        (42 U.S.C. 1395ee) is amended--
                    (A) in the heading, by adding at the end the 
                following: ``telehealth advisory committee''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(c) Telehealth Advisory Committee.--
            ``(1) In general.--The Secretary shall appoint a Telehealth 
        Advisory Committee (in this subsection referred to as the 
        `Advisory Committee') to make recommendations to the Secretary 
        on policies of the Centers for Medicare & Medicaid Services 
        regarding telehealth services as established under section 
        1834(m), including the appropriate addition or deletion of 
        services (and HCPCS codes) to those specified in paragraphs 
        (4)(F)(i) and (4)(F)(ii) of such section and for authorized 
        payment under paragraph (1) of such section.
            ``(2) Membership; terms.--
                    ``(A) Membership.--
                            ``(i) In general.--The Advisory Committee 
                        shall be composed of 9 members, to be appointed 
                        by the Secretary, of whom--
                                    ``(I) 5 shall be practicing 
                                physicians;
                                    ``(II) 2 shall be practicing non-
                                physician health care practitioners; 
                                and
                                    ``(III) 2 shall be administrators 
                                of telehealth programs.
                            ``(ii) Requirements for appointing 
                        members.--In appointing members of the Advisory 
                        Committee, the Secretary shall--
                                    ``(I) ensure that each member has 
                                prior experience with the practice of 
                                telemedicine or telehealth;
                                    ``(II) give preference to 
                                individuals who are currently providing 
                                telemedicine or telehealth services or 
                                who are involved in telemedicine or 
                                telehealth programs;
                                    ``(III) ensure that the membership 
                                of the Advisory Committee represents a 
                                balance of specialties and geographic 
                                regions; and
                                    ``(IV) take into account the 
                                recommendations of stakeholders.
                    ``(B) Terms.--The members of the Advisory Committee 
                shall serve for such term as the Secretary may specify.
                    ``(C) Conflicts of interest.--An advisory committee 
                member may not participate with respect to a particular 
                matter considered in an advisory committee meeting if 
                such member (or an immediate family member of such 
                member) has a financial interest that could be affected 
                by the advice given to the Secretary with respect to 
                such matter.
            ``(3) Meetings.--The Advisory Committee shall meet twice 
        each calendar year and at such other times as the Secretary may 
        provide.
            ``(4) Permanent committee.--Section 14 of the Federal 
        Advisory Committee Act (5 U.S.C. App.) shall not apply to the 
        Advisory Committee.''
            (2) Following recommendations.--Section 1834(m)(4)(F) of 
        such Act (42 U.S.C. 1395m(m)(4)(F)) is amended by adding at the 
        end the following new clause:
                            ``(iii) Recommendations of the telehealth 
                        advisory committee.--In making determinations 
                        under clauses (i) and (ii), the Secretary shall 
                        take into account the recommendations of the 
                        Telehealth Advisory Committee (established 
                        under section 1868(c)) when adding or deleting 
                        services (and HCPCS codes) and in establishing 
                        policies of the Centers for Medicare & Medicaid 
                        Services regarding the delivery of telehealth 
                        services. If the Secretary does not implement 
                        such a recommendation, the Secretary shall 
                        publish in the Federal Register a statement 
                        regarding the reason such recommendation was 
                        not implemented.''
            (3) Waiver of administrative limitation.--The Secretary of 
        Health and Human Services shall establish the Telehealth 
        Advisory Committee under the amendment made by paragraph (1) 
        notwithstanding any limitation that may apply to the number of 
        advisory committees that may be established (within the 
        Department of Health and Human Services or otherwise).
    (c) Hospital Credentialing of Telemedicine Physicians and 
Practitioners.--
            (1) In general.--Not later than 60 days after the date of 
        the enactment of this Act, the Secretary of Health and Human 
        Services shall issue guidance for hospitals (as defined in 
        paragraph (4)) to simplify requirements regarding compiling 
        practitioner credentials for the purpose of rendering a medical 
        staff privileging decision (under bylaws of the type described 
        in section 1861(e)(3) of the Social Security Act) for 
        physicians and practitioners (as defined in paragraph (4)) 
        delivering telehealth services that are furnished via a 
        telecommunications system.
            (2) Flexibility in accepting credentialing by another 
        medicare participating hospital.--
                    (A) In general.--Such guidance shall permit a 
                hospital to accept credentialing packages compiled by 
                another hospital participating under Medicare with 
                regard to physicians and practitioners who seek medical 
                staff privileges in the hospital to provide telehealth 
                services via a telecommunications system from a site 
                other than the hospital where the patient is located.
                    (B) Construction.--Nothing in this subsection shall 
                be construed to require a hospital to accept the 
                credentialing package compiled by another facility.
                    (C) No oversight required.--If a hospital does 
                accept the credentialing materials prepared by another 
                hospital, the hospital shall not be required to 
                exercise oversight over the other hospital's process 
                for compiling and verifying credentials.  
                    (D) Privileging.--This paragraph shall only apply 
                to credentialing and does not relieve a hospital from 
                any applicable privileging requirements.
            (3) Construction.--This subsection shall not be construed 
        as limiting the ability of the Secretary to issue additional 
        guidance regarding the requirements for the compilation of 
        credentials for physicians and practitioners not described in 
        paragraph (1).
            (4) Definitions.--In this subsection:
                    (A) The term ``hospital'' has the meaning given 
                such term in subsection (e) of section 1861 of the 
                Social Security Act (42 U.S.C. 1395x) and includes a 
                critical access hospital (as defined in subsection 
                (mm)(1) of such section).
                    (B) The term ``physician'' has the meaning given 
                such term in subsection (r) of such section.
                    (C) The term ``practitioner'' means a practitioner 
                described in section 1842(b)(18)(C) of the Social 
                Security Act (42 U.S.C. 1395u(b)(18)(C)).

SEC. 1192. EXTENSION OF OUTPATIENT HOLD HARMLESS PROVISION.

     Section 1833(t)(7)(D)(i) of the Social Security Act (42 U.S.C. 
1395l(t)(7)(D)(i)) is amended--
            (1) in subclause (II)--
                    (A) in the first sentence, by striking ```2010'' 
                and inserting ``2012''; and
                    (B) in the second sentence, by striking ``or 2009'' 
                and inserting ``, 2009, 2010, or 2011''; and
            (2) in subclause (III), by striking ``January 1, 2010'' and 
        inserting ``January 1, 2012''.

SEC. 1193. EXTENSION OF SECTION 508 HOSPITAL RECLASSIFICATIONS.

    (a) In General.--Subsection (a) of section 106 of division B of the 
Tax Relief and Health Care Act of 2006 (42 U.S.C. 1395 note), as 
amended by section 117 of the Medicare, Medicaid, and SCHIP Extension 
Act of 2007 (Public Law 110-173) and section 124 of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275), is amended by striking ``September 30, 2009'' and inserting 
``September 30, 2011''.
    (b) Use of Particular Wage Index for Fiscal Year 2010.--For 
purposes of implementation of the amendment made by subsection (a) for 
fiscal year 2010, the Secretary shall use the hospital wage index that 
was promulgated by the Secretary in the Federal Register on August 27, 
2009 (74 Fed. Reg. 43754), and any subsequent corrections.

SEC. 1194. EXTENSION OF GEOGRAPHIC FLOOR FOR WORK.

    Section 1848(e)(1)(E) of the Social Security Act (42 U.S.C. 1395w-
4(e)(1)(E)) is amended by striking ``before January 1, 2010'' and 
inserting ``before January 1, 2012''.

SEC. 1195. EXTENSION OF PAYMENT FOR TECHNICAL COMPONENT OF CERTAIN 
              PHYSICIAN PATHOLOGY SERVICES.

    Section 542(c) of the Medicare, Medicaid, and SCHIP Benefits 
Improvement and Protection Act of 2000 (as enacted into law by section 
1(a)(6) of Public Law 106-554), as amended by section 732 of the 
Medicare Prescription Drug, Improvement, and Modernization Act of 2003 
(42 U.S.C. 1395w-4 note), section 104 of division B of the Tax Relief 
and Health Care Act of 2006 (42 U.S.C. 1395w-4 note), section 104 of 
the Medicare, Medicaid, and SCHIP Extension Act of 2007 (Public Law 
110-173), and section 136 of the Medicare Improvements for Patients and 
Providers Act of 1008 (Public Law 110-275), is amended by striking 
``and 2009'' and inserting ``2009, 2010, and 2011''.

SEC. 1196. EXTENSION OF AMBULANCE ADD-ONS.

    (a) In General.--Section 1834(l)(13) of the Social Security Act (42 
U.S.C. 1395m(l)(13)) is amended--
            (1) in subparagraph (A)--
                    (A) in the matter preceding clause (i), by striking 
                ``before January 1, 2010'' and inserting ``before 
                January 1, 2012''; and
                    (B) in each of clauses (i) and (ii), by striking 
                ``before January 1, 2010'' and inserting ``before 
                January 1, 2012''.
    (b) Air Ambulance Improvements.--Section 146(b)(1) of the Medicare 
Improvements for Patients and Providers Act of 2008 (Public Law 110-
275) is amended by striking ``ending on December 31, 2009'' and 
inserting ``ending on December 31, 2011''.

              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.

    (a) Application of Highest Level Permitted Under LIS to All Subsidy 
Eligible Individuals.--
            (1) In general.--Section 1860D-14(a)(1) of the Social 
        Security Act (42 U.S.C. 1395w-114(a)(1)) is amended in the 
        matter before subparagraph (A), by inserting ``(or, beginning 
        with 2012, paragraph (3)(E))'' after ``paragraph (3)(D)''.
            (2) Annual increase in lis resource test.--Section 1860D-
        14(a)(3)(E)(i) of such Act (42 U.S.C. 1395w-114(a)(3)(E)(i)) is 
        amended--
                    (A) by striking ``and'' at the end of subclause 
                (I);
                    (B) in subclause (II), by inserting ``(before 
                2012)'' after ``subsequent year'';
                    (C) by striking the period at the end of subclause 
                (II) and inserting a semicolon;
                    (D) by inserting after subclause (II) the following 
                new subclauses:
                                    ``(III) for 2012, $17,000 (or 
                                $34,000 in the case of the combined 
                                value of the individual's assets or 
                                resources and the assets or resources 
                                of the individual's spouse); and
                                    ``(IV) for a subsequent year, the 
                                dollar amounts specified in this 
                                subclause (or subclause (III)) for the 
                                previous year increased by the annual 
                                percentage increase in the consumer 
                                price index (all items; U.S. city 
                                average) as of September of such 
                                previous year.''; and
                    (E) in the last sentence, by inserting ``or (IV)'' 
                after ``subclause (II)''.
            (3) Application of lis test under medicare savings 
        program.--Section 1905(p)(1)(C) of such Act (42 U.S.C. 
        1396d(p)(1)(C)) is amended--
                    (A) by striking ``effective beginning with January 
                1, 2010'' and inserting ``effective for the period 
                beginning with January 1, 2010, and ending with 
                December 31, 2011''; and
                    (B) by inserting before the period at the end the 
                following: ``or, effective beginning with January 1, 
                2012, whose resources (as so determined) do not exceed 
                the maximum resource level applied for the year under 
                subparagraph (E) of section 1860D-14(a)(3) (determined 
                without regard to the life insurance policy exclusion 
                provided under subparagraph (G) of such section) 
                applicable to an individual or to the individual and 
                the individual's spouse (as the case may be)''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to eligibility determinations for income-related subsidies and 
medicare cost-sharing furnished for periods beginning on or after 
January 1, 2012.

SEC. 1202. ELIMINATION OF PART D COST-SHARING FOR CERTAIN NON-
              INSTITUTIONALIZED FULL-BENEFIT DUAL ELIGIBLE INDIVIDUALS.

    (a) In General.--Section 1860D-14(a)(1)(D)(i) of the Social 
Security Act (42 U.S.C. 1395w-114(a)(1)(D)(i)) is amended--
            (1) by striking ``Institutionalized individuals.--In'' and 
        inserting ``Elimination of cost-sharing for certain full-
        benefit dual eligible individuals.--
                                    ``(I) Institutionalized 
                                individuals.--In''; and
            (2) by adding at the end the following new subclause:
                                    ``(II) Certain other individuals.--
                                In the case of an individual who is a 
                                full-benefit dual eligible individual 
                                and with respect to whom there has been 
                                a determination that but for the 
                                provision of home and community based 
                                care (whether under section 1915, 1932, 
                                or under a waiver under section 1115) 
                                the individual would require the level 
                                of care provided in a hospital or a 
                                nursing facility or intermediate care 
                                facility for the mentally retarded the 
                                cost of which could be reimbursed under 
                                the State plan under title XIX, the 
                                elimination of any beneficiary 
                                coinsurance described in section 1860D-
                                2(b)(2) (for all amounts through the 
                                total amount of expenditures at which 
                                benefits are available under section 
                                1860D-2(b)(4)).''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to drugs dispensed on or after January 1, 2011.

SEC. 1203. ELIMINATING BARRIERS TO ENROLLMENT.

    (a) Administrative Verification of Income and Resources Under the 
Low-income Subsidy Program.--
            (1) In general.--Clause (iii) of section 1860D-14(a)(3)(E) 
        of the Social Security Act (42 U.S.C. 1395w-114(a)(3)(E)) is 
        amended to read as follows:
                            ``(iii) Certification of income and 
                        resources.--For purposes of applying this 
                        section--
                                    ``(I) an individual shall be 
                                permitted to apply on the basis of 
                                self-certification of income and 
                                resources; and
                                    ``(II) matters attested to in the 
                                application shall be subject to 
                                appropriate methods of verification 
                                without the need of the individual to 
                                provide additional documentation, 
                                except in extraordinary situations as 
                                determined by the Commissioner.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply beginning January 1, 2010.
    (b) 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.--For provision authorizing disclosure 
of return information to facilitate identification of individuals 
likely to be ineligible for low-income subsidies under Medicare 
prescription drug program, see section 1801.

SEC. 1204. ENHANCED OVERSIGHT RELATING TO REIMBURSEMENTS FOR 
              RETROACTIVE LOW INCOME SUBSIDY ENROLLMENT.

    (a) In General.--In the case of a retroactive LIS enrollment 
beneficiary who is enrolled under a prescription drug plan under part D 
of title XVIII of the Social Security Act (or an MA-PD plan under part 
C of such title), the beneficiary (or any eligible third party) is 
entitled to reimbursement by the plan for covered drug costs incurred 
by the beneficiary during the retroactive coverage period of the 
beneficiary in accordance with subsection (b) and in the case of such a 
beneficiary described in subsection (c)(4)(A)(i), such reimbursement 
shall be made automatically by the plan upon receipt of appropriate 
notice the beneficiary is eligible for assistance described in such 
subsection (c)(4)(A)(i) without further information required to be 
filed with the plan by the beneficiary.
    (b) Administrative Requirements Relating to Reimbursements.--
            (1) Line-item description.--Each reimbursement made by a 
        prescription drug plan or MA-PD plan under subsection (a) shall 
        include a line-item description of the items for which the 
        reimbursement is made.
            (2) Timing of reimbursements.--A prescription drug plan or 
        MA-PD plan must make a reimbursement under subsection (a) to a 
        retroactive LIS enrollment beneficiary, with respect to a 
        claim, not later than 45 days after--
                    (A) in the case of a beneficiary described in 
                subsection (c)(4)(A)(i), the date on which the plan 
                receives notice from the Secretary that the beneficiary 
                is eligible for assistance described in such 
                subsection; or
                    (B) in the case of a beneficiary described in 
                subsection (c)(4)(A)(ii), the date on which the 
                beneficiary files the claim with the plan.
            (3) Reporting requirement.--For each month beginning with 
        January 2011, each prescription drug plan and each MA-PD plan 
        shall report to the Secretary the following:
                    (A) The number of claims the plan has readjudicated 
                during the month due to a beneficiary becoming 
                retroactively eligible for subsidies available under 
                section 1860D-14 of the Social Security Act.
                    (B) The total value of the readjudicated claim 
                amount for the month.
                    (C) The Medicare Health Insurance Claims Number of 
                beneficiaries for whom claims were readjudicated.
                    (D) For the claims described in subparagraphs (A) 
                and (B), an attestation to the Administrator of the 
                Centers for Medicare & Medicaid Services of the total 
                amount of reimbursement the plan has provided to 
                beneficiaries for premiums and cost-sharing that the 
                beneficiary overpaid for which the plan received 
                payment from the Centers for Medicare & Medicaid 
                Services.
    (c) Definitions.--For purposes of this section:
            (1) Covered drug costs.--The term ``covered drug costs'' 
        means, with respect to a retroactive LIS enrollment beneficiary 
        enrolled under a prescription drug plan under part D of title 
        XVIII of the Social Security Act (or an MA-PD plan under part C 
        of such title), the amount by which--
                    (A) the costs incurred by such beneficiary during 
                the retroactive coverage period of the beneficiary for 
                covered part D drugs, premiums, and cost-sharing under 
                such title; exceeds
                    (B) such costs that would have been incurred by 
                such beneficiary during such period if the beneficiary 
                had been both enrolled in the plan and recognized by 
                such plan as qualified during such period for the low 
                income subsidy under section 1860D-14 of the Social 
                Security Act to which the individual is entitled.
            (2) Eligible third party.--The term ``eligible third 
        party'' means, with respect to a retroactive LIS enrollment 
        beneficiary, an organization or other third party that is owed 
        payment on behalf of such beneficiary for covered drug costs 
        incurred by such beneficiary during the retroactive coverage 
        period of such beneficiary.
            (3) Retroactive coverage period.--The term ``retroactive 
        coverage period'' means--
                    (A) with respect to a retroactive LIS enrollment 
                beneficiary described in paragraph (4)(A)(i), the 
                period--
                            (i) beginning on the effective date of the 
                        assistance described in such paragraph for 
                        which the individual is eligible; and
                            (ii) ending on the date the plan 
                        effectuates the status of such individual as so 
                        eligible; and
                    (B) with respect to a retroactive LIS enrollment 
                beneficiary described in paragraph (4)(A)(ii), the 
                period--
                            (i) beginning on the date the individual is 
                        both entitled to benefits under part A, or 
                        enrolled under part B, of title XVIII of the 
                        Social Security Act and eligible for medical 
                        assistance under a State plan under title XIX 
                        of such Act; and
                            (ii) ending on the date the plan 
                        effectuates the status of such individual as a 
                        full-benefit dual eligible individual (as 
                        defined in section 1935(c)(6) of such Act).
            (4) Retroactive lis enrollment beneficiary.--
                    (A) In general.--The term ``retroactive LIS 
                enrollment beneficiary'' means an individual who--
                            (i) is enrolled in a prescription drug plan 
                        under part D of title XVIII of the Social 
                        Security Act (or an MA-PD plan under part C of 
                        such title) and subsequently becomes eligible 
                        as a full-benefit dual eligible individual (as 
                        defined in section 1935(c)(6) of such Act), an 
                        individual receiving a low-income subsidy under 
                        section 1860D-14 of such Act, an individual 
                        receiving assistance under the Medicare Savings 
                        Program implemented under clauses (i), (iii), 
                        and (iv) of section 1902(a)(10)(E) of such Act, 
                        or an individual receiving assistance under the 
                        supplemental security income program under 
                        section 1611 of such Act; or
                            (ii) subject to subparagraph (B)(i), is a 
                        full-benefit dual eligible individual (as 
                        defined in section 1935(c)(6) of such Act) who 
                        is automatically enrolled in such a plan under 
                        section 1860D-1(b)(1)(C) of such Act.
                    (B) Exception for beneficiaries enrolled in rfp 
                plan.--
                            (i) In general.--In no case shall an 
                        individual described in subparagraph (A)(ii) 
                        include an individual who is enrolled, pursuant 
                        to a RFP contract described in clause (ii), in 
                        a prescription drug plan offered by the sponsor 
                        of such plan awarded such contract.
                            (ii) RFP contract described.--The RFP 
                        contract described in this section is a 
                        contract entered into between the Secretary and 
                        a sponsor of a prescription drug plan pursuant 
                        to the Centers for Medicare & Medicaid 
                        Services' request for proposals issued on 
                        February 17, 2009, relating to Medicare part D 
                        retroactive coverage for certain low income 
                        beneficiaries, or a similar subsequent request 
                        for proposals.

SEC. 1205. INTELLIGENT ASSIGNMENT IN ENROLLMENT.

    (a) In General.--Section 1860D-1(b)(1)(C) of the Social Security 
Act (42 U.S.C. 1395w-101(b)(1)(C)) is amended by adding after ``PDP 
region'' the following: ``or through use of an intelligent assignment 
process that is designed to maximize the access of such individual to 
necessary prescription drugs while minimizing costs to such individual 
and to the program under this part to the greatest extent possible. In 
the case the Secretary enrolls such individuals through use of an 
intelligent assignment process, such process shall take into account 
the extent to which prescription drugs necessary for the individual are 
covered in the case of a PDP sponsor of a prescription drug plan that 
uses a formulary, the use of prior authorization or other restrictions 
on access to coverage of such prescription drugs by such a sponsor, and 
the overall quality of a prescription drug plan as measured by quality 
ratings established by the Secretary''
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect for contract years beginning with 2012.

SEC. 1206. SPECIAL ENROLLMENT PERIOD AND AUTOMATIC ENROLLMENT PROCESS 
              FOR CERTAIN SUBSIDY ELIGIBLE INDIVIDUALS.

    (a) Special Enrollment Period.--Section 1860D-1(b)(3)(D) of the 
Social Security Act (42 U.S.C. 1395w-101(b)(3)(D)) is amended to read 
as follows:
                    ``(D) Subsidy eligible individuals.--In the case of 
                an individual (as determined by the Secretary) who is 
                determined under subparagraph (B) of section 1860D-
                14(a)(3) to be a subsidy eligible individual.''.
    (b) Automatic Enrollment.--Section 1860D-1(b)(1) of the Social 
Security Act (42 U.S.C. 1395w-101(b)(1)) is amended by adding at the 
end the following new subparagraph:
                    ``(D) Special rule for subsidy eligible 
                individuals.--The process established under 
                subparagraph (A) shall include, in the case of an 
                individual described in section 1860D-1(b)(3)(D) who 
                fails to enroll in a prescription drug plan or an MA-PD 
                plan during the special enrollment established under 
                such section applicable to such individual, the 
                application of the assignment process described in 
                subparagraph (C) to such individual in the same manner 
                as such assignment process applies to a part D eligible 
                individual described in such subparagraph (C). Nothing 
                in the previous sentence shall prevent an individual 
                described in such sentence from declining enrollment in 
                a plan determined appropriate by the Secretary (or in 
                the program under this part) or from changing such 
                enrollment.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to subsidy determinations made for months beginning with January 
2011.

SEC. 1207. APPLICATION OF MA PREMIUMS PRIOR TO REBATE AND QUALITY BONUS 
              PAYMENTS IN CALCULATION OF LOW INCOME SUBSIDY BENCHMARK.

    (a) In General.--Section 1860D-14(b)(2)(B)(iii) of the Social 
Security Act (42 U.S.C. 1395w-114(b)(2)(B)(iii)) is amended by 
inserting before the period the following: ``before the application of 
the monthly rebate computed under section 1854(b)(1)(C)(i) for that 
plan and year involved and, in the case of a qualifying plan in a 
qualifying county, before the application of the increase under section 
1853(o) for that plan and year involved''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to subsidy determinations made for months beginning with January 
2011.

                Subtitle B--Reducing Health Disparities

SEC. 1221. ENSURING EFFECTIVE COMMUNICATION IN MEDICARE.

    (a) Ensuring Effective Communication by the Centers for Medicare & 
Medicaid Services.--
            (1) Study on medicare payments for language services.--The 
        Secretary of Health and Human Services shall conduct a study 
        that examines the extent to which Medicare service providers 
        utilize, offer, or make available language services for 
        beneficiaries who are limited English proficient and ways that 
        Medicare should develop payment systems for language services.
            (2) Analyses.--The study shall include an analysis of each 
        of the following:
                    (A) How to develop and structure appropriate 
                payment systems for language services for all Medicare 
                service providers.
                    (B) The feasibility of adopting a payment 
                methodology for on-site interpreters, including 
                interpreters who work as independent contractors and 
                interpreters who work for agencies that provide on-site 
                interpretation, pursuant to which such interpreters 
                could directly bill Medicare for services provided in 
                support of physician office services for an LEP 
                Medicare patient.
                    (C) The feasibility of Medicare contracting 
                directly with agencies that provide off-site 
                interpretation including telephonic and video 
                interpretation pursuant to which such contractors could 
                directly bill Medicare for the services provided in 
                support of physician office services for an LEP 
                Medicare patient.
                    (D) The feasibility of modifying the existing 
                Medicare resource-based relative value scale (RBRVS) by 
                using adjustments (such as multipliers or add-ons) when 
                a patient is LEP.
                    (E) How each of options described in a previous 
                paragraph would be funded and how such funding would 
                affect physician payments, a physician's practice, and 
                beneficiary cost-sharing.
                    (F) The extent to which providers under parts A and 
                B of title XVIII of the Social Security Act, MA 
                organizations offering Medicare Advantage plans under 
                part C of such title and PDP sponsors of a prescription 
                drug plan under part D of such title utilize, offer, or 
                make available language services for beneficiaries with 
                limited English proficiency.
                    (G) The nature and type of language services 
                provided by States under title XIX of the Social 
                Security Act and the extent to which such services 
                could be utilized by beneficiaries and providers under 
                title XVIII of such Act.
                    (H) The extent to which interpreters and 
                translators providing services to Medicare 
                beneficiaries under title XVIII of such Act are trained 
                or accredited.
            (3) Variation in payment system described.--The payment 
        systems described in paragraph (2)(A) may allow variations 
        based upon types of service providers, available delivery 
        methods, and costs for providing language services including 
        such factors as--
                    (A) the type of language services provided (such as 
                provision of health care or health care related 
                services directly in a non-English language by a 
                bilingual provider or use of an interpreter);
                    (B) type of interpretation services provided (such 
                as in-person, telephonic, video interpretation);
                    (C) the methods and costs of providing language 
                services (including the costs of providing language 
                services with internal staff or through contract with 
                external independent contractors or agencies, or both);
                    (D) providing services for languages not frequently 
                encountered in the United States; and
                    (E) providing services in rural areas.
            (4) Report.--The Secretary shall submit a report on the 
        study conducted under subsection (a) to appropriate committees 
        of Congress not later than 12 months after the date of the 
        enactment of this Act.
            (5) Exemption from paperwork reduction act.--Chapter 35 of 
        title 44, United States Code (commonly known as the ``Paperwork 
        Reduction Act'' ), shall not apply for purposes of carrying out 
        this subsection.
            (6) Authorization of appropriations.--The Secretary shall 
        provide for the transfer, from the Federal Supplementary 
        Medical Insurance Trust Fund under section 1841 of the Social 
        Security Act (42 U.S.C. 1395t) of $2,000,000 for purposes of 
        carrying out this subsection.
    (b) Health Plans.--Section 1857(g)(1) of the Social Security Act 
(42 U.S.C. 1395w-27(g)(1)) is amended--
            (1) by striking ``or'' at the end of subparagraph (F);
            (2) by adding ``or'' at the end of subparagraph (G); and
            (3) by inserting after subparagraph (G) the following new 
        subparagraph:
                    ``(H) fails substantially to provide language 
                services to limited English proficient beneficiaries 
                enrolled in the plan that are required under law;''.

SEC. 1222. DEMONSTRATION TO PROMOTE ACCESS FOR MEDICARE BENEFICIARIES 
              WITH LIMITED ENGLISH PROFICIENCY BY PROVIDING 
              REIMBURSEMENT FOR CULTURALLY AND LINGUISTICALLY 
              APPROPRIATE SERVICES.

    (a) In General.--Not later than 6 months after the date of the 
completion of the study described in section 1221(a) of this Act, the 
Secretary, acting through the Centers for Medicare & Medicaid Services 
and the Center for Medicare and Medicaid Innovation established under 
section 1115A of the Social Security Act (as added by section 1907) and 
consistent with the applicable provisions of such section, shall carry 
out a demonstration program under which the Secretary shall award not 
fewer than 24 3-year grants to eligible Medicare service providers (as 
described in subsection (b)(1)) to improve effective communication 
between such providers and Medicare beneficiaries who are living in 
communities where racial and ethnic minorities, including populations 
that face language barriers, are underserved with respect to such 
services. In designing and carrying out the demonstration the Secretary 
shall take into consideration the results of the study conducted under 
section 1221(a) of this Act and adjust, as appropriate, the 
distribution of grants so as to better target Medicare beneficiaries 
who are in the greatest need of language services. The Secretary shall 
not authorize a grant larger than $500,000 over three years for any 
grantee.
    (b) Eligibility; Priority.--
            (1) Eligibility.--To be eligible to receive a grant under 
        subsection (a) an entity shall--
                    (A) be--
                            (i) a provider of services under part A of 
                        title XVIII of the Social Security Act;
                            (ii) a service provider under part B of 
                        such title;
                            (iii) a part C organization offering a 
                        Medicare part C plan under part C of such 
                        title; or
                            (iv) a PDP sponsor of a prescription drug 
                        plan under part D of such title; and
                    (B) prepare and submit to the Secretary an 
                application, at such time, in such manner, and 
                accompanied by such additional information as the 
                Secretary may require.
            (2) Priority.--
                    (A) Distribution.--To the extent feasible, in 
                awarding grants under this section, the Secretary shall 
                award--
                            (i) at least 6 grants to providers of 
                        services described in paragraph (1)(A)(i);
                            (ii) at least 6 grants to service providers 
                        described in paragraph (1)(A)(ii);
                            (iii) at least 6 grants to organizations 
                        described in paragraph (1)(A)(iii); and
                            (iv) at least 6 grants to sponsors 
                        described in paragraph (1)(A)(iv).
                    (B) For community organizations.--The Secretary 
                shall give priority to applicants that have developed 
                partnerships with community organizations or with 
                agencies with experience in language access.
                    (C) Variation in grantees.--The Secretary shall 
                also ensure that the grantees under this section 
                represent, among other factors--
                            (i) different types of language services 
                        provided and of service providers and 
                        organizations under parts A through D of title 
                        XVIII of the Social Security Act;
                            (ii) variations in languages needed and 
                        their frequency of use;
                            (iii) urban and rural settings;
                            (iv) at least two geographic regions, as 
                        defined by the Secretary; and
                            (v) at least two large metropolitan 
                        statistical areas with diverse populations.
    (c) Use of Funds.--
            (1) In general.--A grantee shall use grant funds received 
        under this section to pay for the provision of competent 
        language services to Medicare beneficiaries who are limited 
        English proficient. Competent interpreter services may be 
        provided through on-site interpretation, telephonic 
        interpretation, or video interpretation or direct provision of 
        health care or health care related services by a bilingual 
        health care provider. A grantee may use bilingual providers, 
        staff, or contract interpreters. A grantee may use grant funds 
        to pay for competent translation services. A grantee may use up 
        to 10 percent of the grant funds to pay for administrative 
        costs associated with the provision of competent language 
        services and for reporting required under subsection (e).
            (2) Organizations.--Grantees that are part C organizations 
        or PDP sponsors must ensure that their network providers 
        receive at least 50 percent of the grant funds to pay for the 
        provision of competent language services to Medicare 
        beneficiaries who are limited English proficient, including 
        physicians and pharmacies.
            (3) Determination of payments for language services.--
        Payments to grantees shall be calculated based on the estimated 
        numbers of limited English proficient Medicare beneficiaries in 
        a grantee's service area utilizing--
                    (A) data on the numbers of limited English 
                proficient individuals who speak English less than 
                ``very well'' from the most recently available data 
                from the Bureau of the Census or other State-based 
                study the Secretary determines likely to yield accurate 
                data regarding the number of such individuals served by 
                the grantee; or
                    (B) the grantee's own data if the grantee routinely 
                collects data on Medicare beneficiaries' primary 
                language in a manner determined by the Secretary to 
                yield accurate data and such data shows greater numbers 
                of limited English proficient individuals than the data 
                listed in subparagraph (A).
            (4) Limitations.--
                    (A) Reporting.--Payments shall only be provided 
                under this section to grantees that report their costs 
                of providing language services as required under 
                subsection (e) and may be modified annually at the 
                discretion of the Secretary. If a grantee fails to 
                provide the reports under such section for the first 
                year of a grant, the Secretary may terminate the grant 
                and solicit applications from new grantees to 
                participate in the subsequent two years of the 
                demonstration program.
                    (B) Type of services.--
                            (i) In general.--Subject to clause (ii), 
                        payments shall be provided under this section 
                        only to grantees that utilize competent 
                        bilingual staff or competent interpreter or 
                        translation services which--
                                    (I) if the grantee operates in a 
                                State that has statewide health care 
                                interpreter standards, meet the State 
                                standards currently in effect; or
                                    (II) if the grantee operates in a 
                                State that does not have statewide 
                                health care interpreter standards, 
                                utilizes competent interpreters who 
                                follow the National Council on 
                                Interpreting in Health Care's Code of 
                                Ethics and Standards of Practice.
                            (ii) Exemptions.--The requirements of 
                        clause (i) shall not apply--
                                    (I) in the case of a Medicare 
                                beneficiary who is limited English 
                                proficient (who has been informed in 
                                the beneficiary's primary language of 
                                the availability of free interpreter 
                                and translation services) and who 
                                requests the use of family, friends, or 
                                other persons untrained in 
                                interpretation or translation and the 
                                grantee documents the request in the 
                                beneficiary's record; and
                                    (II) in the case of a medical 
                                emergency where the delay directly 
                                associated with obtaining a competent 
                                interpreter or translation services 
                                would jeopardize the health of the 
                                patient.
                        Nothing in clause (ii)(II) shall be construed 
                        to exempt emergency rooms or similar entities 
                        that regularly provide health care services in 
                        medical emergencies from having in place 
                        systems to provide competent interpreter and 
                        translation services without undue delay.
    (d) Assurances.--Grantees under this section shall--
            (1) ensure that appropriate clinical and support staff 
        receive ongoing education and training in linguistically 
        appropriate service delivery;
            (2) ensure the linguistic competence of bilingual 
        providers;
            (3) offer and provide appropriate language services at no 
        additional charge to each patient with limited English 
        proficiency at all points of contact, in a timely manner during 
        all hours of operation;
            (4) notify Medicare beneficiaries of their right to receive 
        language services in their primary language;
            (5) post signage in the languages of the commonly 
        encountered group or groups present in the service area of the 
        organization; and
            (6) ensure that--
                    (A) primary language data are collected for 
                recipients of language services and are consistent with 
                standards developed under section 1709(b)(3)(B)(iv) of 
                the Public Health Service Act, as added by section 2402 
                of this Act, to the extent such standards are available 
                upon the initiation of the demonstration; and
                    (B) consistent with the privacy protections 
                provided under the regulations promulgated pursuant to 
                section 264(c) of the Health Insurance Portability and 
                Accountability Act of 1996 (42 U.S.C. 1320d-2 note), if 
                the recipient of language services is a minor or is 
                incapacitated, the primary language of the parent or 
                legal guardian is collected and utilized.
    (e) Reporting Requirements.--Grantees under this section shall 
provide the Secretary with reports at the conclusion of the each year 
of a grant under this section. Each report shall include at least the 
following information:
            (1) The number of Medicare beneficiaries to whom language 
        services are provided.
            (2) The languages of those Medicare beneficiaries.
            (3) The types of language services provided (such as 
        provision of services directly in non-English language by a 
        bilingual health care provider or use of an interpreter).
            (4) Type of interpretation (such as in-person, telephonic, 
        or video interpretation).
            (5) The methods of providing language services (such as 
        staff or contract with external independent contractors or 
        agencies).
            (6) The length of time for each interpretation encounter.
            (7) The costs of providing language services (which may be 
        actual or estimated, as determined by the Secretary).
            (8) An account of the training or accreditation of 
        bilingual staff, interpreters, or translators providing 
        services under this demonstration.
    (f) No Cost Sharing.--Limited English proficient Medicare 
beneficiaries shall not have to pay cost-sharing or co-pays for 
language services provided through this demonstration program.
    (g) Evaluation and Report.--The Secretary shall conduct an 
evaluation of the demonstration program under this section and shall 
submit to the appropriate committees of Congress a report not later 
than 1 year after the completion of the program. The report shall 
include the following:
            (1) An analysis of the patient outcomes and costs of 
        furnishing care to the limited English proficient Medicare 
        beneficiaries participating in the project as compared to such 
        outcomes and costs for limited English proficient Medicare 
        beneficiaries not participating.
            (2) The effect of delivering culturally and linguistically 
        appropriate services on beneficiary access to care, utilization 
        of services, efficiency and cost-effectiveness of health care 
        delivery, patient satisfaction, and select health outcomes.
            (3) The extent to which bilingual staff, interpreters, and 
        translators providing services under such demonstration were 
        trained or accredited and the nature of accreditation or 
        training needed by type of provider, service, or other category 
        as determined by the Secretary to ensure the provision of high-
        quality interpretation, translation, or other language services 
        to Medicare beneficiaries if such services are expanded 
        pursuant to subsection (c) of section 1907 of this Act.
            (4) Recommendations, if any, regarding the extension of 
        such project to the entire Medicare program.
    (h) Accreditation or Training for Providers of Interpretation, 
Translation or Language Services in Medicare.--
            (1) In general.--
                    (A) Designation of standards.--If the Secretary, 
                pursuant to section 1907(c) of this Act, expands the 
                model initially developed through the demonstration 
                program under this section, the Secretary shall use the 
                results of the study under section 1221 and the 
                demonstration under this section to designate standards 
                for training or accreditation.   The Secretary may 
                designate one or more  training or  accreditation 
                organizations, as appropriate for the nature and type 
                of interpretation and translation services provided to 
                Medicare beneficiaries to ensure that payments are made 
                only for approved services by trained or accredited 
                language services providers.
                    (B) Alternatives to training or accreditation.--If 
                the Secretary designates one or more   training or 
                accreditation organizations but determines that 
                accreditation is not available in all languages for 
                which payments may be initiated, the Secretary shall 
                provide payments for and accept alternatives to  
                training or  accreditation for certain languages, 
                including languages of lesser diffusion.   The 
                Secretary must ensure that the alternatives to  
                training or  accreditation provide, at a minimum--
                            (i) a determination that the interpreter is 
                        proficient and able to communicate information 
                        accurately in both English and in the language 
                        for which interpreting is needed;
                            (ii) an attestation from the interpreter to 
                        comply with and adhere to the role of an 
                        interpreter as defined by the National Code of 
                        Ethics and National Standards of Practice as 
                        published by the National Council on 
                        Interpreting in Health Care; and
                            (iii) an attestation to adhere to HIPAA 
                        privacy and security law, as defined in section 
                        3009(a)(2) of the Public Health Service Act, to 
                        the same extent as the healthcare provider for 
                        whom interpreting is provided.
                    (C) Modifiers, add-ons, and other forms of 
                payment.--If the Secretary decides that modifiers, add-
                ons, or other forms of payment may be made for the 
                provision of services directly by bilingual providers, 
                the Secretary shall designate standards to ensure the 
                competency of such providers delivering such services 
                in a non-English language.
            (2) Consultation with stakeholders and considerations for 
        accreditation or training.--
                    (A) Consultation.--In designating accreditation or 
                training requirements under this subsection, the 
                Secretary shall consult with patients, providers, 
                organizations that advocate on behalf of limited 
                English proficient individuals, and other individuals 
                or entities determined appropriate by the Secretary.
                    (B) Considerations.--In designating accreditation 
                or training requirements under this section, the 
                Secretary shall consider, as appropriate--
                            (i) standards for qualifications of health 
                        care interpreters who interpret infrequently 
                        encountered languages;
                            (ii) standards for qualifications of health 
                        care interpreters who interpret in languages of 
                        lesser diffusion;
                            (iii) standards for training of 
                        interpreters;   and  
                            (iv) standards for continuing education of 
                        interpreters.
    (i) General Provisions.--Nothing in this section shall be construed 
to limit otherwise existing obligations of recipients of Federal 
financial assistance under title VI of the Civil Rights Act of 1964 (42 
U.S.C. 2000(d) et seq.) or any other statute.
    (j) Appropriations.--There are appropriated to carry out this 
section, in equal parts from the Federal Hospital Insurance Trust Fund 
and the Federal Supplementary Medical Insurance Trust Fund, $16,000,000 
for each fiscal year of the demonstration program.

SEC. 1223. IOM REPORT ON IMPACT OF LANGUAGE ACCESS SERVICES.

    (a) In General.--The Secretary of Health and Human Services shall 
enter into an arrangement with the Institute of Medicine under which 
the Institute will prepare and publish, not later than 3 years after 
the date of the enactment of this Act, a report on the impact of 
language access services on the health and health care of limited 
English proficient populations.
    (b) Contents.--Such report shall include--
            (1) recommendations on the development and implementation 
        of policies and practices by health care organizations and 
        providers for limited English proficient patient populations;
            (2) a description of the effect of providing language 
        access services on quality of health care and access to care 
        and reduced medical error; and
            (3) a description of the costs associated with or savings 
        related to provision of language access services.

SEC. 1224. DEFINITIONS.

    In this subtitle:
            (1) Bilingual.--The term ``bilingual'' with respect to an 
        individual means a person who has sufficient degree of 
        proficiency in two languages and can ensure effective 
        communication can occur in both languages.
            (2) Competent interpreter services.--The term ``competent 
        interpreter services'' means a trans-language rendition of a 
        spoken message in which the interpreter comprehends the source 
        language and can speak comprehensively in the target language 
        to convey the meaning intended in the source language. The 
        interpreter knows health and health-related terminology and 
        provides accurate interpretations by choosing equivalent 
        expressions that convey the best matching and meaning to the 
        source language and captures, to the greatest possible extent, 
        all nuances intended in the source message.
            (3) Competent translation services.--The term ``competent 
        translation services'' means a trans-language rendition of a 
        written document in which the translator comprehends the source 
        language and can write comprehensively in the target language 
        to convey the meaning intended in the source language. The 
        translator knows health and health-related terminology and 
        provides accurate translations by choosing equivalent 
        expressions that convey the best matching and meaning to the 
        source language and captures, to the greatest possible extent, 
        all nuances intended in the source document.
            (4) Effective communication.--The term ``effective 
        communication'' means an exchange of information between the 
        provider of health care or health care-related services and the 
        limited English proficient recipient of such services that 
        enables limited English proficient individuals to access, 
        understand, and benefit from health care or health care-related 
        services.
            (5) Interpreting/interpretation.--The terms 
        ``interpreting'' and ``interpretation'' mean the transmission 
        of a spoken message from one language into another, faithfully, 
        accurately, and objectively.
            (6) Health care services.--The term ``health care 
        services'' means services that address physical as well as 
        mental health conditions in all care settings.
            (7) Health care-related services.--The term ``health care-
        related services'' means human or social services programs or 
        activities that provide access, referrals or links to health 
        care.
            (8) Language access.--The term ``language access'' means 
        the provision of language services to an LEP individual 
        designed to enhance that individual's access to, understanding 
        of or benefit from health care or health care-related services.
            (9) Language services.--The term ``language services'' 
        means provision of health care services directly in a non-
        English language, interpretation, translation, and non-English 
        signage.
            (10) Limited english proficient.--The term ``limited 
        English proficient'' or ``LEP'' with respect to an individual 
        means an individual who speaks a primary language other than 
        English and who cannot speak, read, write or understand the 
        English language at a level that permits the individual to 
        effectively communicate with clinical or nonclinical staff at 
        an entity providing health care or health care related 
        services.
            (11) Medicare beneficiary.--The term ``Medicare 
        beneficiary'' means an individual entitled to benefits under 
        part A of title XVIII of the Social Security Act or enrolled 
        under part B of such title.
            (12) Medicare program.--The term ``Medicare program'' means 
        the programs under parts A through D of title XVIII of the 
        Social Security Act.
            (13) Service provider.--The term ``service provider'' 
        includes all suppliers, providers of services, or entities 
        under contract to provide coverage, items or services under any 
        part of title XVIII of the Social Security Act.

                 Subtitle C--Miscellaneous Improvements

SEC. 1231. EXTENSION OF THERAPY CAPS EXCEPTIONS PROCESS.

     Section 1833(g)(5) of the Social Security Act (42 U.S.C. 
1395l(g)(5)), as amended by section 141 of the Medicare Improvements 
for Patients and Providers Act of 2008 (Public Law 110-275), is amended 
by striking ``December 31, 2009'' and inserting ``December 31, 2011''.

SEC. 1232. EXTENDED MONTHS OF COVERAGE OF IMMUNOSUPPRESSIVE DRUGS FOR 
              KIDNEY TRANSPLANT PATIENTS AND OTHER RENAL DIALYSIS 
              PROVISIONS.

    (a) Provision of Appropriate Coverage of Immunosuppressive Drugs 
Under the Medicare Program for Kidney Transplant Recipients.--
            (1) Continued entitlement to immunosuppressive drugs.--
                    (A) Kidney transplant recipients.--Section 
                226A(b)(2) of the Social Security Act (42 U.S.C. 426-
                1(b)(2)) is amended by inserting ``(except for coverage 
                of immunosuppressive drugs under section 
                1861(s)(2)(J))'' before ``, with the thirty-sixth 
                month''.
                    (B) Application.--Section 1836 of such Act (42 
                U.S.C. 1395o) is amended--
                            (i) by striking ``Every individual who'' 
                        and inserting ``(a) In General.--Every 
                        individual who''; and
                            (ii) by adding at the end the following new 
                        subsection:
    ``(b) Special Rules Applicable to Individuals Only Eligible for 
Coverage of Immunosuppressive Drugs.--
            ``(1) In general.--In the case of an individual whose 
        eligibility for benefits under this title has ended on or after 
        January 1, 2012, except for the coverage of immunosuppressive 
        drugs by reason of section 226A(b)(2), the following rules 
        shall apply:
                    ``(A) The individual shall be deemed to be enrolled 
                under this part for purposes of receiving coverage of 
                such drugs.
                    ``(B) The individual shall be responsible for 
                providing for payment of the portion of the premium 
                under section 1839 which is not covered under the 
                Medicare savings program (as defined in section 
                1144(c)(7)) in order to receive such coverage.
                    ``(C) The provision of such drugs shall be subject 
                to the application of--
                            ``(i) the deductible under section 1833(b); 
                        and
                            ``(ii) the coinsurance amount applicable 
                        for such drugs (as determined under this part).
                    ``(D) If the individual is an inpatient of a 
                hospital or other entity, the individual is entitled to 
                receive coverage of such drugs under this part.
            ``(2) Establishment of procedures in order to implement 
        coverage.--The Secretary shall establish procedures for--
                    ``(A) identifying individuals that are entitled to 
                coverage of immunosuppressive drugs by reason of 
                section 226A(b)(2); and
                    ``(B) distinguishing such individuals from 
                individuals that are enrolled under this part for the 
                complete package of benefits under this part.''.
                    (C) Technical amendment to correct duplicate 
                subsection designation.--Subsection (c) of section 226A 
                of such Act (42 U.S.C. 426-1), as added by section 
                201(a)(3)(D)(ii) of the Social Security Independence 
                and Program Improvements Act of 1994 (Public Law 103-
                296; 108 Stat. 1497), is redesignated as subsection 
                (d).
            (2) Extension of secondary payer requirements for esrd 
        beneficiaries.--Section 1862(b)(1)(C) of such Act (42 U.S.C. 
        1395y(b)(1)(C)) is amended by adding at the end the following 
        new sentence: ``With regard to immunosuppressive drugs 
        furnished on or after the date of the enactment of the 
        Affordable Health Care for America Act, this subparagraph shall 
        be applied without regard to any time limitation.''.
    (b) Medicare Coverage for ESRD Patients.--Section 1881 of such Act 
is further amended--
            (1) in subsection (b)(14)(B)(iii), by inserting ``, 
        including oral drugs that are not the oral equivalent of an 
        intravenous drug (such as oral phosphate binders and 
        calcimimetics),'' after ``other drugs and biologicals'';
            (2) in subsection (b)(14)(E)(ii)--
                    (A) in the first sentence--
                            (i) by striking ``a one-time election to be 
                        excluded from the phase-in'' and inserting ``an 
                        election, with respect to 2011, 2012, or 2013, 
                        to be excluded from the phase-in (or the 
                        remainder of the phase-in)''; and
                            (ii) by adding before the period at the end 
                        the following: ``for such year and for each 
                        subsequent year during the phase-in described 
                        in clause (i)''; and
                    (B) in the second sentence--
                            (i) by striking ``January 1, 2011'' and 
                        inserting ``the first date of such year''; and
                            (ii) by inserting ``and at a time'' after 
                        ``form and manner''; and
            (3) in subsection (h)(4)(E), by striking ``lesser'' and 
        inserting ``greater''.

SEC. 1233. VOLUNTARY ADVANCE CARE PLANNING CONSULTATION.

    (a) In General.--Section 1861 of the Social Security Act (42 U.S.C. 
1395x) is amended--
            (1) in subsection (s)(2)--
                    (A) by striking ``and'' at the end of subparagraph 
                (DD);
                    (B) by adding ``and'' at the end of subparagraph 
                (EE); and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(FF) voluntary advance care planning consultation (as 
        defined in subsection (hhh)(1));''; and
            (2) by adding at the end the following new subsection:

             ``Voluntary Advance Care Planning Consultation

    ``(hhh)(1) Subject to paragraphs (3) and (4), the term `voluntary 
advance care planning consultation' means an optional consultation 
between the individual and a practitioner described in paragraph (2) 
regarding advance care planning. Such consultation may include the 
following, as specified by the Secretary:
            ``(A) An explanation by the practitioner of advance care 
        planning, including a review of key questions and 
        considerations, advance directives (including living wills and 
        durable powers of attorney) and their uses.
            ``(B) An explanation by the practitioner of the role and 
        responsibilities of a health care proxy and of the continuum of 
        end-of-life services and supports available, including 
        palliative care and hospice, and benefits for such services and 
        supports that are available under this title.
            ``(C) An explanation by the practitioner of physician 
        orders regarding life sustaining treatment or similar orders, 
        in States where such orders or similar orders exist.
    ``(2) A practitioner described in this paragraph is--
            ``(A) a physician (as defined in subsection (r)(1)); and
            ``(B) another health care professional (as specified by the 
        Secretary and who has the authority under State law to sign 
        orders for life sustaining treatments, such as a nurse 
        practitioner or physician assistant).
    ``(3) An individual may receive the voluntary advance care planning 
care planning consultation provided for under this subsection no more 
than once every 5 years unless there is a significant change in the 
health or health-related condition of the individual.
    ``(4) For purposes of this section, the term `order regarding life 
sustaining treatment' means, with respect to an individual, an 
actionable medical order relating to the treatment of that individual 
that effectively communicates the individual's preferences regarding 
life sustaining treatment, is signed and dated by a practitioner, and 
is in a form that permits it to be followed by health care 
professionals across the continuum of care.''.
    (b) Construction.--The voluntary advance care planning consultation 
described in section 1861(hhh) of the Social Security Act, as added by 
subsection (a), shall be completely optional. Nothing in this section 
shall--
            (1) require an individual to complete an advance directive, 
        an order for life sustaining treatment, or other advance care 
        planning document;
            (2) require an individual to consent to restrictions on the 
        amount, duration, or scope of medical benefits an individual is 
        entitled to receive under this title; or
            (3) encourage the promotion of suicide or assisted suicide.
    (c) Payment.--Section 1848(j)(3) of such Act (42 U.S.C. 1395w-
4(j)(3)) is amended by inserting ``(2)(FF),'' after ``(2)(EE),''.
    (d) Frequency Limitation.--Section 1862(a) of such Act (42 U.S.C. 
1395y(a)) is amended--
            (1) in paragraph (1)--
                    (A) in subparagraph (N), by striking ``and'' at the 
                end;
                    (B) in subparagraph (O) by striking the semicolon 
                at the end and inserting ``, and''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(P) in the case of voluntary advance care 
                planning consultations (as defined in paragraph (1) of 
                section 1861(hhh)), which are performed more frequently 
                than is covered under such section;''; and
            (2) in paragraph (7), by striking ``or (K)'' and inserting 
        ``(K), or (P)''.
    (e) Effective Date.--The amendments made by this section shall 
apply to consultations furnished on or after January 1, 2011.

SEC. 1234. PART B SPECIAL ENROLLMENT PERIOD AND WAIVER OF LIMITED 
              ENROLLMENT PENALTY FOR TRICARE BENEFICIARIES.

    (a) Part B Special Enrollment Period.--
            (1) In general.--Section 1837 of the Social Security Act 
        (42 U.S.C. 1395p) is amended by adding at the end the following 
        new subsection:
    ``(l)(1) In the case of any individual who is a covered beneficiary 
(as defined in section 1072(5) of title 10, United States Code) at the 
time the individual is entitled to hospital insurance benefits under 
part A under section 226(b) or section 226A and who is eligible to 
enroll but who has elected not to enroll (or to be deemed enrolled) 
during the individual's initial enrollment period, there shall be a 
special enrollment period described in paragraph (2).
    ``(2) The special enrollment period described in this paragraph, 
with respect to an individual, is the 12-month period beginning on the 
day after the last day of the initial enrollment period of the 
individual or, if later, the 12-month period beginning with the month 
the individual is notified of enrollment under this section.
    ``(3) In the case of an individual who enrolls during the special 
enrollment period provided under paragraph (1), the coverage period 
under this part shall begin on the first day of the month in which the 
individual enrolls or, at the option of the individual, on the first 
day of the second month following the last month of the individual's 
initial enrollment period.
    ``(4) The Secretary of Defense shall establish a method for 
identifying individuals described in paragraph (1) and providing notice 
to them of their eligibility for enrollment during the special 
enrollment period described in paragraph (2).''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to elections made on or after the date of the 
        enactment of this Act.
    (b) Waiver of Increase of Premium.--
            (1) In general.--Section 1839(b) of the Social Security Act 
        (42 U.S.C. 1395r(b)) is amended by striking ``section 
        1837(i)(4)'' and inserting ``subsection (i)(4) or (l) of 
        section 1837''.
            (2) Effective date.--
                    (A) In general.--The amendment made by paragraph 
                (1) shall apply with respect to elections made on or 
                after the date of the enactment of this Act.
                    (B) Rebates for certain disabled and esrd 
                beneficiaries.--
                            (i) In general.--With respect to premiums 
                        for months on or after January 2005 and before 
                        the month of the enactment of this Act, no 
                        increase in the premium shall be effected for a 
                        month in the case of any individual who is a 
                        covered beneficiary (as defined in section 
                        1072(5) of title 10, United States Code) at the 
                        time the individual is entitled to hospital 
                        insurance benefits under part A of title XVIII 
                        of the Social Security Act under section 226(b) 
                        or 226A of such Act, and who is eligible to 
                        enroll, but who has elected not to enroll (or 
                        to be deemed enrolled), during the individual's 
                        initial enrollment period, and who enrolls 
                        under this part within the 12-month period that 
                        begins on the first day of the month after the 
                        month of notification of entitlement under this 
                        part.
                            (ii) Consultation with department of 
                        defense.--The Secretary of Health and Human 
                        Services shall consult with the Secretary of 
                        Defense in identifying individuals described in 
                        this paragraph.
                            (iii) Rebates.--The Secretary of Health and 
                        Human Services shall establish a method for 
                        providing rebates of premium increases paid for 
                        months on or after January 1, 2005, and before 
                        the month of the enactment of this Act for 
                        which a penalty was applied and collected.

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.

    (a) In General.--Section 1839(i)(4)(C)(ii)(II) of the Social 
Security Act (42 U.S.C. 1395r(i)(4)(C)(ii)(II)) is amended by inserting 
``sale of primary residence,'' after ``divorce of such individual,''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to premiums and payments for years beginning with 2011.

SEC. 1236. DEMONSTRATION PROGRAM ON USE OF PATIENT DECISIONS AIDS.

    (a) In General.--The Secretary of Health and Human Services , 
acting through the Center for Medicare and Medicaid Innovation 
established under section 1115A of the Social Security Act (as added by 
section 1907) and consistent with the applicable provisions of such 
section, shall establish a shared decision making demonstration program 
(in this subsection referred to as the ``program'') under the Medicare 
program using patient decision aids to meet the objective of improving 
the understanding by Medicare beneficiaries of their medical treatment 
options, as compared to comparable Medicare beneficiaries who do not 
participate in a shared decision making process using patient decision 
aids.
    (b) Sites.--
            (1) Enrollment.--The Secretary shall enroll in the program 
        not more than 30 eligible providers who have experience in 
        implementing, and have invested in the necessary infrastructure 
        to implement, shared decision making using patient decision 
        aids.
            (2) Application.--An eligible provider seeking to 
        participate in the program shall submit to the Secretary an 
        application at such time and containing such information as the 
        Secretary may require.
            (3) Preference.--In enrolling eligible providers in the 
        program, the Secretary shall give preference to eligible 
        providers that--
                    (A) have documented experience in using patient 
                decision aids for the conditions identified by the 
                Secretary and in using shared decision making;
                    (B) have the necessary information technology 
                infrastructure to collect the information required by 
                the Secretary for reporting purposes; and
                    (C) are trained in how to use patient decision aids 
                and shared decision making.
    (c) Follow-up Counseling Visit.--
            (1) In general.--An eligible provider participating in the 
        program shall routinely schedule Medicare beneficiaries for a 
        counseling visit after the viewing of such a patient decision 
        aid to answer any questions the beneficiary may have with 
        respect to the medical care of the condition involved and to 
        assist the beneficiary in thinking through how their 
        preferences and concerns relate to their medical care.
            (2) Payment for follow-up counseling visit.--The Secretary 
        shall establish procedures for making payments for such 
        counseling visits provided to Medicare beneficiaries under the 
        program. Such procedures shall provide for the establishment--
                    (A) of a code (or codes) to represent such 
                services; and
                    (B) of a single payment amount for such service 
                that includes the professional time of the health care 
                provider and a portion of the reasonable costs of the 
                infrastructure of the eligible provider such as would 
                be made under the applicable payment systems to that 
                provider for similar covered services.
    (d) Costs of Aids.--An eligible provider participating in the 
program shall be responsible for the costs of selecting, purchasing, 
and incorporating such patient decision aids into the provider's 
practice, and reporting data on quality and outcome measures under the 
program.
    (e) Funding.--The Secretary shall provide for the transfer from the 
Federal Supplementary Medical Insurance Trust Fund established under 
section 1841 of the Social Security Act (42 U.S.C. 1395t) of such funds 
as are necessary for the costs of carrying out the program.
    (f) Waiver Authority.--The Secretary may waive such requirements of 
titles XI and XVIII of the Social Security Act (42 U.S.C. 1301 et seq. 
and 1395 et seq.) as may be necessary for the purpose of carrying out 
the program.
    (g) Report.--Not later than 12 months after the date of completion 
of the program, the Secretary shall submit to Congress a report on such 
program, together with recommendations for such legislation and 
administrative action as the Secretary determines to be appropriate. 
The final report shall include an evaluation of the impact of the use 
of the program on health quality, utilization of health care services, 
and on improving the quality of life of such beneficiaries.
    (h) Definitions.--In this section:
            (1) Eligible provider.--The term ``eligible provider'' 
        means the following:
                    (A) A primary care practice.
                    (B) A specialty practice.
                    (C) A multispecialty group practice.
                    (D) A hospital.
                    (E) A rural health clinic.
                    (F) A Federally qualified health center (as defined 
                in section 1861(aa)(4) of the Social Security Act (42 
                U.S.C. 1395x(aa)(4)).
                    (G) An integrated delivery system.
                    (H) A State cooperative entity that includes the 
                State government and at least one other health care 
                provider which is set up for the purpose of testing 
                shared decision making and patient decision aids.
            (2) Patient decision aid.--The term ``patient decision 
        aid'' means an educational tool (such as the Internet, a video, 
        or a pamphlet) that helps patients (or, if appropriate, the 
        family caregiver of the patient) understand and communicate 
        their beliefs and preferences related to their treatment 
        options, and to decide with their health care provider what 
        treatments are best for them based on their treatment options, 
        scientific evidence, circumstances, beliefs, and preferences.
            (3) Shared decision making.--The term ``shared decision 
        making'' means a collaborative process between patient and 
        clinician that engages the patient in decision making, provides 
        patients with information about trade-offs among treatment 
        options, and facilitates the incorporation of patient 
        preferences and values into the medical plan.

    TITLE III--PROMOTING PRIMARY CARE, MENTAL HEALTH SERVICES, AND 
                            COORDINATED CARE

SEC. 1301. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

    Title XVIII of the Social Security Act is amended by inserting 
after section 1866D, as added by section 1152(f), the following new 
section:

             ``accountable care organization pilot program

    ``Sec. 1866E.  (a) Establishment.--
    ``(1) In General.-- The Secretary shall conduct a pilot program (in 
this section referred to as the `pilot program') to test different 
payment incentive models, including (to the extent practicable) the 
specific payment incentive models described in subsection (c), designed 
to reduce the growth of expenditures and improve health outcomes in the 
provision of items and services under this title to applicable 
beneficiaries (as defined in subsection (e)) by qualifying accountable 
care organizations (as defined in subsection (b)(1)) in order to--
            ``(A) promote accountability for a patient population and 
        coordinate items and services under parts A and B (and may 
        include Part D, if the Secretary determines appropriate);
            ``(B) encourage investment in infrastructure and redesigned 
        care processes for high quality and efficient service delivery; 
        and
            ``(C) reward physician practices and other physician 
        organizational models for the provision of high quality and 
        efficient health care services.
    ``(2) Scope.--The Secretary shall set specific goals for the number 
of accountable care organizations, participating practitioners, and 
patients served in the initial tests under the pilot program to ensure 
that the pilot program is of sufficient size and scope to--
            ``(A) test the approach involved in a variety of settings, 
        including urban, rural, and underserved areas; and
            ``(B) subject to subsection (g)(1), disseminate such 
        approach rapidly on a national basis.
To the extent that the Secretary finds a qualifying accountable care 
organization model to be successful in improving quality and reducing 
costs, the Secretary shall seek to implement such models on as large a 
geographic scale as practical and economical.
    ``(b) Qualifying Accountable Care Organizations (ACOs).--
            ``(1) Qualifying aco defined.--In this section:
                    ``(A) In general.--The terms `qualifying 
                accountable care organization' and `qualifying ACO' 
                mean a group of physicians or other physician 
                organizational model (as defined in subparagraph (D)) 
                that--
                            ``(i) is organized at least in part for the 
                        purpose of providing physicians' services; and
                            ``(ii) meets such criteria as the Secretary 
                        determines to be appropriate to participate in 
                        the pilot program, including the criteria 
                        specified in paragraph (2).
                    ``(B) Inclusion of other providers of services and 
                suppliers.--Nothing in this subsection shall be 
                construed as preventing a qualifying ACO from including 
                a hospital or any other provider of services or 
                supplier furnishing items or services for which payment 
                may be made under this title that is affiliated with 
                the ACO under an arrangement structured so that such 
                provider or supplier participates in the pilot program 
                and shares in any incentive payments under the pilot 
                program.
                    ``(C) Physician.--The term `physician' includes, 
                except as the Secretary may otherwise provide, any 
                individual who furnishes services for which payment may 
                be made as physicians' services under this title.
                    ``(D) Other physician organizational model.--The 
                term `other physician organization model' means, with 
                respect to a qualifying ACO any model of organization 
                under which physicians enter into agreements with other 
                providers of services for the purposes of participation 
                in the pilot program in order to provide high quality 
                and efficient health care services and share in any 
                incentive payments under such program
                    ``(E) Other services.--Nothing in this paragraph 
                shall be construed as preventing a qualifying ACO from 
                furnishing items or services, for which payment may not 
                be made under this title, for purposes of achieving 
                performance goals under the pilot program.
            ``(2) Qualifying criteria.--The following are criteria 
        described in this paragraph for an organized group of 
        physicians to be a qualifying ACO:
                    ``(A) The group has a legal structure that would 
                allow the group to receive and distribute incentive 
                payments under this section.
                    ``(B) The group includes a sufficient number of 
                primary care physicians (regardless of specialty) for 
                the applicable beneficiaries for whose care the group 
                is accountable (as determined by the Secretary).
                    ``(C) The group reports on quality measures in such 
                form, manner, and frequency as specified by the 
                Secretary (which may be for the group, for providers of 
                services and suppliers, or both).
                    ``(D) The group reports to the Secretary (in a 
                form, manner and frequency as specified by the 
                Secretary) such data as the Secretary determines 
                appropriate to monitor and evaluate the pilot program.
                    ``(E) The group provides notice to applicable 
                beneficiaries regarding the pilot program (as 
                determined appropriate by the Secretary).
                    ``(F) The group contributes to a best practices 
                network or website, that shall be maintained by the 
                Secretary for the purpose of sharing strategies on 
                quality improvement, care coordination, and efficiency 
                that the groups believe are effective.
                    ``(G) The group utilizes patient-centered processes 
                of care, including those that emphasize patient and 
                caregiver involvement in planning and monitoring of 
                ongoing care management plan.
                    ``(H) The group meets other criteria determined to 
                be appropriate by the Secretary.
    ``(c) Specific Payment Incentive Models.--The specific payment 
incentive models described in this subsection are the following:
            ``(1) Performance target model.--Under the performance 
        target model under this paragraph (in this paragraph referred 
        to as the `performance target model'):
                    ``(A) In general.--A qualifying ACO qualifies to 
                receive an incentive payment if expenditures for items 
                and services for applicable beneficiaries are less than 
                a target spending level or a target rate of growth. The 
                incentive payment shall be made only if savings are 
                greater than would result from normal variation in 
                expenditures for items and services covered under parts 
                A and B (and may include Part D, if the Secretary 
                determines appropriate).
                    ``(B) Computation of performance target.--
                            ``(i) In general.--The Secretary shall 
                        establish a performance target for each 
                        qualifying ACO comprised of a base amount 
                        (described in clause (ii)) increased to the 
                        current year by an adjustment factor (described 
                        in clause (iii)). Such a target may be 
                        established on a per capita basis or adjusted 
                        for risk, as the Secretary determines to be 
                        appropriate.
                            ``(ii) Base amount.--For purposes of clause 
                        (i), the base amount in this subparagraph is 
                        equal to the average total payments (or allowed 
                        charges) under parts A and B (and may include 
                        part D, if the Secretary determines 
                        appropriate) for applicable beneficiaries for 
                        whom the qualifying ACO furnishes items and 
                        services in a base period determined by the 
                        Secretary. Such base amount may be determined 
                        on a per capita basis or adjusted for risk.
                            ``(iii) Adjustment factor.--For purposes of 
                        clause (i), the adjustment factor in this 
                        clause may equal an annual per capita amount 
                        that reflects changes in expenditures from the 
                        period of the base amount to the current year 
                        that would represent an appropriate performance 
                        target for applicable beneficiaries (as 
                        determined by the Secretary).
                            ``(iv) Rebasing.--Under this model the 
                        Secretary shall periodically rebase the base 
                        expenditure amount described in clause (ii).
                    ``(C) Meeting target.--
                            ``(i) In general.--Subject to clause (ii), 
                        a qualifying ACO that meets or exceeds annual 
                        quality and performance targets for a year 
                        shall receive an incentive payment for such 
                        year equal to a portion (as determined 
                        appropriate by the Secretary) of the amount by 
                        which payments under this title for such year 
                        are estimated to be below the performance 
                        target for such year, as determined by the 
                        Secretary. The Secretary may establish a cap on 
                        incentive payments for a year for a qualifying 
                        ACO.
                            ``(ii) Limitation.-- The Secretary shall 
                        limit incentive payments to each qualifying ACO 
                        under this paragraph as necessary to ensure 
                        that the aggregate expenditures with respect to 
                        applicable beneficiaries for such ACOs under 
                        this title (inclusive of incentive payments 
                        described in this subparagraph) do not exceed 
                        the amount that the Secretary estimates would 
                        be expended for such ACO for such beneficiaries 
                        if the pilot program under this section were 
                        not implemented.
                    ``(D) Reporting and other requirements.--In 
                carrying out such model, the Secretary may (as the 
                Secretary determines to be appropriate) incorporate 
                reporting requirements, incentive payments, and 
                penalties related to the physician quality reporting 
                initiative (PQRI), electronic prescribing, electronic 
                health records, and other similar initiatives under 
                section 1848, and may use alternative criteria than 
                would otherwise apply under such section for 
                determining whether to make such payments. The 
                incentive payments described in this subparagraph shall 
                not be included in the limit described in subparagraph 
                (C)(ii) or in the performance target model described in 
                this paragraph.
            ``(2) Partial capitation model.--
                    ``(A) In general.--Subject to subparagraph (B), a 
                partial capitation model described in this paragraph 
                (in this paragraph referred to as a `partial capitation 
                model') is a model in which a qualifying ACO would be 
                at financial risk for some, but not all, of the items 
                and services covered under parts A and B (and may 
                include part D, if the Secretary determines 
                appropriate), such as at risk for some or all 
                physicians' services or all items and services under 
                part B. The Secretary may limit a partial capitation 
                model to ACOs that are highly integrated systems of 
                care and to ACOs capable of bearing risk, as determined 
                to be appropriate by the Secretary.
                    ``(B) No additional program expenditures.--Payments 
                to a qualifying ACO for items and services under this 
                title for applicable beneficiaries for a year under the 
                partial capitation model shall be established in a 
                manner that does not result in spending more for such 
                ACO for such beneficiaries than would otherwise be 
                expended for such ACO for such beneficiaries for such 
                year if the pilot program were not implemented, as 
                estimated by the Secretary.
            ``(3) Other payment models.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Secretary may develop other payment models that meet 
                the goals of this pilot program to improve quality and 
                efficiency.
                    ``(B) No additional program expenditures.--
                Subparagraph (B) of paragraph (2) shall apply to a 
                payment model under subparagraph (A) in a similar 
                manner as such subparagraph (B) applies to the payment 
                model under paragraph (2).
    ``(d) Annual Quality Targets.--
            ``(1) In general.--The Secretary shall establish annual 
        quality targets that qualifying ACOs must meet to receive 
        incentive payments, operate at financial risk, or otherwise 
        participate in alternative financing models under this section. 
        The Secretary shall establish a process for developing annual 
        targets based on ACO reporting of multiple quality measures. In 
        selecting measures the Secretary shall--
                    ``(A) for years one and two of each ACOs 
                participation in the pilot program established by this 
                section, require reporting of a starter set of measures 
                focused on clinical care, care coordination and patient 
                experience of care; and
                    ``(B) for each subsequent year, require reporting 
                of a more comprehensive set of clinical outcomes 
                measures, care coordination measures and patient 
                experience of care measures.
            ``(2) Measure selection.--To the extent feasible, the 
        Secretary shall select measures that reflect national 
        priorities for quality improvement and patient-centered care 
        consistent with the measures developed under section 
        1192(c)(1).
    ``(e) Applicable Beneficiaries.--
            ``(1) In general.--In this section, the term `applicable 
        beneficiary' means, with respect to a qualifying ACO, an 
        individual who--
                    ``(A) is enrolled under part B and entitled to 
                benefits under part A;
                    ``(B) is not enrolled in a Medicare Advantage plan 
                under part C or a PACE program under section 1894; and
                    ``(C) meets such other criteria as the Secretary 
                determines appropriate, which may include criteria 
                relating to frequency of contact with physicians in the 
                ACO
            ``(2) Following applicable beneficiaries.--The Secretary 
        may monitor data on expenditures and quality of services under 
        this title after an applicable beneficiary discontinues 
        receiving services under this title through a qualifying ACO.
    ``(f) Implementation.--
            ``(1) Starting date.--The pilot program shall begin no 
        later than January 1, 2012. An agreement with a qualifying ACO 
        under the pilot program may cover a multi-year period of 
        between 3 and 5 years.
            ``(2) Waiver.--The Secretary may waive such provisions of 
        this title (including section 1877) and title XI in the manner 
        the Secretary determines necessary in order implement the pilot 
        program.
            ``(3) Performance results reports.--The Secretary shall 
        report performance results to qualifying ACOs under the pilot 
        program at least annually.
            ``(4) Limitations on review.--There shall be no 
        administrative or judicial review under section 1869, section 
        1878, or otherwise of--
                    ``(A) the elements, parameters, scope, and duration 
                of the pilot program;
                    ``(B) the selection of qualifying ACOs for the 
                pilot program;
                    ``(C) the establishment of targets, measurement of 
                performance, determinations with respect to whether 
                savings have been achieved and the amount of savings;
                    ``(D) determinations regarding whether, to whom, 
                and in what amounts incentive payments are paid; and
                    ``(E) decisions about the extension of the program 
                under subsection (h), expansion of the program under 
                subsection (i) or extensions under subsections (j) or 
                (k).
            ``(5) Administration.--Chapter 35 of title 44, United 
        States Code shall not apply to this section.
    ``(g) Evaluation; Monitoring.--
            ``(1) In general.--The Secretary shall evaluate the payment 
        incentive model for each qualifying ACO under the pilot program 
        to assess impacts on beneficiaries, providers of services, 
        suppliers and the program under this title. The Secretary shall 
        make such evaluation publicly available within 60 days of the 
        date of completion of such report.
            ``(2) Monitoring.--The Inspector General of the Department 
        of Health and Human Services shall provide for monitoring of 
        the operation of ACOs under the pilot program with regard to 
        violations of section 1877 (popularly known as the `Stark 
        law').
    ``(h) Extension of Pilot Agreement With Successful Organizations.--
            ``(1) Reports to congress.--Not later than 2 years after 
        the date the first agreement is entered into under this 
        section, and biennially thereafter for six years, the Secretary 
        shall submit to Congress and make publicly available a report 
        on the use of ACO payment models under the pilot program. Each 
        report shall address the impact of the use of those models on 
        expenditures, access, and quality under this title.
            ``(2) Extension.--Subject to the report provided under 
        paragraph (1), with respect to a qualifying ACO, the Secretary 
        may extend the duration of the agreement for such ACO under the 
        pilot program as the Secretary determines appropriate if--
                    ``(A) the ACO receives incentive payments with 
                respect to any of the first 4 years of the pilot 
                agreement and is consistently meeting quality standards 
                or
                    ``(B) the ACO is consistently exceeding quality 
                standards and is not increasing spending under the 
                program.
            ``(3) Termination.--The Secretary may terminate an 
        agreement with a qualifying ACO under the pilot program if such 
        ACO did not receive incentive payments or consistently failed 
        to meet quality standards in any of the first 3 years under the 
        program.
    ``(i) Expansion to Additional ACOs.--
            ``(1) Testing and refinement of payment incentive models.--
        Subject to the evaluation described in subsection (g), the 
        Secretary may enter into agreements under the pilot program 
        with additional qualifying ACOs to further test and refine 
        payment incentive models with respect to qualifying ACOs.
            ``(2) Expanding use of successful models to program 
        implementation.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Secretary may issue regulations to implement, on a 
                permanent basis, 1 or more models if, and to the extent 
                that, such models are beneficial to the program under 
                this title, as determined by the Secretary.
                    ``(B) Certification.--The Chief Actuary of the 
                Centers for Medicare & Medicaid Services shall certify 
                that 1 or more of such models described in subparagraph 
                (A) would result in estimated spending that would be 
                less than what spending would otherwise be estimated to 
                be in the absence of such expansion.
    ``(j) Treatment of Physician Group Practice Demonstration.--
            ``(1) Extension.--The Secretary may enter in to an 
        agreement with a qualifying ACO under the demonstration under 
        section 1866A, subject to rebasing and other modifications 
        deemed appropriate by the Secretary, until the pilot program 
        under this section is operational.
            ``(2) Transition.--For purposes of extension of an 
        agreement with a qualifying ACO under subsection (h)(2), the 
        Secretary shall treat receipt of an incentive payment for a 
        year by an organization under the physician group practice 
        demonstration pursuant to section 1866A as a year for which an 
        incentive payment is made under such subsection, as long as 
        such practice group practice organization meets the criteria 
        under subsection (b)(2).
    ``(k) Additional Provisions.--
            ``(1) Authority for separate incentive arrangements.--The 
        Secretary may create separate incentive arrangements (including 
        using multiple years of data, varying thresholds, varying 
        shared savings amounts, and varying shared savings limits) for 
        different categories of qualifying ACOs to reflect variation in 
        average annual attributable expenditures and other matters the 
        Secretary deems appropriate.
            ``(2) Encouragement of participation of smaller 
        organizations.--In order to encourage the participation of 
        smaller accountable care organizations under the pilot program, 
        the Secretary may limit a qualifying ACO's exposure to high 
        cost patients under the program.
            ``(3) Involvement in private payer and other third party 
        arrangements.--The Secretary may give preference to ACOs who 
        are participating in similar arrangements with other payers.
            ``(4) Antidiscrimination limitation.--The Secretary shall 
        not enter into an agreement with an entity to provide health 
        care items or services under the pilot program, or with an 
        entity to administer the program, unless such entity guarantees 
        that it will not deny, limit, or condition the coverage or 
        provision of benefits under the program, for individuals 
        eligible to be enrolled under such program, based on any health 
        status-related factor described in section 2702(a)(1) of the 
        Public Health Service Act.
            ``(5) Funding.--For purposes of administering and carrying 
        out the pilot program, other than for payments for items and 
        services furnished under this title and incentive payments 
        under subsection (c)(1), in addition to funds otherwise 
        appropriated, there are appropriated to the Secretary for the 
        Center for Medicare & Medicaid Services Program Management 
        Account $25,000,000 for each of fiscal years 2010 through 2014 
        and $20,000,000 for fiscal year 2015. Amounts appropriated 
        under this paragraph for a fiscal year shall be available until 
        expended.
            ``(6) No duplication in payments to physicians in multiple 
        pilots.--The Secretary shall not make payments under this 
        section to any physician group that is paid under section 1866F 
        (relating to medical homes) or section 1866G (relating to 
        independence at home).''.

SEC. 1302. MEDICAL HOME PILOT PROGRAM.

    (a) In General.--Title XVIII of the Social Security Act is amended 
by inserting after section 1866E, as inserted by section 1301, the 
following new section:

                      ``medical home pilot program

    ``Sec. 1866F.  (a) Establishment and Medical Home Models.--
            ``(1) Establishment of pilot program.--The Secretary shall 
        establish a medical home pilot program (in this section 
        referred to as the `pilot program') for the purpose of 
        evaluating the feasibility and advisability of reimbursing 
        qualified patient-centered medical homes for furnishing medical 
        home services (as defined under subsection (b)(1)) to 
        beneficiaries (as defined in subsection (b)(4)) and to targeted 
        high need beneficiaries (as defined in subsection (c)(1)(C)).
            ``(2) Scope.--Subject to subsection (g), the Secretary 
        shall set specific goals for the number of practices and 
        communities, and the number of patients served, under the pilot 
        program in the initial tests to ensure that the pilot program 
        is of sufficient size and scope to--
                    ``(A) test the approach involved in a variety of 
                settings, including urban, rural, and underserved 
                areas; and
                    ``(B) subject to subsection (e)(1), disseminate 
                such approach rapidly on a national basis.
        To the extent that the Secretary finds a medical home model to 
        be successful in improving quality and reducing costs, the 
        Secretary shall implement such model on as large a geographic 
        scale as practical and economical.
            ``(3) Models of medical homes in the pilot program.--The 
        pilot program shall evaluate each of the following medical home 
        models:
                    ``(A) Independent patient-centered medical home 
                model.--Independent patient-centered medical home model 
                under subsection (c).
                    ``(B) Community-based medical home model.--
                Community-based medical home model under subsection 
                (d).
            ``(4) Participation of nurse practitioners and physician 
        assistants.--
                    ``(A) Nothing in this section shall be construed as 
                preventing a nurse practitioner from leading a patient 
                centered medical home so long as--
                            ``(i) all the requirements of this section 
                        are met; and
                            ``(ii) the nurse practitioner is acting in 
                        a manner that is consistent with State law.
                    ``(B) Nothing in this section shall be construed as 
                preventing a physician assistant from participating in 
                a patient centered medical home so long as--
                            ``(i) all the requirements of this section 
                        are met; and
                            ``(ii) the physician assistant is acting in 
                        a manner that is consistent with State law.
    ``(b) Definitions.--For purposes of this section:
            ``(1) Patient-centered medical home services.--The term 
        `patient-centered medical home services' means services that--
                    ``(A) provide beneficiaries with direct and ongoing 
                access to a primary care or principal care physician or 
                nurse practitioner who accepts responsibility for 
                providing first contact, continuous and comprehensive 
                care to such beneficiary;
                    ``(B) coordinate the care provided to a beneficiary 
                by a team of individuals at the practice level across 
                office, provider of services, and home settings led by 
                a primary care or principal care physician or nurse 
                practitioner, as needed and appropriate;
                    ``(C) provide for all the patient's health care 
                needs or take responsibility for appropriately 
                arranging care with other qualified physicians or 
                providers for all stages of life;
                    ``(D) provide continuous access to care and 
                communication with participating beneficiaries;
                    ``(E) provide support for patient self-management, 
                proactive and regular patient monitoring, support for 
                family caregivers, use patient-centered processes, and 
                coordination with community resources;
                    ``(F) integrate readily accessible, clinically 
                useful information on participating patients that 
                enables the practice to treat such patients 
                comprehensively and systematically; and
                    ``(G) implement evidence-based guidelines and apply 
                such guidelines to the identified needs of 
                beneficiaries over time and with the intensity needed 
                by such beneficiaries.
            ``(2) Primary care.--The term `primary care' means health 
        care that is provided by a physician, nurse practitioner, or 
        physician assistant who practices in the field of family 
        medicine, general internal medicine, geriatric medicine, or 
        pediatric medicine.
            ``(3) Principal care.--The term `principal care' means 
        integrated, accessible health care that is provided by a 
        physician who is a medical specialist or subspecialist that 
        addresses the majority of the personal health care needs of 
        patients with chronic conditions requiring the specialist's or 
        subspecialist's expertise, and for whom the specialist or 
        subspecialist assumes care management.
            ``(4) Beneficiaries.--The term `beneficiaries' means, with 
        respect to a qualifying medical home, an individual who--
                    ``(A) is enrolled under part B and entitled to 
                benefits under part A;
                    ``(B) is not enrolled in a Medicare Advantage plan 
                under part C or a PACE program under section 1894; and
                    ``(C) meets such other criteria as the Secretary 
                determines appropriate.
    ``(c) Independent Patient-centered Medical Home Model.--
            ``(1) In general.--
                    ``(A) Payment authority.--Under the independent 
                patient-centered medical home model under this 
                subsection, the Secretary shall make payments for 
                medical home services furnished by an independent 
                patient-centered medical home (as defined in 
                subparagraph (B)) pursuant to paragraph (3) for 
                targeted high need beneficiaries (as defined in 
                subparagraph (C)).
                    ``(B) Independent patient-centered medical home 
                defined.--In this section, the term `independent 
                patient-centered medical home' means a physician-
                directed or nurse-practitioner-directed practice that 
                is qualified under paragraph (2) as--
                            ``(i) providing beneficiaries with patient-
                        centered medical home services; and
                            ``(ii) meets such other requirements as the 
                        Secretary may specify.
                    ``(C) Targeted high need beneficiary defined.--For 
                purposes of this subsection, the term `targeted high 
                need beneficiary' means a beneficiary who, based on a 
                risk score as specified by the Secretary, is generally 
                within the upper 50th percentile of Medicare 
                beneficiaries.
                    ``(D) Beneficiary election to participate.--The 
                Secretary shall determine an appropriate method of 
                ensuring that beneficiaries have agreed to participate 
                in the pilot program.
                    ``(E) Implementation.--The pilot program under this 
                subsection shall begin no later than 12 months after 
                the date of the enactment of this section and shall 
                operate for 5 years.
            ``(2) Qualification process for patient-centered medical 
        homes.--The Secretary shall establish a process for practices 
        to qualify as medical homes.
            ``(3)  Payment.--
                    ``(A) Establishment of methodology.--The Secretary 
                shall establish a methodology for the payment for 
                medical home services furnished by independent patient-
                centered medical homes. Under such methodology, the 
                Secretary shall adjust payments to medical homes based 
                on beneficiary risk scores to ensure that higher 
                payments are made for higher risk beneficiaries.
                    ``(B) Per beneficiary per month payments.--Under 
                such payment methodology, the Secretary shall pay 
                independent patient-centered medical homes a monthly 
                fee for each targeted high need beneficiary who 
                consents to receive medical home services through such 
                medical home.
                    ``(C) Prospective payment.--The fee under 
                subparagraph (B) shall be paid on a prospective basis.
                    ``(D) Amount of payment.--In determining the amount 
                of such fee, the Secretary shall consider the 
                following:
                            ``(i) The clinical work and practice 
                        expenses involved in providing the medical home 
                        services provided by the independent patient-
                        centered medical home (such as providing 
                        increased access, care coordination, population 
                        disease management, and teaching self-care 
                        skills for managing chronic illnesses) for 
                        which payment is not made under this title as 
                        of the date of the enactment of this section.
                            ``(ii) Allow for differential payments 
                        based on capabilities of the independent 
                        patient-centered medical home.
                            ``(iii) Use appropriate risk-adjustment in 
                        determining the amount of the per beneficiary 
                        per month payment under this paragraph in a 
                        manner that ensures that higher payments are 
                        made for higher risk beneficiaries.
            ``(4) Encouraging participation of variety of practices.--
        The pilot program under this subsection shall be designed to 
        include the participation of physicians in practices with fewer 
        than 10 full-time equivalent physicians, as well as physicians 
        in larger practices, particularly in underserved and rural 
        areas, as well as federally qualified health centers, and rural 
        health centers.
    ``(d) Community-based Medical Home Model.--
            ``(1) In general.--
                    ``(A) Authority for payments.--Under the community-
                based medical home model under this subsection (in this 
                section referred to as the `CBMH model'), the Secretary 
                shall make payments for the furnishing of medical home 
                services by a community-based medical home (as defined 
                in subparagraph (B)) pursuant to paragraph (5)(B) for 
                beneficiaries.
                    ``(B) Community-based medical home defined.--In 
                this section, the term `community-based medical home' 
                means a nonprofit community-based or State-based 
                organization or a State that is certified under 
                paragraph (2) as meeting the following requirements:
                            ``(i) The organization provides 
                        beneficiaries with medical home services.
                            ``(ii) The organization provides medical 
                        home services under the supervision of and in 
                        close collaboration with the primary care or 
                        principal care physician, nurse practitioner, 
                        or physician assistant designated by the 
                        beneficiary as his or her community-based 
                        medical home provider.
                            ``(iii) The organization employs community 
                        health workers, including nurses or other non-
                        physician practitioners, lay health workers, or 
                        other persons as determined appropriate by the 
                        Secretary, that assist the primary or principal 
                        care physician, nurse practitioner, or 
                        physician assistant in chronic care management 
                        activities such as teaching self-care skills 
                        for managing chronic illnesses, transitional 
                        care services, care plan setting, nutritional 
                        counseling, medication therapy management 
                        services for patients with multiple chronic 
                        diseases, or help beneficiaries access the 
                        health care and community-based resources in 
                        their local geographic area.
                            ``(iv) The organization meets such other 
                        requirements as the Secretary may specify.
            ``(2) Qualification process for community-based medical 
        homes.--The Secretary shall establish a process to provide for 
        the review and qualification of community-based medical homes 
        pursuant to criteria established by the Secretary.
            ``(3) Duration.--The pilot program for community-based 
        medical homes under this subsection shall start no later than 2 
        years after the date of the enactment of this section. Each 
        demonstration site under the pilot program shall operate for a 
        period of up to 5 years after the initial implementation phase, 
        without regard to the receipt of a initial implementation 
        funding under paragraph (6).
            ``(4) Preference.--In selecting sites for the CBMH model, 
        the Secretary shall give preference to applications which seek 
        to eliminate health disparities, as defined in section 3171 of 
        the Public Health Service Act and may give preference to any of 
        the following:
                    ``(A) Applications that propose to coordinate 
                health care items and services under this title for 
                chronically ill beneficiaries who rely, for primary 
                care, on small physician or nurse practitioner 
                practices, federally qualified health centers, rural 
                health clinics, or other settings with limited 
                resources and scope of services.
                    ``(B) Applications that include other third-party 
                payors that furnish medical home services for 
                chronically ill patients covered by such third-party 
                payors.
                    ``(C) Applications from States that propose to use 
                the medical home model to coordinate health care 
                services for--
                            ``(i) individuals enrolled under this 
                        title;
                            ``(ii) individuals enrolled under title 
                        XIX; and
                            ``(iii) full-benefit dual eligible 
                        individuals (as defined in section 1935(c)(6)),
                with chronic diseases across a variety of health care 
                settings.
            ``(5)  Payments.--
                    ``(A) Establishment of methodology.--The Secretary 
                shall establish a methodology for the payment for 
                medical home services furnished under the CBMH model.
                    ``(B) Per beneficiary per month payments.--Under 
                such payment methodology, the Secretary shall make two 
                separate monthly payments for each beneficiary who 
                consents to receive medical home services through such 
                medical home, as follows:
                            ``(i) Payment to community-based 
                        organization.--One monthly payment to a 
                        community-based or State-based organization or 
                        State.
                            ``(ii) Payment to primary or principal care 
                        practice.--One monthly payment to the primary 
                        or principal care practice for such 
                        beneficiary.
                    ``(C) Prospective payment.--The payments under 
                subparagraph (B) shall be paid on a prospective basis.
                    ``(D) Amount of payment.--In determining the amount 
                of such payment under subparagraph (B), the Secretary 
                shall consider the following:
                            ``(i) The clinical work and practice 
                        expenses involved in providing the medical home 
                        services provided by the primary or principal 
                        care practice (such as providing increased 
                        access, care coordination, care planning, 
                        population disease management, and teaching 
                        self-care skills for managing chronic 
                        illnesses) for which payment is not made under 
                        this title as of the date of the enactment of 
                        this section.
                            ``(ii) Use appropriate risk-adjustment in 
                        determining the amount of the per beneficiary 
                        per month payment under this paragraph.
                            ``(iii) In the case of the models described 
                        in subparagraphs (B) and (C) of paragraph (4), 
                        the Secretary may determine an appropriate 
                        payment amount.
            ``(6) Initial implementation funding.--The Secretary may 
        make available initial implementation funding to a non-profit 
        community based or State-based organization or a State that is 
        participating in the pilot program under this subsection. Such 
        organization shall provide the Secretary with a detailed 
        implementation plan that includes how such funds will be used. 
        The Secretary shall select a territory of the United States as 
        one of the locations in which to implement the pilot program 
        under this subsection, unless no organization in a territory is 
        able to comply with the requirements under paragraph (1)(B).
    ``(e) Expansion of Program.--
            ``(1) Evaluation of cost and quality.--The Secretary shall 
        evaluate the pilot program to determine--
                    ``(A) the extent to which medical homes result in--
                            ``(i) improvement in the quality and 
                        coordination of items and services under this 
                        title, particularly with regard to the care of 
                        complex patients;
                            ``(ii) improvement in reducing health 
                        disparities;
                            ``(iii) reductions in preventable 
                        hospitalizations;
                            ``(iv) prevention of readmissions;
                            ``(v) reductions in emergency room visits;
                            ``(vi) improvement in health outcomes, 
                        including patient functional status where 
                        applicable;
                            ``(vii) improvement in patient 
                        satisfaction;
                            ``(viii) improved efficiency of care such 
                        as reducing duplicative diagnostic tests and 
                        laboratory tests; and
                            ``(ix) reductions in health care 
                        expenditures; and
                    ``(B) the feasability and advisability of 
                reimbursing medical homes for medical home services 
                under this title on a permanent basis.
            ``(2) Report.--Not later than 60 days after the date of 
        completion of the evaluation under paragraph (1), the Secretary 
        shall submit to Congress and make available to the public a 
        report on the findings of the evaluation under paragraph (1) 
        and the extent to which standards for the certification of 
        medical homes need to be periodically updated.
            ``(3) Expansion of program.--
                    ``(A) In general.--Subject to the results of the 
                evaluation under paragraph (1) and subparagraph (B), 
                the Secretary may issue regulations to implement, on a 
                permanent basis, one or more models, if, and to the 
                extent that such model or models, are beneficial to the 
                program under this title, including that such 
                implementation will improve quality of care, as 
                determined by the Secretary.
                    ``(B) Certification requirement.--The Secretary may 
                not issue such regulations unless the Chief Actuary of 
                the Centers for Medicare & Medicaid Services certifies 
                that the expansion of the components of the pilot 
                program described in subparagraph (A) would result in 
                estimated spending under this title that would be no 
                more than the level of spending that the Secretary 
                estimates would otherwise be spent under this title in 
                the absence of such expansion.
                    ``(C) Updated standards.--The Secretary shall 
                periodically review and update the standards for 
                qualification as an independent patient centered 
                medical home and as a community based medical home and 
                shall establish a process for ensuring that medical 
                homes meet such updated standards, as applicable
    ``(f) Administrative Provisions.--
            ``(1) No duplication in payments for individuals in medical 
        homes.--During any month, the Secretary may not make payments 
        under this section under more than one model or through more 
        than one medical home under any model for the furnishing of 
        medical home services to an individual.
            ``(2) No effect on payment for medical visits.--Payments 
        made under this section are in addition to, and have no effect 
        on the amount of, payment for medical visits made under this 
        title
            ``(3) Administration.--Chapter 35 of title 44, United 
        States Code shall not apply to this section.
            ``(4) No duplication in physician pilot participation.--The 
        Secretary shall not make payments to an independent or 
        community based medical home both under this section and 
        section 1866E or 1866G, unless the pilot program under this 
        section has been implemented on a permanent basis under 
        subsection (e)(3).
            ``(5) Waiver.--The Secretary may waive such provisions of 
        this title and title XI in the manner the Secretary determines 
        necessary in order to implement this section.
    ``(g) Funding.--
            ``(1) Operational costs.--For purposes of administering and 
        carrying out the pilot program (including the design, 
        implementation, technical assistance for and evaluation of such 
        program), in addition to funds otherwise available, there shall 
        be transferred from the Federal Supplementary Medical Insurance 
        Trust Fund under section 1841 to the Secretary for the Centers 
        for Medicare & Medicaid Services Program Management Account 
        $6,000,000 for each of fiscal years 2010 through 2014. Amounts 
        appropriated under this paragraph for a fiscal year shall be 
        available until expended.
            ``(2) Patient-centered medical home services.--In addition 
        to funds otherwise available, there shall be available to the 
        Secretary for the Centers for Medicare & Medicaid Services, 
        from the Federal Supplementary Medical Insurance Trust Fund 
        under section 1841--
                    ``(A) $200,000,000 for each of fiscal years 2010 
                through 2014 for payments for medical home services 
                under subsection (c)(3); and
                    ``(B) $125,000,000 for each of fiscal years 2012 
                through 2016, for payments under subsection (d)(5).
        Amounts available under this paragraph for a fiscal year shall 
        be available until expended.
            ``(3) Initial implementation.--In addition to funds 
        otherwise available, there shall be available to the Secretary 
        for the Centers for Medicare & Medicaid Services, from the 
        Federal Supplementary Medical Insurance Trust Fund under 
        section 1841, $2,500,000 for each of fiscal years 2010 through 
        2012, under subsection (d)(6). Amounts available under this 
        paragraph for a fiscal year shall be available until expended.
    ``(h) Treatment of TRHCA Medicare Medical Home Demonstration 
Funding.--
            ``(1) In addition to funds otherwise available for payment 
        of medical home services under subsection (c)(3), there shall 
        also be available the amount provided in subsection (g) of 
        section 204 of division B of the Tax Relief and Health Care Act 
        of 2006 (42 U.S.C. 1395b-1 note), as added by section 133 of 
        the Medicare Improvements for Patients and Providers Act of 
        2008 (Public Law 110-275).
            ``(2) Notwithstanding section 1302(c) of the Affordable 
        Health Care for America Act, in addition to funds provided in 
        paragraph (1) and subsection (g)(2)(A), the funding for medical 
        home services that would otherwise have been available if such 
        section 204 medical home demonstration had been implemented 
        (without regard to subsection (g) of such section) shall be 
        available to the independent patient-centered medical home 
        model described in subsection (c).''.
    (b) Effective Date.--The amendment made by this section shall apply 
to services furnished on or after the date of the enactment of this 
Act.
    (c) Conforming Repeal.--Section 204 of division B of the Tax Relief 
and Health Care Act of 2006 (42 U.S.C. 1395b-1 note), as amended by 
section 133(a)(2) of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110-275), is repealed.

SEC. 1303. PAYMENT INCENTIVE FOR SELECTED PRIMARY CARE SERVICES.

    (a) In General.--Section 1833 of the Social Security Act is amended 
by inserting after subsection (o) the following new subsection:
    ``(p) Primary Care Payment Incentives.--
            ``(1) In general.--In the case of primary care services (as 
        defined in paragraph (2)) furnished on or after January 1, 
        2011, by a primary care practitioner (as defined in paragraph 
        (3)) for which amounts are payable under section 1848, in 
        addition to the amount otherwise paid under this part there 
        shall also be paid to the practitioner (or to an employer or 
        facility in the cases described in clause (A) of section 
        1842(b)(6)) (on a monthly or quarterly basis) from the Federal 
        Supplementary Medical Insurance Trust Fund an amount equal 5 
        percent (or 10 percent if the practitioner predominately 
        furnishes such services in an area that is designated (under 
        section 332(a)(1)(A) of the Public Health Service Act) as a 
        primary care health professional shortage area.
            ``(2) Primary care services defined.--In this subsection, 
        the term `primary care services'--
                    ``(A) mean evaluation and management services, 
                without regard to the specialty of the physician 
                furnishing the services, that are procedure codes (for 
                services covered under this title) for--
                            ``(i) services in the category designated 
                        Evaluation and Management in the Health Care 
                        Common Procedure Coding System (established by 
                        the Secretary under section 1848(c)(5) as of 
                        December 31, 2009, and as subsequently modified 
                        by the Secretary); and
                            ``(ii) preventive services (as defined in 
                        section 1861(iii) for which payment is made 
                        under this section; and
                    ``(B) includes services furnished by another health 
                care professional that would be described in 
                subparagraph (A) if furnished by a physician.
            ``(3) Primary care practitioner defined.--In this 
        subsection, the term `primary care practitioner'--
                    ``(A) means a physician or other health care 
                practitioner (including a nurse practitioner) who--
                            ``(i) specializes in family medicine, 
                        general internal medicine, general pediatrics, 
                        geriatrics, or obstetrics and gynecology; and
                            ``(ii) has allowed charges for primary care 
                        services that account for at least 50 percent 
                        of the physician's or practitioner's total 
                        allowed charges under section 1848, as 
                        determined by the Secretary for the most recent 
                        period for which data are available; and
                    ``(B) includes a physician assistant who is under 
                the supervision of a physician described in 
                subparagraph (A).
            ``(4) Limitation on review.--There shall be no 
        administrative or judicial review under section 1869, section 
        1878, or otherwise, respecting--
                    ``(A) any determination or designation under this 
                subsection;
                    ``(B) the identification of services as primary 
                care services under this subsection; and
                    ``(C) the identification of a practitioner as a 
                primary care practitioner under this subsection.
            ``(5) Coordination with other payments.--
                    ``(A) With other primary care incentives.--The 
                provisions of this subsection shall not be taken into 
                account in applying subsections (m) and (u) and any 
                payment under such subsections shall not be taken into 
                account in computing payments under this subsection.
                    ``(B) With quality incentives.--Payments under this 
                subsection shall not be taken into account in 
                determining the amounts that would otherwise be paid 
                under this part for purposes of section 
                1834(g)(2)(B).''.
    (b) Conforming Amendments.--
            (1) Section 1833(m) of such Act (42 U.S.C. 1395l(m)) is 
        amended by redesignating paragraph (4) as paragraph (5) and by 
        inserting after paragraph (3) the following new paragraph:
    ``(4) The provisions of this subsection shall not be taken into 
account in applying subsections (m) or (u) and any payment under such 
subsections shall not be taken into account in computing payments under 
this subsection.''.
            (2) Section 1848(m)(5)(B) of such Act (42 U.S.C. 1395w-
        4(m)(5)(B)) is amended by inserting ``, (p),'' after ``(m)''.
            (3) Section 1848(o)(1)(B)(iv) of such Act (42 U.S.C. 1395w-
        4(o)(1)(B)(iv)) is amended by inserting ``primary care'' before 
        ``health professional shortage area''.

SEC. 1304. INCREASED REIMBURSEMENT RATE FOR CERTIFIED NURSE-MIDWIVES.

    (a) In General.--Section 1833(a)(1)(K) of the Social Security Act 
(42 U.S.C.1395l(a)(1)(K)) is amended by striking ``(but in no event'' 
and all that follows through ``performed by a physician)''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to services furnished on or after January 1, 2011.

SEC. 1305. COVERAGE AND WAIVER OF COST-SHARING FOR PREVENTIVE SERVICES.

    (a) Medicare Covered Preventive Services Defined.--Section 1861 of 
the Social Security Act (42 U.S.C. 1395x), as amended by section 
1233(a)(1)(B), is amended by adding at the end the following new 
subsection:

                 ``Medicare Covered Preventive Services

    ``(iii)(1) Subject to the succeeding provisions of this subsection, 
the term `Medicare covered preventive services' means the following:
            ``(A) Prostate cancer screening tests (as defined in 
        subsection (oo)).
            ``(B) Colorectal cancer screening tests (as defined in 
        subsection (pp).
            ``(C) Diabetes outpatient self-management training services 
        (as defined in subsection (qq)).
            ``(D) Screening for glaucoma for certain individuals (as 
        described in subsection (s)(2)(U)).
            ``(E) Medical nutrition therapy services for certain 
        individuals (as described in subsection (s)(2)(V)).
            ``(F) An initial preventive physical examination (as 
        defined in subsection (ww)).
            ``(G) Cardiovascular screening blood tests (as defined in 
        subsection (xx)(1)).
            ``(H) Diabetes screening tests (as defined in subsection 
        (yy)).
            ``(I) Ultrasound screening for abdominal aortic aneurysm 
        for certain individuals (as described in subsection 
        (s)(2)(AA)).
            ``(J) Federally approved and recommended vaccines and their 
        administration as described in subsection (s)(10).
            ``(K) Screening mammography (as defined in subsection 
        (jj)).
            ``(L) Screening pap smear and screening pelvic exam (as 
        defined in subsection (nn)).
            ``(M) Bone mass measurement (as defined in subsection 
        (rr)).
            ``(N) Kidney disease education services (as defined in 
        subsection (ggg)).
            ``(O) Additional preventive services (as defined in 
        subsection (ddd)).
    ``(2) With respect to specific Medicare covered preventive 
services, the limitations and conditions described in the provisions 
referenced in paragraph (1) with respect to such services shall 
apply.''.
    (b) Payment and Elimination of Cost-sharing.--
            (1) In general.--
                    (A) In general.--Section 1833(a) of the Social 
                Security Act (42 U.S.C. 1395l(a)) is amended by adding 
                after and below paragraph (9) the following:
``With respect to Medicare covered preventive services, in any case in 
which the payment rate otherwise provided under this part is computed 
as a percent of less than 100 percent of an actual charge, fee schedule 
rate, or other rate, such percentage shall be increased to 100 
percent.''.
                    (B) Application to sigmoidoscopies and 
                colonoscopies.--Section 1834(d) of such Act (42 U.S.C. 
                1395m(d)) is amended--
                            (i) in paragraph (2)(C), by amending clause 
                        (ii) to read as follows:
                            ``(ii) No coinsurance.--In the case of a 
                        beneficiary who receives services described in 
                        clause (i), there shall be no coinsurance 
                        applied.''; and
                            (ii) in paragraph (3)(C), by amending 
                        clause (ii) to read as follows:
                            ``(ii) No coinsurance.--In the case of a 
                        beneficiary who receives services described in 
                        clause (i), there shall be no coinsurance 
                        applied.''.
            (2) Elimination of coinsurance in outpatient hospital 
        settings.--
                    (A) Exclusion from opd fee schedule.--Section 
                1833(t)(1)(B)(iv) of the Social Security Act (42 U.S.C. 
                1395l(t)(1)(B)(iv)) is amended by striking ``screening 
                mammography (as defined in section 1861(jj)) and 
                diagnostic mammography'' and inserting ``diagnostic 
                mammograms and Medicare covered preventive services (as 
                defined in section 1861(iii)(1))''.
                    (B) Conforming amendments.--Section 1833(a)(2) of 
                the Social Security Act (42 U.S.C. 1395l(a)(2)) is 
                amended--
                            (i) in subparagraph (F), by striking 
                        ``and'' after the semicolon at the end;
                            (ii) in subparagraph (G), by adding ``and'' 
                        at the end; and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(H) with respect to additional preventive 
                services (as defined in section 1861(ddd)) furnished by 
                an outpatient department of a hospital, the amount 
                determined under paragraph (1)(W);''.
            (3) Waiver of application of deductible for all preventive 
        services.--The first sentence of section 1833(b) of the Social 
        Security Act (42 U.S.C. 1395l(b)) is amended--
                    (A) in clause (1), by striking ``items and services 
                described in section 1861(s)(10)(A)'' and inserting 
                ``Medicare covered preventive services (as defined in 
                section 1861(iii))'';
                    (B) by inserting ``and'' before ``(4)''; and
                    (C) by striking clauses (5) through (8).
            (4) Application to providers of services.--Section 
        1866(a)(2)(A)(ii) of such Act (42 U.S.C. 1395cc(a)(2)(A)(ii)) 
        is amended by inserting ``other than for Medicare covered 
        preventive services and'' after ``for such items and services 
        (''.
    (c) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2011.
    (d) Preventive Services.--
            (1) Report to congress on barriers to preventive 
        services.--Not later than 12 months after the date of the 
        enactment of this Act, the Secretary of Health and Human 
        Services shall report to Congress on barriers, if any, facing 
        Medicare beneficiaries in accessing the benefit to abdominal 
        aortic aneurysm screening and other preventative services 
        through the Welcome to Medicare Physical Exam.
            (2) Abdominal aortic aneurysm screen access.--The Secretary 
        shall, to the extent practical, identify and implement policies 
        promoting proper use of abdominal aortic aneurysm screening 
        among Medicare beneficiaries at risk for such aneurysms.

SEC. 1306. WAIVER OF DEDUCTIBLE FOR COLORECTAL CANCER SCREENING TESTS 
              REGARDLESS OF CODING, SUBSEQUENT DIAGNOSIS, OR ANCILLARY 
              TISSUE REMOVAL.

    (a) In General.--Section 1833 of the Social Security Act (42 U.S.C. 
1395l(b)), as amended by section 1305(b), is further amended--
            (1) in subsection (a), in the sentence added by section 
        1305(b)(1)(A), by inserting ``(including services described in 
        the last sentence of section 1833(b))'' after ``preventive 
        services''; and
            (2) in subsection (b), by adding at the end the following 
        new sentence: ``Clause (1) of the first sentence of this 
        subsection shall apply with respect to a colorectal cancer 
        screening test regardless of the code that is billed for the 
        establishment of a diagnosis as a result of the test, or for 
        the removal of tissue or other matter or other procedure that 
        is furnished in connection with, as a result of, and in the 
        same clinical encounter as, the screening test.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to items and services furnished on or after January 1, 2011.

SEC. 1307. EXCLUDING CLINICAL SOCIAL WORKER SERVICES FROM COVERAGE 
              UNDER THE MEDICARE SKILLED NURSING FACILITY PROSPECTIVE 
              PAYMENT SYSTEM AND CONSOLIDATED PAYMENT.

    (a) In General.--Section 1888(e)(2)(A)(ii) of the Social Security 
Act (42 U.S.C. 1395yy(e)(2)(A)(ii)) is amended by inserting ``clinical 
social worker services,'' after ``qualified psychologist services,''.
    (b) Conforming Amendment.--Section 1861(hh)(2) of the Social 
Security Act (42 U.S.C. 1395x(hh)(2)) is amended by striking ``and 
other than services furnished to an inpatient of a skilled nursing 
facility which the facility is required to provide as a requirement for 
participation''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after October 1, 2010.

SEC. 1308. COVERAGE OF MARRIAGE AND FAMILY THERAPIST SERVICES AND 
              MENTAL HEALTH COUNSELOR SERVICES.

    (a) Coverage of Marriage and Family Therapist Services.--
            (1) Coverage of services.--Section 1861(s)(2) of the Social 
        Security Act (42 U.S.C. 1395x(s)(2)), as amended by section 
        1235, is amended--
                    (A) in subparagraph (EE), by striking ``and'' at 
                the end;
                    (B) in subparagraph (FF), by adding ``and'' at the 
                end; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(GG) marriage and family therapist services (as 
                defined in subsection (jjj));''.
            (2) Definition.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x), as amended by sections 1233 and 1305, is 
        amended by adding at the end the following new subsection:

                ``Marriage and Family Therapist Services

    ``(jjj)(1) The term `marriage and family therapist services' means 
services performed by a marriage and family therapist (as defined in 
paragraph (2)) for the diagnosis and treatment of mental illnesses, 
which the marriage and family therapist is legally authorized to 
perform under State law (or the State regulatory mechanism provided by 
State law) of the State in which such services are performed, as would 
otherwise be covered if furnished by a physician or as incident to a 
physician's professional service, but only if no facility or other 
provider charges or is paid any amounts with respect to the furnishing 
of such services.
    ``(2) The term `marriage and family therapist' means an individual 
who--
            ``(A) possesses a master's or doctoral degree which 
        qualifies for licensure or certification as a marriage and 
        family therapist pursuant to State law;
            ``(B) after obtaining such degree has performed at least 2 
        years of clinical supervised experience in marriage and family 
        therapy; and
            ``(C) is licensed or certified as a marriage and family 
        therapist in the State in which marriage and family therapist 
        services are performed.''.
            (3) Provision for payment under part b.--Section 
        1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
        1395k(a)(2)(B)) is amended by adding at the end the following 
        new clause:
                            ``(v) marriage and family therapist 
                        services;''.
            (4) Amount of payment.--
                    (A) In general.--Section 1833(a)(1) of the Social 
                Security Act (42 U.S.C. 1395l(a)(1)) is amended--
                            (i) by striking ``and'' before ``(W)''; and
                            (ii) by inserting before the semicolon at 
                        the end the following: ``, and (X) with respect 
                        to marriage and family therapist services under 
                        section 1861(s)(2)(GG), the amounts paid shall 
                        be 80 percent of the lesser of the actual 
                        charge for the services or 75 percent of the 
                        amount determined for payment of a psychologist 
                        under clause (L)''.
                    (B) Development of criteria with respect to 
                consultation with a health care professional.--The 
                Secretary of Health and Human Services shall, taking 
                into consideration concerns for patient 
                confidentiality, develop criteria with respect to 
                payment for marriage and family therapist services for 
                which payment may be made directly to the marriage and 
                family therapist under part B of title XVIII of the 
                Social Security Act (42 U.S.C. 1395j et seq.) under 
                which such a therapist must agree to consult with a 
                patient's attending or primary care physician or nurse 
                practitioner in accordance with such criteria.
            (5) Exclusion of marriage and family therapist services 
        from skilled nursing facility prospective payment system.--
        Section 1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
        1395yy(e)(2)(A)(ii)), as amended by section 1307(a), is amended 
        by inserting ``marriage and family therapist services (as 
        defined in subsection (jjj)(1)),'' after ``clinical social 
        worker services,''.
            (6) Coverage of marriage and family therapist services 
        provided in rural health clinics and federally qualified health 
        centers.--Section 1861(aa)(1)(B) of the Social Security Act (42 
        U.S.C. 1395x(aa)(1)(B)) is amended by striking ``or by a 
        clinical social worker (as defined in subsection (hh)(1)),'' 
        and inserting ``, by a clinical social worker (as defined in 
        subsection (hh)(1)), or by a marriage and family therapist (as 
        defined in subsection (jjj)(2)),''.
            (7) Inclusion of marriage and family therapists as 
        practitioners for assignment of claims.--Section 1842(b)(18)(C) 
        of the Social Security Act (42 U.S.C. 1395u(b)(18)(C)) is 
        amended by adding at the end the following new clause:
            ``(vii) A marriage and family therapist (as defined in 
        section 1861(jjj)(2)).''.
    (b) Coverage of Mental Health Counselor Services.--
            (1) Coverage of services.--Section 1861(s)(2) of the Social 
        Security Act (42 U.S.C. 1395x(s)(2)), as previously amended, is 
        further amended--
                    (A) in subparagraph (FF), by striking ``and'' at 
                the end;
                    (B) in subparagraph (GG), by inserting ``and'' at 
                the end; and
                    (C) by adding at the end the following new 
                subparagraph:
            ``(HH) mental health counselor services (as defined in 
        subsection (kkk)(1));''.
            (2) Definition.--Section 1861 of the Social Security Act 
        (42 U.S.C. 1395x), as previously amended, is amended by adding 
        at the end the following new subsection:

                   ``Mental Health Counselor Services

    ``(kkk)(1) The term `mental health counselor services' means 
services performed by a mental health counselor (as defined in 
paragraph (2)) for the diagnosis and treatment of mental illnesses 
which the mental health counselor is legally authorized to perform 
under State law (or the State regulatory mechanism provided by the 
State law) of the State in which such services are performed, as would 
otherwise be covered if furnished by a physician or as incident to a 
physician's professional service, but only if no facility or other 
provider charges or is paid any amounts with respect to the furnishing 
of such services.
    ``(2) The term `mental health counselor' means an individual who--
            ``(A) possesses a master's or doctor's degree which 
        qualifies the individual for licensure or certification for the 
        practice of mental health counseling in the State in which the 
        services are performed;
            ``(B) after obtaining such a degree has performed at least 
        2 years of supervised mental health counselor practice; and
            ``(C) is licensed or certified as a mental health counselor 
        or professional counselor by the State in which the services 
        are performed.''.
            (3) Provision for payment under part b.--Section 
        1832(a)(2)(B) of the Social Security Act (42 U.S.C. 
        1395k(a)(2)(B)), as amended by subsection (a)(3), is further 
        amended--
                    (A) by striking ``and'' at the end of clause (iv);
                    (B) by adding ``and'' at the end of clause (v); and
                    (C) by adding at the end the following new clause:
                            ``(vi) mental health counselor services;''.
            (4) Amount of payment.--
                    (A) In general.--Section 1833(a)(1) of the Social 
                Security Act (42 U.S.C. 1395l(a)(1)), as amended by 
                subsection (a), is further amended--
                            (i) by striking ``and'' before ``(X)''; and
                            (ii) by inserting before the semicolon at 
                        the end the following: ``, and (Y), with 
                        respect to mental health counselor services 
                        under section 1861(s)(2)(HH), the amounts paid 
                        shall be 80 percent of the lesser of the actual 
                        charge for the services or 75 percent of the 
                        amount determined for payment of a psychologist 
                        under clause (L)''.
                    (B) Development of criteria with respect to 
                consultation with a physician.--The Secretary of Health 
                and Human Services shall, taking into consideration 
                concerns for patient confidentiality, develop criteria 
                with respect to payment for mental health counselor 
                services for which payment may be made directly to the 
                mental health counselor under part B of title XVIII of 
                the Social Security Act (42 U.S.C. 1395j et seq.) under 
                which such a counselor must agree to consult with a 
                patient's attending or primary care physician in 
                accordance with such criteria.
            (5) Exclusion of mental health counselor services from 
        skilled nursing facility prospective payment system.--Section 
        1888(e)(2)(A)(ii) of the Social Security Act (42 U.S.C. 
        1395yy(e)(2)(A)(ii)), as amended by section 1307(a) and 
        subsection (a), is amended by inserting ``mental health 
        counselor services (as defined in section 1861(kkk)(1)),'' 
        after ``marriage and family therapist services (as defined in 
        subsection (jjj)(1)),''.
            (6) Coverage of mental health counselor services provided 
        in rural health clinics and federally qualified health 
        centers.--Section 1861(aa)(1)(B) of the Social Security Act (42 
        U.S.C. 1395x(aa)(1)(B)), as amended by subsection (a), is 
        amended by striking ``or by a marriage and family therapist (as 
        defined in subsection (jjj)(2)),'' and inserting ``by a 
        marriage and family therapist (as defined in subsection 
        (jjj)(2)), or a mental health counselor (as defined in 
        subsection (kkk)(2)),''.
            (7) Inclusion of mental health counselors as practitioners 
        for assignment of claims.--Section 1842(b)(18)(C) of the Social 
        Security Act (42 U.S.C. 1395u(b)(18)(C)), as amended by 
        subsection (a)(7), is amended by adding at the end the 
        following new clause:
            ``(viii) A mental health counselor (as defined in section 
        1861(kkk)(2)).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after January 1, 2011.

SEC. 1309. EXTENSION OF PHYSICIAN FEE SCHEDULE MENTAL HEALTH ADD-ON.

    Section 138(a)(1) of the Medicare Improvements for Patients and 
Providers Act of 2008 (Public Law 110-275) is amended by striking 
``December 31, 2009'' and inserting ``December 31, 2011''.

SEC. 1310. EXPANDING ACCESS TO VACCINES.

    (a) In General.--Paragraph (10) of section 1861(s) of the Social 
Security Act (42 U.S.C. 1395w(s)) is amended to read as follows:
            ``(10) federally approved and recommended vaccines (as 
        defined in subsection (lll)) and their respective 
        administration;''.
    (b) Federally Approved and Recommended Vaccines Defined.--Section 
1861 of such Act is further amended by adding at the end the following 
new subsection:

             ``Federally Approved and Recommended Vaccines

    ``(lll) The term `federally approved and recommended vaccine' means 
a vaccine that--
            ``(1) is licensed under section 351 of the Public Health 
        Service Act, approved under the Federal Food, Drug, and 
        Cosmetic Act, or authorized for emergency use under section 564 
        of the Federal, Food, Drug, and Cosmetic Act; and
            ``(2) is recommended by the Director of the Centers for 
        Disease Control and Prevention.''.
    (c) Conforming Amendments.--
            (1) Section 1833 of such Act (42 U.S.C. 1395l) is amended, 
        in each of subsections (a)(1)(B), (a)(2)(G), and (a)(3)(A), by 
        striking ``1861(s)(10)(A)'' and inserting ``1861(s)(10)'' each 
        place it appears.
            (2) Section 1842(o)(1)(A)(iv) of such Act (42 U.S.C. 
        1395u(o)(1)(A)(iv)) is amended--
                    (A) by striking ``subparagraph (A) or (B) of''; and
                    (B) by inserting before the period the following: 
                ``and before January 1, 2011, and influenza vaccines 
                furnished on or after January 1, 2011''.
            (3) Section 1847A(c)(6) of such Act (42 U.S.C. 1395w-
        3a(c)(6)) is amended--
                    (A) in subparagraph (D)(i), by inserting ``, 
                including a vaccine furnished on or after January 1, 
                2010''; and
                    (B) by the following new paragraph:
                    ``(H) Implementation.--Chapter 35 of title 44, 
                United States Code shall not apply to manufacturer 
                provision of information pursuant to section 
                1927(b)(3)(A)(iii) or subsection (f)(2) for purposes of 
                implementation of this section.''.
            (4) Section 1860D-2(e)(1) of such Act (42 U.S.C. 1395w-
        102(e)(1)) is amended by striking ``such term includes a 
        vaccine'' and all that follows through ``its administration) 
        and''.
            (5) Section 1861(ww)(2)(A) of such Act (42 U.S.C. 
        1395x(ww)(2)(A))) is amended by striking ``Pneumococcal, 
        influenza, and hepatitis B vaccine and administration'' and 
        inserting ``federally approved or authorized vaccines (as 
        defined in subsection (lll)) and their respective 
        administration''.
            (6) Section 1927(b)(3)(A)(iii) of such Act (42 U.S.C. 
        1396r-8(b)(3)(A)(iii)) is amended, in the matter following 
        subclause (III), by inserting ``(A)(iv) (including influenza 
        vaccines furnished on or after January 1, 2011),'' after 
        ``described in subparagraph''.
            (7) Section 1847A(f) of such Act (42 U.S.C. 1395w-3a(f)) is 
        amended--
                    (A) by striking ``For'' and inserting ``(1) In 
                general.--For'';
                    (B) by indenting paragraph (1), as redesignated in 
                subparagraph (A), 2 ems to the left; and--
                    (C) by adding at the end the following new 
                paragraph:
            ``(2) Treatment of certain manufacturers.--In the case of a 
        manufacturer of a drug or biological described in subparagraphs 
        (A)(iv), (C), (D), (E), or (G) of section 1842(o)(1) that does 
        not have a rebate agreement under section 1927(a), no payment 
        may be made under this part for such drug or biological if such 
        manufacturer does not submit the information described in 
        section 1927(b)(3)(A)(iii) in the same manner as if the 
        manufacturer had such a rebate agreement in effect. 
        Subparagraphs (C) and (D) of section 1927(b)(3) shall apply to 
        information reported pursuant to the previous sentence in the 
        same manner as such subparagraphs apply with respect to 
        information reported pursuant to such section.''.''.
    (d) Effective Dates.--The amendments made--
            (1) by this section (other than by subsection (c)(6)) shall 
        apply to vaccines administered on or after January 1, 2011; and
            (2) by subsection (c)(6) shall apply to calendar quarters 
        beginning on or after January 1, 2010.

SEC. 1311. EXPANSION OF MEDICARE-COVERED PREVENTIVE SERVICES AT 
              FEDERALLY QUALIFIED HEALTH CENTERS.

    (a) In General.--Section 1861(aa)(3)(A) of the Social Security Act 
(42 U.S.C. 1395w (aa)(3)(A)) is amended to read as follows:             
  
                    ``(A) services of the type described subparagraphs 
                (A) through (C) of paragraph (1) and services described 
                in section 1861(iii); and''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply not later than January 1, 2011.

SEC. 1312. INDEPENDENCE AT HOME DEMONSTRATION PROGRAM.

    Title XVIII of the Social Security Act is amended by inserting 
after section 1866F, as inserted by section 1302, the following new 
section:

     ``independence at home medical practice demonstration program

    ``Sec. 1866G.  (a) Establishment.--
            ``(1) In general.--The Secretary shall conduct a 
        demonstration program (in this section referred to as the 
        `demonstration program') to test a payment incentive and 
        service delivery model that utilizes physician and nurse 
        practitioner directed home-based primary care teams designed to 
        reduce expenditures and improve health outcomes in the 
        provision of items and services under this title to applicable 
        beneficiaries (as defined in subsection (d)).
            ``(2) Requirement.--The demonstration program shall test 
        whether a model described in paragraph (1), which is 
        accountable for providing comprehensive, coordinated, 
        continuous, and accessible care to high-need populations at 
        home and coordinating health care across all treatment 
        settings, results in--
                    ``(A) reducing preventable hospitalizations;
                    ``(B) preventing hospital readmissions;
                    ``(C) reducing emergency room visits;
                    ``(D) improving health outcomes commensurate with 
                the beneficiaries' stage of chronic illness;
                    ``(E) improving the efficiency of care, such as by 
                reducing duplicative diagnostic and laboratory tests;
                    ``(F) reducing the cost of health care services 
                covered under this title; and
                    ``(G) achieving beneficiary and family caregiver 
                satisfaction.
    ``(b) Independence at Home Medical Practice.--
            ``(1) Independence at home medical practice defined.--In 
        this section:
                    ``(A) In general.--The term `independence at home 
                medical practice' means a legal entity that--
                            ``(i) is comprised of an individual 
                        physician or nurse practitioner or group of 
                        physicians and nurse practitioners that 
                        provides care as part of a team that includes 
                        physicians, nurses, physician assistants, 
                        pharmacists, and other health and social 
                        services staff as appropriate who have 
                        experience providing home-based primary care to 
                        applicable beneficiaries, make in-home visits, 
                        and are available 24 hours per day, 7 days per 
                        week to carry out plans of care that are 
                        tailored to the individual beneficiary's 
                        chronic conditions and designed to achieve the 
                        results in subsection (a);
                            ``(ii) is organized at least in part for 
                        the purpose of providing physicians' services;
                            ``(iii) has documented experience in 
                        providing home-based primary care services to 
                        high cost chronically ill beneficiaries, as 
                        determined appropriate by the Secretary;
                            ``(iv) includes at least 200 applicable 
                        beneficiaries as defined in subsection (d);
                            ``(v) has entered into an agreement with 
                        the Secretary;
                            ``(vi) uses electronic health information 
                        systems, remote monitoring, and mobile 
                        diagnostic technology; and
                            ``(vii) meets such other criteria as the 
                        Secretary determines to be appropriate to 
                        participate in the demonstration program.
                    ``(B) Physician.--The term `physician' includes, 
                except as the Secretary may otherwise provide, any 
                individual who furnishes services for which payment may 
                be made as physicians' services and has the medical 
                training or experience to fulfill the physician's role 
                described in subparagraph (A)(i).
            ``(2) Participation of nurse practitioners and physician 
        assistants.--Nothing in this section shall be construed to 
        prevent a nurse practitioner or physician assistant from 
        participating in, or leading, a home-based primary care team as 
        part of an independence at home medical practice if--
                    ``(A) all the requirements of this section are met;
                    ``(B) the nurse practitioner or physician 
                assistant, as the case may be, is acting consistent 
                with State law; and
                    ``(C) the nurse practitioner or physician assistant 
                has the medical training or experience to fulfill the 
                nurse practitioner or physician assistant role 
                described in paragraph (1)(A)(i).
            ``(3) Inclusion of providers and practitioners.--Nothing in 
        this subsection shall be construed as preventing an 
        independence at home medical practice from including a provider 
        of services or a participating practitioner described in 
        section 1842(b)(18)(C) that is affiliated with the practice 
        under an arrangement structured so that such provider of 
        services or practitioner participates in the demonstration 
        program and shares in any savings under the demonstration 
        program.
            ``(4) Quality and performance standards.--
                    ``(A) In general.--An independence at home medical 
                practice participating in the demonstration program 
                shall report on quality measures (in such form, manner, 
                and frequency as specified by the Secretary, which may 
                be for the group, for providers of services and 
                suppliers, or both) and report to the Secretary (in a 
                form, manner, and frequency as specified by the 
                Secretary) such data as the Secretary determines 
                appropriate to monitor and evaluate the demonstration 
                program.
                    ``(B) Development of quality performance 
                standards.--The Secretary shall develop quality 
                performance standards for independence at home medical 
                practices participating in the demonstration program.
    ``(c) Shared Savings Payment Methodology.--
            ``(1) Establishment of target spending level.--The 
        Secretary shall establish annual target spending levels for 
        items and services covered under parts A and B furnished to 
        applicable beneficiaries by qualifying independence at home 
        medical practices under this section. The Secretary may set an 
        aggregate target spending level for all qualifying practices, 
        or may set different target spending levels for groups of 
        practices or a single practice. Such target spending levels may 
        be determined on a per capita basis and shall take into account 
        normal variation in expenditures for items and services covered 
        under parts A and B furnished to such beneficiaries. The target 
        shall also be adjusted for the size of the practice, number of 
        practices included in the target spending level, 
        characteristics of applicable beneficiaries and such other 
        factors as the Secretary determines appropriate. The Secretary 
        may periodically adjust or rebase the target spending level 
        under this paragraph.
            ``(2) Shared savings amounts.--
                    ``(A) In general.--Subject to subparagraph (B), 
                qualifying independence at home medical practices are 
                eligible to receive an incentive payment under this 
                section if aggregate expenditures for a year for 
                applicable beneficiaries are less than the target 
                spending level for qualifying independence at home 
                medical practices for such year. An incentive payment 
                for such year shall be equal to a portion (as 
                determined by the Secretary) of the amount by which 
                total payments for applicable beneficiaries under parts 
                A and B for such year are estimated to be less than 5 
                percent less than the target spending level for such 
                year, as determined by the Secretary.
                    ``(B) Apportionment of savings.--The Secretary 
                shall designate how, and to what extent, an incentive 
                payment under this section is to be apportioned among 
                qualifying independence at home medical practices, 
                taking into account the size of the practice, 
                characteristics of the individuals enrolled in each 
                practice, performance on quality performance measures, 
                and such other factors as the Secretary determines 
                appropriate.
            ``(3) Savings to the medicare program.--The Secretary shall 
        limit incentive payments to each qualifying independence at 
        home medical practice under this paragraph, with respect to a 
        year, as necessary to ensure that the aggregate expenditures 
        for items and services under parts A and B with respect to 
        applicable beneficiaries for such independence at home medical 
        practice (inclusive of shared savings payments) do not exceed 
        the amount that the Secretary estimates would be expended for 
        such items and services for such beneficiaries during such year 
        (taking into account normal variation in expenditures and other 
        factors the Secretary deems appropriate) if the demonstration 
        program under this section were not implemented, minus 5 
        percent.
    ``(d) Applicable Beneficiaries.--
            ``(1) Definition.--In this section, the term `applicable 
        beneficiary' means, with respect to a qualifying independence 
        at home medical practice, an individual who the practice has 
        determined--
                    ``(A) is entitled to benefits under part A and 
                enrolled for benefits under part B;
                    ``(B) is not enrolled in a Medicare Advantage plan 
                under part C or a PACE program under section 1894;
                    ``(C) has 2 or more chronic illnesses, such as 
                congestive heart failure, diabetes, other dementias 
                designated by the Secretary, chronic obstructive 
                pulmonary disease, ischemic heart disease, stroke, 
                Alzheimer's Disease and neurodegenerative diseases, and 
                other diseases and conditions designated by the 
                Secretary which result in high costs under this title;
                    ``(D) within the past 12 months has had a 
                nonelective hospital admission;
                    ``(E) within the past 12 months has received acute 
                or subacute rehabilitation services;
                    ``(F) has 2 or more functional dependencies 
                requiring the assistance of another person (such as 
                bathing, dressing, toileting, walking, or feeding); and
                    ``(G) meets such other criteria as the Secretary 
                determines appropriate.
            ``(2) Patient election to participate.--The Secretary shall 
        determine an appropriate method of ensuring that applicable 
        beneficiaries have agreed to enroll in an independence at home 
        medical practice under the demonstration program. Enrollment in 
        the demonstration program shall be voluntary.
            ``(3) Beneficiary access to services.--Nothing in this 
        section shall be construed as encouraging physicians or nurse 
        practitioners to limit applicable beneficiary access to 
        services covered under this title and applicable beneficiaries 
        shall not be required to relinquish access to any benefit under 
        this title as a condition of receiving services from an 
        independence at home medical practice.
    ``(e) Implementation.--
            ``(1) Starting date.--The demonstration program shall begin 
        not later than January 1, 2012. An agreement with an 
        independence at home medical practice under the demonstration 
        program may cover not more than a 3-year period.
            ``(2) No physician duplication in demonstration 
        participation.--The Secretary shall not pay an independence at 
        home medical practice under this section that participates in 
        section 1866D or section 1866E.
            ``(3) No beneficiary duplication in demonstration 
        participation.--The Secretary shall ensure that no applicable 
        beneficiary enrolled in an independence at home medical 
        practice under this section is participating in the programs 
        under section 1866D or section 1866E.
            ``(4) Preference.--In approving an independence at home 
        medical practice, the Secretary shall give preference to 
        practices that are--
                    ``(A) located in high-cost areas of the country;
                    ``(B) have experience in furnishing health care 
                services to applicable beneficiaries in the home; and
                    ``(C) use electronic medical records, health 
                information technology, and individualized plans of 
                care.
            ``(5) Number of practices.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                Secretary shall enter into agreements with as many 
                independence at home medial practices as practicable 
                and consistent with this subsection to test the 
                potential of the independence at home medical practice 
                model under this section in order to achieve the 
                results described in subsection (a) across practices 
                serving varying numbers of applicable beneficiaries.
                    ``(B) Limitation.--In selecting qualified 
                independence at home medial practices to participate 
                under the demonstration program, the Secretary shall 
                limit the number of applicable beneficiaries that may 
                participate in the demonstration program to 10,000.
            ``(6) Waiver.--The Secretary may waive such provisions of 
        this title and title XI as the Secretary determines necessary 
        in order to implement the demonstration program.
            ``(7) Administration.--Chapter 35 of title 44, United 
        States Code, shall not apply to this section.
    ``(f) Evaluation and Monitoring.--
            ``(1) In general.--The Secretary shall evaluate each 
        independence at home medical practice under the demonstration 
        program to assess whether the practice achieved the results 
        described in subsection (a).
            ``(2) Following applicable beneficiaries.--The Secretary 
        may monitor data on expenditures and quality of services under 
        this title after an applicable beneficiary discontinues 
        receiving services under this title through a qualifying 
        independence at home medical practice.
    ``(g) Reports to Congress.--The Secretary shall conduct an 
independent evaluation of the demonstration program and submit to 
Congress a final report, including best practices under the 
demonstration program. Such report shall include an analysis of the 
demonstration program on coordination of care, expenditures under this 
title, applicable beneficiary access to services, and the quality of 
health care services provided to applicable beneficiaries.
    ``(h) Funding.--For purposes of administering and carrying out the 
demonstration program, other than for payments for items and services 
furnished under this title and shared savings under subsection (c), in 
addition to funds otherwise appropriated, there shall be transferred to 
the Secretary for the Center for Medicare & Medicaid Services Program 
Management Account from the Federal Hospital Insurance Trust Fund under 
section 1817 and the Federal Supplementary Medical Insurance Trust Fund 
under section 1841 $5,000,000 for each of fiscal years 2010 through 
2015. Amounts transferred under this subsection for a fiscal year shall 
be available until expended.
    ``(i) Antidiscrimination Limitation.--The Secretary shall not enter 
into an agreement with an entity to provide health care items or 
services under the demonstration program unless such entity guarantees 
that for individuals eligible to be enrolled in such program, the 
entity will not deny, limit, or condition the coverage or provision of 
benefits to which the individual would have otherwise been entitled to 
on the basis of health status if not included in this program.
    ``(j) Termination.--The Secretary may terminate an agreement with 
an independence at home medical practice if such practice does not 
receive incentive payments under subsection (c)(2) or consistently 
fails to meet quality standards.''.

SEC. 1313. RECOGNITION OF CERTIFIED DIABETES EDUCATORS AS CERTIFIED 
              PROVIDERS FOR PURPOSES OF MEDICARE DIABETES OUTPATIENT 
              SELF-MANAGEMENT TRAINING SERVICES.

    (a) In General.--Section 1861(qq) of the Social Security Act (42 
U.S.C. 1395x(qq)) is amended--
            (1) in paragraph (1), by inserting ``or by a certified 
        diabetes educator (as defined in paragraph (3))'' after 
        ``paragraph (2)(B)''; and
            (2) by adding at the end the following new paragraphs:
            ``(3) For purposes of paragraph (1), the term `certified 
        diabetes educator' means an individual who--
                    ``(A) is licensed or registered by the State in 
                which the services are performed as a health care 
                professional;
                    ``(B) specializes in teaching individuals with 
                diabetes to develop the necessary skills and knowledge 
                to manage the individual's diabetic condition; and
                    ``(C) is certified as a diabetes educator by a 
                recognized certifying body (as defined in paragraph 
                (4)).
            ``(4)(A) For purposes of paragraph (3)(C), the term 
        `recognized certifying body' means--
                    ``(i) the National Certification Board for Diabetes 
                Educators, or
                    ``(ii) a certifying body for diabetes educators, 
                which is recognized by the Secretary as authorized to 
                grant certification of diabetes educators for purposes 
                of this subsection pursuant to standards established by 
                the Secretary, if the Secretary determines such Board 
                or body, respectively, meets the requirement of 
                subparagraph (B).
            ``(B) The National Certification Board for Diabetes 
        Educators or a certifying body for diabetes educators meets the 
        requirement of this subparagraph, with respect to the 
        certification of an individual, if the Board or body, 
        respectively, is incorporated and registered to do business in 
        the United States and requires as a condition of such 
        certification each of the following:
                    ``(i) The individual has a qualifying credential in 
                a specified health care profession.
                    ``(ii) The individual has professional practice 
                experience in diabetes self-management training that 
                includes a minimum number of hours and years of 
                experience in such training.
                    ``(iii) The individual has successfully completed a 
                national certification examination offered by such 
                entity.
                    ``(iv) The individual periodically renews 
                certification status following initial 
                certification.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to diabetes outpatient self-management training services 
furnished on or after the first day of the first calendar year that is 
at least 6 months after the date of the enactment of this Act.

                           TITLE IV--QUALITY

             Subtitle A--Comparative Effectiveness Research

SEC. 1401. COMPARATIVE EFFECTIVENESS RESEARCH.

    (a) In General.--Title XI of the Social Security Act is amended by 
adding at the end the following new part:

              ``Part D--Comparative Effectiveness Research

                  ``comparative effectiveness research

    ``Sec. 1181.  (a) Center for Comparative Effectiveness Research 
Established.--
            ``(1) In general.--The Secretary shall establish within the 
        Agency for Healthcare Research and Quality a Center for 
        Comparative Effectiveness Research (in this section referred to 
        as the `Center') to conduct, support, and synthesize research 
        (including research conducted or supported under section 1013 
        of the Medicare Prescription Drug, Improvement, and 
        Modernization Act of 2003) with respect to the outcomes, 
        effectiveness, and appropriateness of health care services and 
        procedures in order to identify the manner in which diseases, 
        disorders, and other health conditions can most effectively and 
        appropriately be prevented, diagnosed, treated, and managed 
        clinically.
            ``(2) Duties.--The Center shall--
                    ``(A) conduct, support, and synthesize research 
                relevant to the comparative effectiveness of the full 
                spectrum of health care items, services and systems, 
                including pharmaceuticals, medical devices, medical and 
                surgical procedures, and other medical interventions;
                    ``(B) conduct and support systematic reviews of 
                clinical research, including original research 
                conducted subsequent to the date of the enactment of 
                this section;
                    ``(C) continuously develop rigorous scientific 
                methodologies for conducting comparative effectiveness 
                studies, and use such methodologies appropriately;
                    ``(D) submit to the Comparative Effectiveness 
                Research Commission, the Secretary, and Congress 
                appropriate relevant reports described in subsection 
                (d)(2);
                    ``(E) not later than one year after the date of the 
                enactment of this section, enter into an arrangement 
                under which the Institute of Medicine of the National 
                Academy of Sciences shall conduct an evaluation and 
                report on standards of evidence for highly credible 
                research;
                    ``(F) encourage, as appropriate, the development 
                and use of clinical registries and the development of 
                clinical effectiveness research data networks from 
                electronic health records, post marketing drug and 
                medical device surveillance efforts, and other forms of 
                electronic health data; and
                    ``(G) appoint clinical perspective advisory panels 
                for research priorities under this section, which shall 
                consult with patients and other stakeholders and advise 
                the Center on research questions, methods, and evidence 
                gaps in terms of clinical outcomes for the specific 
                research inquiry to be examined with respect to such 
                priority to ensure that the information produced from 
                such research is clinically relevant to decisions made 
                by clinicians and patients at the point of care.
            ``(3) Powers.--
                    ``(A) Obtaining official data.--The Center may 
                secure directly from any department or agency of the 
                United States information necessary to enable it to 
                carry out this section. Upon request of the Center, the 
                head of such department or agency shall furnish that 
                information to the Center on an agreed upon schedule.
                    ``(B) Data collection.--In order to carry out its 
                functions, the Center shall--
                            ``(i) utilize existing information, both 
                        published and unpublished, where possible, 
                        collected and assessed either by its own staff 
                        or under other arrangements made in accordance 
                        with this section;
                            ``(ii) carry out, or award grants or 
                        contracts for, original research and 
                        experimentation, where existing information is 
                        inadequate; and
                            ``(iii) adopt procedures allowing any 
                        interested party to submit information for the 
                        use by the Center in making reports and 
                        recommendations.
                In carrying out clause (ii), the Center may award 
                grants or contracts (or provide for intergovernmental 
                transfers, as applicable) to private entities and 
                governmental agencies with experience in conducting 
                comparative effectiveness research, such as the 
                National Institutes of Health and other relevant 
                Federal health agencies.
                    ``(C) Access of gao to information.--The 
                Comptroller General shall have unrestricted access to 
                all deliberations, records, and nonproprietary data of 
                the Center and Commission under subsection (b), 
                immediately upon request.
                    ``(D) Periodic audit.--The Center and Commission 
                under subsection (b) shall be subject to periodic audit 
                by the Comptroller General.
    ``(b) Comparative Effectiveness Research Commission.--
            ``(1) In general.--There is established an independent 
        Comparative Effectiveness Research Commission (in this section 
        referred to as the `Commission') to advise the Center and 
        evaluate the activities carried out by the Center under 
        subsection (a) to ensure such activities result in highly 
        credible research and information resulting from such research.
            ``(2) Duties.--The Commission shall--
                    ``(A)(i) recommend to the Center national 
                priorities for research described in subsection (a) 
                which shall take into account--
                            ``(I) disease incidence, prevalence, and 
                        burden in the United States;
                            ``(II) evidence gaps in terms of clinical 
                        outcomes;
                            ``(III) variations in practice, delivery, 
                        and outcomes by geography, treatment site, 
                        provider type, disability, variation in age 
                        group (including children, adolescents, adults, 
                        and seniors), racial and ethnic background, 
                        gender, genetic and molecular subtypes, and 
                        other appropriate populations or 
                        subpopulations; and
                            ``(IV) the potential for new evidence 
                        concerning certain categories, health care 
                        services, or treatments to improve patient 
                        health and well-being, and the quality of care; 
                        and
                    ``(ii) in making such recommendations consult with 
                a broad array of public and private stakeholders, 
                including patients and health care providers and 
                payers;
                    ``(B) monitor the appropriateness of use of the 
                CERTF described in subsection (g) with respect to the 
                timely production of comparative effectiveness research 
                recommended to be a national priority under 
                subparagraph (A);
                    ``(C) identify highly credible research methods and 
                standards of evidence for such research to be 
                considered by the Center;
                    ``(D) review the methodologies developed by the 
                center under subsection (a)(2)(C);
                    ``(E) support forums to increase stakeholder 
                awareness and permit stakeholder feedback on the 
                efforts of the Center to advance methods and standards 
                that promote highly credible research;
                    ``(F) make recommendations to the Center for 
                policies that would allow for public access of data 
                produced under this section, in accordance with 
                appropriate privacy and proprietary practices, while 
                ensuring that the information produced through such 
                data is timely and credible;
                    ``(G) make recommendations to the Center for the 
                priority for periodic reviews of previous comparative 
                effectiveness research and studies conducted by the 
                Center under subsection (a);
                    ``(H) at least annually review the processes of the 
                Center and make reports to Congress and the President 
                regarding research conducted, supported, or synthesized 
                by the Center to confirm that the information produced 
                by such research is objective, credible, consistent 
                with standards of evidence developed under this 
                section, and developed through a transparent process 
                that includes consultations with appropriate 
                stakeholders;
                    ``(I) make recommendations to the Center for the 
                broad dissemination, consistent with subsection (e), of 
                the findings of research conducted and supported under 
                this section that enables clinicians, patients, 
                consumers, and payers to make more informed health care 
                decisions that improve quality and value; and
                    ``(J) at least twice each year, hold a public 
                meeting with an opportunity for stakeholder input.
        The reports under subparagraph (H) shall not be submitted to 
        the Office of Management and Budget or to any other Federal 
        agency or executive department for any purpose prior to 
        transmittal to Congress and the President. Such reports shall 
        be published on the public internet website of the Commission 
        after the date of such transmittal.
            ``(3) Composition of commission.--
                    ``(A) In general.--The members of the Commission 
                shall consist of--
                            ``(i) the Director of the Agency for 
                        Healthcare Research and Quality or their 
                        designee;
                            ``(ii) the Chief Medical Officer of the 
                        Centers for Medicare & Medicaid Services or 
                        their designee;
                            ``(iii) the Director of the National 
                        Institutes of Health or their designee; and
                            ``(iv) 16 additional members who shall 
                        represent broad constituencies of stakeholders 
                        including clinicians, patients, researchers, 
                        third-party payers, and consumers of Federal 
                        and State beneficiary programs.
                Of such members, at least 10 shall be practicing 
                physicians, health care practitioners, consumers, or 
                patients.
                    ``(B) Qualifications.--
                            ``(i) Diverse representation of 
                        perspectives.--The members of the Commission 
                        shall represent a broad range of perspectives 
                        and shall collectively have experience in the 
                        following areas:
                                    ``(I) Epidemiology.
                                    ``(II) Health services research.
                                    ``(III) Bioethics.
                                    ``(IV) Decision sciences.
                                    ``(V) Health disparities.
                                    ``(VI) Health economics.
                            ``(ii) Diverse representation of health 
                        care community.--At least one member shall 
                        represent each of the following health care 
                        communities:
                                    ``(I) Patients.
                                    ``(II) Health care consumers.
                                    ``(III) Practicing Physicians, 
                                including surgeons.
                                    ``(IV) Other health care 
                                practitioners engaged in clinical care.
                                    ``(V) Organizations with proven 
                                expertise in racial and ethnic minority 
                                health research.
                                    ``(VI) Employers.
                                    ``(VII) Public payers.
                                    ``(VIII) Insurance plans.
                                    ``(IX) Clinical researchers who 
                                conduct research on behalf of 
                                pharmaceutical or device manufacturers.
                    ``(C) Limitation.--No more than 3 of the Members of 
                the Commission may be representatives of pharmaceutical 
                or device manufacturers and such representatives shall 
                be clinical researchers described under subparagraph 
                (B)(ii)(IX).
            ``(4) Appointment.--The Comptroller General shall appoint 
        the members of the Commission.
            ``(5) Chairman; vice chairman.--The Comptroller General 
        shall designate a member of the Commission, at the time of 
        appointment of the member, as Chairman and a member as Vice 
        Chairman for that term of appointment, except that in the case 
        of vacancy of the Chairmanship or Vice Chairmanship, the 
        Comptroller General may designate another member for the 
        remainder of that member's term. The Chairman shall serve as an 
        ex officio member of the National Advisory Council of the 
        Agency for Health Care Research and Quality under section 
        931(c)(3)(B) of the Public Health Service Act.
            ``(6) Terms.--
                    ``(A) In general.--Except as provided in 
                subparagraph (B), each member of the Commission shall 
                be appointed for a term of 4 years.
                    ``(B) Terms of initial appointees.--Of the members 
                first appointed--
                            ``(i) 8 shall be appointed for a term of 4 
                        years; and
                            ``(ii) 8 shall be appointed for a term of 3 
                        years.
            ``(7) Compensation.--While serving on the business of the 
        Commission (including travel time), a member of the Commission 
        shall be entitled to compensation at the per diem equivalent of 
        the rate provided for level IV of the Executive Schedule under 
        section 5315 of title 5, United States Code; and while so 
        serving away from home and the member's regular place of 
        business, a member may be allowed travel expenses, as 
        authorized by the Director of the Commission.
            ``(8) Director and staff; experts and consultants.--Subject 
        to such review as the Comptroller General deems necessary to 
        assure the efficient administration of the Commission, the 
        Commission may--
                    ``(A) appoint and set the compensation for an 
                Executive Director (subject to the approval of the 
                Comptroller General) and such other personnel as 
                Federal employees under section 2105 of title 5, United 
                States Code, as may be necessary to carry out its 
                duties (without regard to the provisions of title 5, 
                United States Code, governing appointments in the 
                competitive service);
                    ``(B) seek such assistance and support as may be 
                required in the performance of its duties from 
                appropriate Federal departments and agencies;
                    ``(C) enter into contracts or make other 
                arrangements, as may be necessary for the conduct of 
                the work of the Commission (without regard to section 
                3709 of the Revised Statutes (41 U.S.C. 5));
                    ``(D) make advance, progress, and other payments 
                which relate to the work of the Commission;
                    ``(E) provide transportation and subsistence for 
                persons serving without compensation; and
                    ``(F) prescribe such rules and regulations as it 
                deems necessary with respect to the internal 
                organization and operation of the Commission.
            ``(9) Obtaining official data.--The Commission may secure 
        directly from any department or agency of the United States 
        information necessary to enable the Commission to carry out 
        this section. Upon request of the Chairman of the Commission, 
        the head of such department or agency shall furnish the 
        information to the Commission on an agreed upon schedule.
            ``(10) Availability of reports.--The Commission shall 
        transmit to the Secretary a copy of each report submitted under 
        this subsection and shall make such reports available to the 
        public.
            ``(11) Coordination.--To enhance effectiveness and 
        coordination, the Secretary is encouraged, to the greatest 
        extent possible, to seek coordination between the Commission 
        and the National Advisory Council of the Agency for Healthcare 
        Research and Quality.
            ``(12) Conflicts of interest.--
                    ``(A) In general.--In appointing the members of the 
                Commission or a clinical perspective advisory panel 
                described in subsection (a)(2)(G), the Comptroller 
                General or the Secretary, respectively, shall take into 
                consideration any financial interest (as defined in 
                subparagraph (D)), consistent with this paragraph, and 
                develop a plan for managing any identified conflicts.
                    ``(B) Evaluation and criteria.--When considering an 
                appointment to the Commission or a clinical perspective 
                advisory panel described subsection (a)(2)(G), the 
                Comptroller General or the Secretary, respectively, 
                shall review the expertise of the individual and the 
                financial disclosure report filed by the individual 
                pursuant to the Ethics in Government Act of 1978 for 
                each individual under consideration for the 
                appointment, so as to reduce the likelihood that an 
                appointed individual will later require a written 
                determination as referred to in section 208(b)(1) of 
                title 18, United States Code, a written certification 
                as referred to in section 208(b)(3) of title 18, United 
                States Code, or a waiver as referred to in subparagraph 
                (D)(iii) for service on the Commission at a meeting of 
                the Commission.
                    ``(C) Disclosures; prohibitions on participation; 
                waivers.--
                            ``(i) Disclosure of financial interest.--
                        Prior to a meeting of the Commission or a 
                        clinical perspective advisory panel described 
                        in subsection (a)(2)(G) regarding a `particular 
                        matter' (as that term is used in section 208 of 
                        title 18, United States Code), each member of 
                        the Commission or the clinical perspective 
                        advisory panel who is a full-time Government 
                        employee or special Government employee shall 
                        disclose to the Comptroller General or 
                        Secretary, respectively, financial interests in 
                        accordance with requiring a waiver under 
                        section 208(b) of title 18, United States Code, 
                        or other interests as deemed relevant by the 
                        Secretary.
                            ``(ii) Prohibitions on participation.--
                        Except as provided under clause (iii), a member 
                        of the Commission or a clinical perspective 
                        advisory panel described in subsection 
                        (a)(2)(G) may not participate with respect to a 
                        particular matter considered in meeting of the 
                        Commission or the clinical perspective advisory 
                        panel if such member has a financial interest 
                        that could be affected by the advice given to 
                        the Secretary with respect to such matter, 
                        excluding interests exempted in regulations 
                        issued by the Director of the Office of 
                        Government Ethics as too remote or 
                        inconsequential to affect the integrity of the 
                        services of the Government officers or 
                        employees to which such regulations apply.
                            ``(iii) Waiver.--If the Comptroller General 
                        or Secretary, as applicable, determines it 
                        necessary to afford the Commission or a 
                        clinical perspective advisory panel described 
                        in subsection (a)(2)(G) essential expertise, 
                        the Comptroller General or Secretary, 
                        respectively, may grant a waiver of the 
                        prohibition in clause (ii) to permit a member 
                        described in such subparagraph to--
                                    ``(I) participate as a non-voting 
                                member with respect to a particular 
                                matter considered in a meeting of the 
                                Commission or a clinical perspective 
                                advisory panel, respectively; or
                                    ``(II) participate as a voting 
                                member with respect to a particular 
                                matter considered in a meeting of the 
                                Commission.
                            ``(iv) Limitation on waivers and other 
                        exceptions.--
                                    ``(I) Determination of allowable 
                                exceptions for the commission.--The 
                                number of waivers granted to members of 
                                the Commission cannot exceed one-half 
                                of the total number of members for the 
                                Commission.
                                    ``(II) Prohibition on voting status 
                                on clinical perspective advisory 
                                panels.--No voting member of any 
                                clinical perspective advisory panel 
                                shall be in receipt of a waiver. No 
                                more than two nonvoting members of any 
                                clinical perspective advisory panel 
                                shall receive a waiver.
                    ``(D) Financial interest defined.--For purposes of 
                this paragraph, the term `financial interest' means a 
                financial interest under section 208(a) of title 18, 
                United States Code.
            ``(13) Application of faca.--The Federal Advisory Committee 
        Act (other than section 14 of such Act) shall apply to the 
        Commission to the extent that the provisions of such Act do not 
        conflict with the requirements of this subsection.
    ``(c) Research Requirements.--Any research conducted, supported, or 
synthesized under this section shall meet the following requirements:
            ``(1) Ensuring transparency, credibility, and access.--
                    ``(A) The establishment of a research agenda by the 
                Center shall be informed by the national priorities for 
                research recommended under subsection (b)(2)(A).
                    ``(B) The establishment of the agenda and conduct 
                of the research shall be insulated from inappropriate 
                political or stakeholder influence.
                    ``(C) Methods of conducting such research shall be 
                scientifically based.
                    ``(D) Consistent with applicable law, all aspects 
                of the prioritization of research, conduct of the 
                research, and development of conclusions based on the 
                research shall be transparent to all stakeholders.
                    ``(E) Consistent with applicable law, the process 
                and methods for conducting such research shall be 
                publicly documented and available to all stakeholders.
                    ``(F) Throughout the process of such research, the 
                Center shall provide opportunities for all stakeholders 
                involved to review and provide public comment on the 
                methods and findings of such research.
                    ``(G) Such research shall consider advice given to 
                the Center by the clinical perspective advisory panel 
                for the particular national research priority.
            ``(2) Stakeholder input.--
                    ``(A) In general.--The Commission shall consult 
                with patients, health care providers, health care 
                consumer representatives, and other appropriate 
                stakeholders with an interest in the research through a 
                transparent process recommended by the Commission.
                    ``(B) Specific areas of consultation.--Consultation 
                shall include where deemed appropriate by the 
                Commission--
                            ``(i) recommending research priorities and 
                        questions;
                            ``(ii) recommending research methodologies; 
                        and
                            ``(iii) advising on and assisting with 
                        efforts to disseminate research findings.
                    ``(C) Ombudsman.--The Secretary shall designate a 
                patient ombudsman. The ombudsman shall--
                            ``(i) serve as an available point of 
                        contact for any patients with an interest in 
                        proposed comparative effectiveness studies by 
                        the Center; and
                            ``(ii) ensure that any comments from 
                        patients regarding proposed comparative 
                        effectiveness studies are reviewed by the 
                        Center.
            ``(3) Taking into account potential differences.--Research 
        shall--
                    ``(A) be designed, as appropriate, to take into 
                account the potential for differences in the 
                effectiveness of health care items, services, and 
                systems used with various subpopulations such as racial 
                and ethnic minorities, women, different age groups 
                (including children, adolescents, adults, and seniors), 
                individuals with disabilities, and individuals with 
                different comorbidities and genetic and molecular 
                subtypes; and--
                    ``(B) seek, as feasible and appropriate, to include 
                members of such subpopulations as subjects in the 
                research.
    ``(d) Public Access to Comparative Effectiveness Information.--
            ``(1) In general.--Not later than 90 days after receipt by 
        the Center or Commission, as applicable, of a relevant report 
        described in paragraph (2) made by the Center, Commission, or 
        clinical perspective advisory panel under this section, 
        appropriate information contained in such report shall be 
        posted on the official public Internet site of the Center and 
        of the Commission, as applicable.
            ``(2) Relevant reports described.--For purposes of this 
        section, a relevant report is each of the following submitted 
        by the Center or a grantee or contractor of the Center:
                    ``(A) Any interim or progress reports as deemed 
                appropriate by the Secretary.
                    ``(B) Stakeholder comments.
                    ``(C) A final report.
    ``(e) Dissemination and Incorporation of Comparative Effectiveness 
Information.--
            ``(1) Dissemination.--The Center shall provide for the 
        dissemination of appropriate findings produced by research 
        supported, conducted, or synthesized under this section to 
        health care providers, patients, vendors of health information 
        technology focused on clinical decision support, relevant 
        expert organizations (as defined in subsection (i)(3)(A)), and 
        Federal and private health plans, and other relevant 
        stakeholders. In disseminating such findings the Center shall--
                    ``(A) convey findings of research so that they are 
                comprehensible and useful to patients and providers in 
                making health care decisions;
                    ``(B) discuss findings and other considerations 
                specific to certain sub-populations, risk factors, and 
                comorbidities as appropriate;
                    ``(C) include considerations such as limitations of 
                research and what further research may be needed, as 
                appropriate;
                    ``(D) not include any data that the dissemination 
                of which would violate the privacy of research 
                participants or violate any confidentiality agreements 
                made with respect to the use of data under this 
                section; and
                    ``(E) assist the users of health information 
                technology focused on clinical decision support to 
                promote the timely incorporation of such findings into 
                clinical practices and promote the ease of use of such 
                incorporation.
            ``(2) Dissemination protocols and strategies.--The Center 
        shall develop protocols and strategies for the appropriate 
        dissemination of research findings in order to ensure effective 
        communication of findings and the use and incorporation of such 
        findings into relevant activities for the purpose of informing 
        higher quality and more effective and efficient decisions 
        regarding medical items and services. In developing and 
        adopting such protocols and strategies, the Center shall 
        consult with stakeholders concerning the types of dissemination 
        that will be most useful to the end users of information and 
        may provide for the utilization of multiple formats for 
        conveying findings to different audiences, including 
        dissemination to individuals with limited English proficiency.
    ``(f) Reports to Congress.--
            ``(1) Annual reports.--Beginning not later than one year 
        after the date of the enactment of this section, the Director 
        of the Agency of Healthcare Research and Quality shall submit 
        to Congress an annual report on the activities of the Center, 
        as well as the research, conducted under this section. Each 
        such report shall include a discussion of the Center's 
        compliance with subsection (c)(3)(B), including any reasons for 
        lack of compliance with such subsection.
            ``(2) Recommendation for fair share per capita amount for 
        all-payer financing.--Beginning not later than December 31, 
        2011, the Secretary shall submit to Congress an annual 
        recommendation for a fair share per capita amount described in 
        subsection (c)(1) of section 9511 of the Internal Revenue Code 
        of 1986 for purposes of funding the CERTF under such section.
            ``(3) Analysis and review.--Not later than December 31, 
        2013, the Secretary, in consultation with the Commission, shall 
        submit to Congress a report on all activities conducted or 
        supported under this section as of such date. Such report shall 
        include an evaluation of the overall costs of such activities 
        and an analysis of the backlog of any research proposals 
        approved by the Center but not funded.
    ``(g) Funding of Comparative Effectiveness Research.--For fiscal 
year 2010 and each subsequent fiscal year, amounts in the Comparative 
Effectiveness Research Trust Fund (referred to in this section as the 
`CERTF') under section 9511 of the Internal Revenue Code of 1986 shall 
be available in accordance with such section, without the need for 
further appropriations and without fiscal year limitation, to carry out 
this section.
    ``(h) Construction.--
            ``(1) Coverage.--Nothing in this section shall be 
        construed--
                    ``(A) to permit the Center or Commission to mandate 
                coverage, reimbursement, or other policies for any 
                public or private payer; or
                    ``(B) as preventing the Secretary from covering the 
                routine costs of clinical care received by an 
                individual entitled to, or enrolled for, benefits under 
                title XVIII, XIX, or XXI in the case where such 
                individual is participating in a clinical trial and 
                such costs would otherwise be covered under such title 
                with respect to the beneficiary.
            ``(2) Reports and findings.--None of the reports submitted 
        under this section or research findings disseminated by the 
        Center or Commission shall be construed as mandates, for 
        payment, coverage, or treatment.
            ``(3) Protecting the physician-patient relationship.--
        Nothing in this section shall be construed to authorize any 
        Federal officer or employee to exercise any supervision or 
        control over the practice of medicine.
    ``(i) Consultation With Relevant Expert Organizations.--
            ``(1) Consultation prior to initiation of research.--Prior 
        to recommending priorities or initiating research described in 
        this section, the Commission or the Center shall consult with 
        the relevant expert organizations responsible for standards and 
        protocols of clinical excellence. Such consultation shall be 
        consistent with the processes established under subsection 
        (c)(2).
            ``(2) Consultation in dissemination of research.--Any 
        dissemination of research from the Commission or the Center and 
        findings made by the Commission or the Center shall be 
        consistent with processes established under subsection (e) and 
        shall--
                    ``(A) be based upon evidence-based medicine; and
                    ``(B) take into consideration standards and 
                protocols of clinical excellence developed by relevant 
                expert organizations.
            ``(3) Definitions.--For purposes of this subsection:
                    ``(A) Relevant expert organizations.--The term 
                `relevant expert organization' means an organization 
                with expertise in the rigorous application of evidence-
                based scientific methods for the design of clinical 
                studies, the interpretation of clinical data, and the 
                development of national clinical practice guidelines, 
                including a voluntary health organization, clinical 
                specialty, or other professional organization that 
                represents physicians based on the field of medicine in 
                which each such physician practices or is board 
                certified.
                    ``(B) Standards and protocols of clinical 
                excellence.--The term `standards and protocols of 
                clinical excellence' means clinical or practice 
                guidelines that consist of a set of directions or 
                principles that is based on evidence and is designed to 
                assist a health care practitioner with decisions about 
                appropriate diagnostic, therapeutic, or other clinical 
                procedures for specific clinical circumstances.
    ``(j) Research May Not Be Used to Deny or Ration Care.--Nothing in 
this section shall be construed to make more stringent or otherwise 
change the standards or requirements for coverage of items and services 
under this Act.''.
    (b) Comparative Effectiveness Research Trust Fund; Financing for 
the Trust Fund.--For the provision establishing a Comparative 
Effectiveness Research Trust Fund and financing such Trust Fund, see 
section 1802.

                 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.

    (a) In General.--Section 1124 of the Social Security Act (42 U.S.C. 
1320a-3) is amended by adding at the end the following new subsection:
    ``(c) Required Disclosure of Ownership and Additional Disclosable 
Parties Information.--
            ``(1) Disclosure.--A facility (as defined in paragraph 
        (6)(B)) shall have the information described in paragraph (3) 
        available--
                    ``(A) during the period beginning on the date of 
                the enactment of this subsection and ending on the date 
                such information is made available to the public under 
                section 1411(b) of the Affordable Health Care for 
                America Act, for submission to the Secretary, the 
                Inspector General of the Department of Health and Human 
                Services, the State in which the facility is located, 
                and the State long-term care ombudsman in the case 
                where the Secretary, the Inspector General, the State, 
                or the State long-term care ombudsman requests such 
                information; and
                    ``(B) beginning on the effective date of the final 
                regulations promulgated under paragraph (4)(A), for 
                reporting such information in accordance with such 
                final regulations.
        Nothing in subparagraph (A) shall be construed as authorizing a 
        facility to dispose of or delete information described in such 
        subparagraph after the effective date of the final regulations 
        promulgated under paragraph (4)(A).
            ``(2) Public availability of information.--During the 
        period described in paragraph (1)(A), a facility shall--
                    ``(A) make the information described in paragraph 
                (3) available to the public upon request and update 
                such information as may be necessary to reflect changes 
                in such information; and
                    ``(B) post a notice of the availability of such 
                information in the lobby of the facility in a prominent 
                manner.
            ``(3) Information described.--
                    ``(A) In general.--The following information is 
                described in this paragraph:
                            ``(i) The information described in 
                        subsections (a) and (b), subject to 
                        subparagraph (C).
                            ``(ii) The identity of and information on--
                                    ``(I) each member of the governing 
                                body of the facility, including the 
                                name, title, and period of service of 
                                each such member;
                                    ``(II) each person or entity who is 
                                an officer, director, member, partner, 
                                trustee, or managing employee of the 
                                facility, including the name, title, 
                                and date of start of service of each 
                                such person or entity; and
                                    ``(III) each person or entity who 
                                is an additional disclosable party of 
                                the facility.
                            ``(iii) A description of the organizational 
                        structure and the relationship of each person 
                        and entity described in subclauses (II) and 
                        (III) of clause (ii) to the facility and to one 
                        another.
                    ``(B) Special rule where information is already 
                reported or submitted.--To the extent that information 
                reported by a facility to the Internal Revenue Service 
                on Form 990, information submitted by a facility to the 
                Securities and Exchange Commission, or information 
                otherwise submitted to the Secretary or any other 
                Federal agency contains the information described in 
                clauses (i), (ii), or (iii) of subparagraph (A), the 
                Secretary may allow, to the extent practicable, such 
                Form or such information to meet the requirements of 
                paragraph (1) and to be submitted in a manner specified 
                by the Secretary.
                    ``(C) Special rule.--In applying subparagraph 
                (A)(i)--
                            ``(i) with respect to subsections (a) and 
                        (b), `ownership or control interest' shall 
                        include direct or indirect interests, including 
                        such interests in intermediate entities; and
                            ``(ii) subsection (a)(3)(A)(ii) shall 
                        include the owner of a whole or part interest 
                        in any mortgage, deed of trust, note, or other 
                        obligation secured, in whole or in part, by the 
                        entity or any of the property or assets 
                        thereof, if the interest is equal to or exceeds 
                        5 percent of the total property or assets of 
                        the entirety.
            ``(4) Reporting.--
                    ``(A) In general.--Not later than the date that is 
                2 years after the date of the enactment of this 
                subsection, the Secretary shall promulgate regulations 
                requiring a facility to report the information 
                described in paragraph (3) to the Secretary in a 
                standardized format, and such other regulations as are 
                necessary to carry out this subsection. Such 
                regulations shall specify the frequency of reporting, 
                as determined by the Secretary. Such final regulations 
                shall also require--
                            ``(i) the reporting of such information on 
                        or after the first day of the first calendar 
                        quarter beginning after the date that is 90 
                        days after the date on which such final 
                        regulations are published in the Federal 
                        Register; and--
                            ``(ii) the certification, as a condition of 
                        participation under the program under title 
                        XVIII or XIX, that such information is accurate 
                        and current.
                    ``(B) Guidance.--The Secretary shall provide 
                guidance and technical assistance to States on how to 
                adopt the standardized format under subparagraph (A).
            ``(5) No effect on existing reporting requirements.--
        Nothing in this subsection shall reduce, diminish, or alter any 
        reporting requirement for a facility that is in effect as of 
        the date of the enactment of this subsection.
            ``(6) Definitions.--In this subsection:
                    ``(A) Additional disclosable party.--The term 
                `additional disclosable party' means, with respect to a 
                facility, any person or entity who, through ownership 
                interest, partnership interest, contract, or 
                otherwise--
                            ``(i) directly or indirectly exercises 
                        operational, financial, administrative, or 
                        managerial control or direction over the 
                        facility or a part thereof, or provides 
                        policies or procedures for any of the 
                        operations of the facility, or provides 
                        financial or cash management services to the 
                        facility;
                            ``(ii) leases or subleases real property to 
                        the facility, or owns a whole or part interest 
                        equal to or exceeding 5 percent of the total 
                        value of such real property;
                            ``(iii) lends funds or provides a financial 
                        guarantee to the facility in an amount which is 
                        equal to or exceeds $50,000; or
                            ``(iv) provides management or 
                        administrative services, clinical consulting 
                        services, or accounting or financial services 
                        to the facility.
                    ``(B) Facility.--The term `facility' means a 
                disclosing entity which is--
                            ``(i) a skilled nursing facility (as 
                        defined in section 1819(a)); or
                            ``(ii) a nursing facility (as defined in 
                        section 1919(a)).
                    ``(C) Managing employee.--The term `managing 
                employee' means, with respect to a facility, an 
                individual (including a general manager, business 
                manager, administrator, director, or consultant) who 
                directly or indirectly manages, advises, or supervises 
                any element of the practices, finances, or operations 
                of the facility.
                    ``(D) Organizational structure.--The term 
                `organizational structure' means, in the case of--
                            ``(i) a corporation, the officers, 
                        directors, and shareholders of the corporation 
                        who have an ownership interest in the 
                        corporation which is equal to or exceeds 5 
                        percent;
                            ``(ii) a limited liability company, the 
                        members and managers of the limited liability 
                        company (including, as applicable, what 
                        percentage each member and manager has of the 
                        ownership interest in the limited liability 
                        company);
                            ``(iii) a general partnership, the partners 
                        of the general partnership;
                            ``(iv) a limited partnership, the general 
                        partners and any limited partners of the 
                        limited partnership who have an ownership 
                        interest in the limited partnership which is 
                        equal to or exceeds 10 percent;
                            ``(v) a trust, the trustees of the trust;
                            ``(vi) an individual, contact information 
                        for the individual; and
                            ``(vii) any other person or entity, such 
                        information as the Secretary determines 
                        appropriate.''.
    (b) Public Availability of Information.--Not later than the date 
that is 1 year after the date on which the final regulations 
promulgated under section 1124(c)(4)(A) of the Social Security Act, as 
added by subsection (a), are published in the Federal Register, the 
information reported in accordance with such final regulations shall be 
made available to the public in accordance with procedures established 
by the Secretary of Health and Human Services.
    (a) Conforming Amendments.--
            (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
        Social Security Act (42 U.S.C. 1395i-3(d)(1)) is amended by 
        striking subparagraph (B) and redesignating subparagraph (C) as 
        subparagraph (B).
            (2) Nursing facilities.--Section 1919(d)(1) of the Social 
        Security Act (42 U.S.C. 1396r(d)(1)) is amended by striking 
        subparagraph (B) and redesignating subparagraph (C) as 
        subparagraph (B).

SEC. 1412. ACCOUNTABILITY REQUIREMENTS.

    (a) Effective Compliance and Ethics Programs.--
            (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
        Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by 
        section 1411(c)(1), is amended by adding at the end the 
        following new subparagraph:
                    ``(C) Compliance and ethics programs.--
                            ``(i) Requirement.--On or after the first 
                        day of the first calendar quarter beginning 
                        after the date that is 1 year after the date on 
                        which regulations developed under clause (ii) 
                        are published in the Federal Register, a 
                        skilled nursing facility shall, with respect to 
                        the entity that operates or controls the 
                        facility (in this subparagraph referred to as 
                        the `operating organization' or 
                        `organization'), have in operation a compliance 
                        and ethics program that is effective in 
                        preventing and detecting criminal, civil, and 
                        administrative violations under this Act and in 
                        promoting quality of care consistent with such 
                        regulations.
                            ``(ii) Development of regulations.--
                                    ``(I) In general.--Not later than 
                                the date that is 2 years after the date 
                                of the enactment of this subparagraph, 
                                the Secretary, in consultation with the 
                                Inspector General of the Department of 
                                Health and Human Services, shall 
                                promulgate regulations for an effective 
                                compliance and ethics program for 
                                operating organizations, which may 
                                include a model compliance program.
                                    ``(II) Design of regulations.--Such 
                                regulations with respect to specific 
                                elements or formality of a program may 
                                vary with the size of the organization, 
                                such that larger organizations should 
                                have a more formal and rigorous program 
                                and include established written 
                                policies defining the standards and 
                                procedures to be followed by its 
                                employees. Such requirements shall 
                                specifically apply to the corporate 
                                level management of multi-unit nursing 
                                home chains.
                                    ``(III) Evaluation.--Not later than 
                                3 years after the date on which 
                                compliance and ethics programs 
                                established under this subparagraph are 
                                in operation pursuant to clause (i), 
                                the Secretary shall complete an 
                                evaluation of such programs. Such 
                                evaluation shall determine if such 
                                programs led to changes in deficiency 
                                citations, changes in quality 
                                performance, or changes in other 
                                metrics of resident quality of care. 
                                The Secretary shall submit to Congress 
                                a report on such evaluation and shall 
                                include in such report such 
                                recommendations regarding changes in 
                                the requirements for such programs as 
                                the Secretary determines appropriate.
                            ``(iii) Requirements for compliance and 
                        ethics programs.--In this subparagraph, the 
                        term `compliance and ethics program' means, 
                        with respect to a skilled nursing facility, a 
                        program of the operating organization that--
                                    ``(I) has been reasonably designed, 
                                implemented, and enforced so that it 
                                generally will be effective in 
                                preventing and detecting criminal, 
                                civil, and administrative violations 
                                under this Act and in promoting quality 
                                of care; and
                                    ``(II) includes at least the 
                                required components specified in clause 
                                (iv).
                            ``(iv) Required components of program.--The 
                        required components of a compliance and ethics 
                        program of an organization are the following:
                                    ``(I) The organization must have 
                                established compliance standards and 
                                procedures to be followed by its 
                                employees, contractors, and other 
                                agents that are reasonably capable of 
                                reducing the prospect of criminal, 
                                civil, and administrative violations 
                                under this Act.
                                    ``(II) Specific individuals within 
                                high-level personnel of the 
                                organization must have been assigned 
                                overall responsibility to oversee 
                                compliance with such standards and 
                                procedures and have sufficient 
                                resources and authority to assure such 
                                compliance.
                                    ``(III) The organization must have 
                                used due care not to delegate 
                                substantial discretionary authority to 
                                individuals whom the organization knew, 
                                or should have known through the 
                                exercise of due diligence, had a 
                                propensity to engage in criminal, 
                                civil, and administrative violations 
                                under this Act.
                                    ``(IV) The organization must have 
                                taken steps to communicate effectively 
                                its standards and procedures to all 
                                employees and other agents, such as by 
                                requiring participation in training 
                                programs or by disseminating 
                                publications that explain in a 
                                practical manner what is required.
                                    ``(V) The organization must have 
                                taken reasonable steps to achieve 
                                compliance with its standards, such as 
                                by utilizing monitoring and auditing 
                                systems reasonably designed to detect 
                                criminal, civil, and administrative 
                                violations under this Act by its 
                                employees and other agents and by 
                                having in place and publicizing a 
                                reporting system whereby employees and 
                                other agents could report violations by 
                                others within the organization without 
                                fear of retribution.
                                    ``(VI) The standards must have been 
                                consistently enforced through 
                                appropriate disciplinary mechanisms, 
                                including, as appropriate, discipline 
                                of individuals responsible for the 
                                failure to detect an offense.
                                    ``(VII) After an offense has been 
                                detected, the organization must have 
                                taken all reasonable steps to respond 
                                appropriately to the offense and to 
                                prevent further similar offenses, 
                                including repayment of any funds to 
                                which it was not entitled and any 
                                necessary modification to its program 
                                to prevent and detect criminal, civil, 
                                and administrative violations under 
                                this Act.
                                    ``(VIII) The organization must 
                                periodically undertake reassessment of 
                                its compliance program to identify 
                                changes necessary to reflect changes 
                                within the organization and its 
                                facilities.
                            ``(v) Coordination.--The provisions of this 
                        subparagraph shall apply with respect to a 
                        skilled nursing facility in lieu of section 
                        1874(d).''.
            (2) Nursing facilities.--Section 1919(d)(1) of the Social 
        Security Act (42 U.S.C. 1396r(d)(1)), as amended by section 
        1411(c)(2), is amended by adding at the end the following new 
        subparagraph:
                    ``(C) Compliance and ethics program.--
                            ``(i) Requirement.--On or after the first 
                        day of the first calendar quarter beginning 
                        after the date that is 1 year after the date on 
                        which regulations developed under clause (ii) 
                        are published in the Federal Register, a 
                        skilled nursing facility shall, with respect to 
                        the entity that operates or controls the 
                        facility (in this subparagraph referred to as 
                        the `operating organization' or 
                        `organization'), have in operation a compliance 
                        and ethics program that is effective in 
                        preventing and detecting criminal, civil, and 
                        administrative violations under this Act and in 
                        promoting quality of care consistent with such 
                        regulations.
                            ``(iii) Development of regulations.--
                                    ``(I) In general.--Not later than 
                                the date that is 2 years after the date 
                                of the enactment of this subparagraph, 
                                the Secretary, in consultation with the 
                                Inspector General of the Department of 
                                Health and Human Services, shall 
                                promulgate regulations for an effective 
                                compliance and ethics program for 
                                operating organizations, which may 
                                include a model compliance program.
                                    ``(II) Design of regulations.--Such 
                                regulations with respect to specific 
                                elements or formality of a program may 
                                vary with the size of the organization, 
                                such that larger organizations should 
                                have a more formal and rigorous program 
                                and include established written 
                                policies defining the standards and 
                                procedures to be followed by its 
                                employees. Such requirements shall 
                                specifically apply to the corporate 
                                level management of multi-unit nursing 
                                home chains.
                                    ``(III) Evaluation.--Not later than 
                                3 years after the date on which 
                                compliance and ethics programs 
                                established under this subparagraph are 
                                in operation pursuant to clause (i), 
                                the Secretary shall complete an 
                                evaluation of such programs. Such 
                                evaluation shall determine if such 
                                programs led to changes in deficiency 
                                citations, changes in quality 
                                performance, or changes in other 
                                metrics of resident quality of care. 
                                The Secretary shall submit to Congress 
                                a report on such evaluation and shall 
                                include in such report such 
                                recommendations regarding changes in 
                                the requirements for such programs as 
                                the Secretary determines appropriate.
                            ``(v) Requirements for compliance and 
                        ethics programs.--In this subparagraph, the 
                        term `compliance and ethics program' means, 
                        with respect to a nursing facility, a program 
                        of the operating organization that--
                                    ``(I) has been reasonably designed, 
                                implemented, and enforced so that it 
                                generally will be effective in 
                                preventing and detecting criminal, 
                                civil, and administrative violations 
                                under this Act and in promoting quality 
                                of care; and
                                    ``(II) includes at least the 
                                required components specified in clause 
                                (iv).
                            ``(vi) Required components of program.--The 
                        required components of a compliance and ethics 
                        program of an organization are the following:
                                    ``(I) The organization must have 
                                established compliance standards and 
                                procedures to be followed by its 
                                employees and other agents that are 
                                reasonably capable of reducing the 
                                prospect of criminal, civil, and 
                                administrative violations under this 
                                Act.
                                    ``(II) Specific individuals within 
                                high-level personnel of the 
                                organization must have been assigned 
                                overall responsibility to oversee 
                                compliance with such standards and 
                                procedures and has sufficient resources 
                                and authority to assure such 
                                compliance.
                                    ``(III) The organization must have 
                                used due care not to delegate 
                                substantial discretionary authority to 
                                individuals whom the organization knew, 
                                or should have known through the 
                                exercise of due diligence, had a 
                                propensity to engage in criminal, 
                                civil, and administrative violations 
                                under this Act.
                                    ``(IV) The organization must have 
                                taken steps to communicate effectively 
                                its standards and procedures to all 
                                employees and other agents, such as by 
                                requiring participation in training 
                                programs or by disseminating 
                                publications that explain in a 
                                practical manner what is required.
                                    ``(V) The organization must have 
                                taken reasonable steps to achieve 
                                compliance with its standards, such as 
                                by utilizing monitoring and auditing 
                                systems reasonably designed to detect 
                                criminal, civil, and administrative 
                                violations under this Act by its 
                                employees and other agents and by 
                                having in place and publicizing a 
                                reporting system whereby employees and 
                                other agents could report violations by 
                                others within the organization without 
                                fear of retribution.
                                    ``(VI) The standards must have been 
                                consistently enforced through 
                                appropriate disciplinary mechanisms, 
                                including, as appropriate, discipline 
                                of individuals responsible for the 
                                failure to detect an offense.
                                    ``(VII) After an offense has been 
                                detected, the organization must have 
                                taken all reasonable steps to respond 
                                appropriately to the offense and to 
                                prevent further similar offenses, 
                                including repayment of any funds to 
                                which it was not entitled and any 
                                necessary modification to its program 
                                to prevent and detect criminal, civil, 
                                and administrative violations under 
                                this Act.
                                    ``(VIII) The organization must 
                                periodically undertake reassessment of 
                                its compliance program to identify 
                                changes necessary to reflect changes 
                                within the organization and its 
                                facilities.
                            ``(vii) Coordination.--The provisions of 
                        this subparagraph shall apply with respect to a 
                        nursing facility in lieu of section 
                        1902(a)(77).''.
    (b) Quality Assurance and Performance Improvement Program.--
            (1) Skilled nursing facilities.--Section 1819(b)(1)(B) of 
        the Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
                    (A) by striking ``assurance'' and inserting 
                ``assurance and quality assurance and performance 
                improvement program'';
                    (B) by designating the matter beginning with ``A 
                skilled nursing facility'' as a clause (i) with the 
                heading ``In general.--'' and the appropriate 
                indentation;
                    (C) in clause (i) (as so designated by subparagraph 
                (B)), by redesignating clauses (i) and (ii) as 
                subclauses (I) and (II), respectively; and
                    (D) by adding at the end the following new clause:
                            ``(ii) Quality assurance and performance 
                        improvement program.--
                                    ``(I) In general.--Not later than 
                                December 31, 2011, the Secretary shall 
                                establish and implement a quality 
                                assurance and performance improvement 
                                program (in this clause referred to as 
                                the `QAPI program') for skilled nursing 
                                facilities, including multi-unit chains 
                                of such facilities. Under the QAPI 
                                program, the Secretary shall establish 
                                standards relating to such facilities 
                                and provide technical assistance to 
                                such facilities on the development of 
                                best practices in order to meet such 
                                standards. Not later than 1 year after 
                                the date on which the regulations are 
                                promulgated under subclause (II), a 
                                skilled nursing facility must submit to 
                                the Secretary a plan for the facility 
                                to meet such standards and implement 
                                such best practices, including how to 
                                coordinate the implementation of such 
                                plan with quality assessment and 
                                assurance activities conducted under 
                                clause (i).
                                    ``(II) Regulations.--The Secretary 
                                shall promulgate regulations to carry 
                                out this clause.''.
            (2) Nursing facilities.--Section 1919(b)(1)(B) of the 
        Social Security Act (42 U.S.C. 1396r(b)(1)(B)) is amended--
                    (A) by striking ``assurance'' and inserting 
                ``assurance and quality assurance and performance 
                improvement program'';
                    (B) by designating the matter beginning with ``A 
                nursing facility'' as a clause (i) with the heading 
                ``In general.--'' and the appropriate indentation; and
                    (C) by adding at the end the following new clause:
                            ``(ii) Quality assurance and performance 
                        improvement program.--
                                    ``(I) In general.--Not later than 
                                December 31, 2011, the Secretary shall 
                                establish and implement a quality 
                                assurance and performance improvement 
                                program (in this clause referred to as 
                                the `QAPI program') for nursing 
                                facilities, including multi-unit chains 
                                of such facilities. Under the QAPI 
                                program, the Secretary shall establish 
                                standards relating to such facilities 
                                and provide technical assistance to 
                                such facilities on the development of 
                                best practices in order to meet such 
                                standards. Not later than 1 year after 
                                the date on which the regulations are 
                                promulgated under subclause (II), a 
                                nursing facility must submit to the 
                                Secretary a plan for the facility to 
                                meet such standards and implement such 
                                best practices, including how to 
                                coordinate the implementation of such 
                                plan with quality assessment and 
                                assurance activities conducted under 
                                clause (i).
                                    ``(II) Regulations.--The Secretary 
                                shall promulgate regulations to carry 
                                out this clause.''.
            (3) Proposal to revise quality assurance and performance 
        improvement programs.--The Secretary shall implement policies 
        that modify and strengthen quality assurance and performance 
        improvement programs in skilled nursing facilities and nursing 
        facilities on a periodic basis, as determined by the Secretary.
            (4) Facility plan.--Not later than 1 year after the date on 
        which the regulations are promulgated under subclause (II) of 
        clause (ii) of sections 1819(b)(1)(B) and 1919(b)(1)(B) of the 
        Social Security Act, as added by paragraphs (1) and (2), a 
        skilled nursing facility and a nursing facility must submit to 
        the Secretary a plan for the facility to meet the standards 
        under such regulations and implement such best practices, 
        including how to coordinate the implementation of such plan 
        with quality assessment and assurance activities conducted 
        under clause (i) of such sections.
    (c) GAO Study on Nursing Facility Undercapitalization.--
            (1) In general.--The Comptroller General of the United 
        States shall conduct a study that examines the following:
                    (A) The extent to which corporations that own or 
                operate large numbers of nursing facilities, taking 
                into account ownership type (including private equity 
                and control interests), are undercapitalizing such 
                facilities.
                    (B) The effects of such undercapitalization on 
                quality of care, including staffing and food costs, at 
                such facilities.
                    (C) Options to address such undercapitalization, 
                such as requirements relating to surety bonds, 
                liability insurance, or minimum capitalization.
            (2) Report.--Not later than 18 months after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report on the study conducted under paragraph (1).
            (3) Nursing facility.--In this subsection, the term 
        ``nursing facility'' includes a skilled nursing facility.

SEC. 1413. NURSING HOME COMPARE MEDICARE WEBSITE.

    (a) Skilled Nursing Facilities.--
            (1) In general.--Section 1819 of the Social Security Act 
        (42 U.S.C. 1395i-3) is amended--
                    (A) by redesignating subsection (i) as subsection 
                (j); and
                    (B) by inserting after subsection (h) the following 
                new subsection:
    ``(i) Nursing Home Compare Website.--
            ``(1) Inclusion of additional information.--
                    ``(A) In general.--The Secretary shall ensure that 
                the Department of Health and Human Services includes, 
                as part of the information provided for comparison of 
                nursing homes on the official Internet website of the 
                Federal Government for Medicare beneficiaries (commonly 
                referred to as the `Nursing Home Compare' Medicare 
                website) (or a successor website), the following 
                information in a manner that is prominent, easily 
                accessible, readily understandable to consumers of 
                long-term care services, and searchable:
                            ``(i) Information that is reported to the 
                        Secretary under section 1124(c)(4).
                            ``(ii) Information on the `Special Focus 
                        Facility program' (or a successor program) 
                        established by the Centers for Medicare and 
                        Medicaid Services, according to procedures 
                        established by the Secretary. Such procedures 
                        shall provide for the inclusion of information 
                        with respect to, and the names and locations 
                        of, those facilities that, since the previous 
                        quarter--
                                    ``(I) were newly enrolled in the 
                                program;
                                    ``(II) are enrolled in the program 
                                and have failed to significantly 
                                improve;
                                    ``(III) are enrolled in the program 
                                and have significantly improved;
                                    ``(IV) have graduated from the 
                                program; and
                                    ``(V) have closed voluntarily or no 
                                longer participate under this title.
                            ``(iii) Staffing data for each facility 
                        (including resident census data and data on the 
                        hours of care provided per resident per day) 
                        based on data submitted under subsection 
                        (b)(8)(C), including information on staffing 
                        turnover and tenure, in a format that is 
                        clearly understandable to consumers of long-
                        term care services and allows such consumers to 
                        compare differences in staffing between 
                        facilities and State and national averages for 
                        the facilities. Such format shall include--
                                    ``(I) concise explanations of how 
                                to interpret the data (such as a plain 
                                English explanation of data reflecting 
                                `nursing home staff hours per resident 
                                day');
                                    ``(II) differences in types of 
                                staff (such as training associated with 
                                different categories of staff);
                                    ``(III) the relationship between 
                                nurse staffing levels and quality of 
                                care; and
                                    ``(IV) an explanation that 
                                appropriate staffing levels vary based 
                                on patient case mix.
                            ``(iv) Links to State internet websites 
                        with information regarding State survey and 
                        certification programs, links to Form 2567 
                        State inspection reports (or a successor form) 
                        on such websites, information to guide 
                        consumers in how to interpret and understand 
                        such reports, and the facility plan of 
                        correction or other response to such report.
                            ``(v) The standardized complaint form 
                        developed under subsection (f)(8), including 
                        explanatory material on what complaint forms 
                        are, how they are used, and how to file a 
                        complaint with the State survey and 
                        certification program and the State long-term 
                        care ombudsman program.
                            ``(vi) Summary information on the number, 
                        type, severity, and outcome of substantiated 
                        complaints.
                            ``(vii) The number of adjudicated instances 
                        of criminal violations by employees of a 
                        nursing facility--
                                    ``(I) that were committed inside 
                                the facility;
                                    ``(II) with respect to such 
                                instances of violations or crimes 
                                committed inside of the facility that 
                                were the violations or crimes of abuse, 
                                neglect, and exploitation, criminal 
                                sexual abuse, or other violations or 
                                crimes that resulted in serious bodily 
                                injury; and
                            ``(viii) The number of civil monetary 
                        penalties levied against the facility, 
                        employees, contractors, and other agents.
                            ``(ix) Any other information that the 
                        Secretary determines appropriate.
                The facility shall not make available under clause (iv) 
                identifying information on complainants or residents.
                    ``(B) Deadline for provision of information.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), the Secretary shall ensure that 
                        the information described in subparagraph (A) 
                        is included on such website (or a successor 
                        website) not later than 1 year after the date 
                        of the enactment of this subsection.
                            ``(ii) Exception.--The Secretary shall 
                        ensure that the information described in 
                        subparagraph (A)(i) and (A)(iii) is included on 
                        such website (or a successor website) not later 
                        than 1 year after the dates on which the data 
                        are submitted to the Secretary pursuant to 
                        section 1124(c)(4) and subsection (b)(8)(C), 
                        respectively.
            ``(2) Review and modification of website.--
                    ``(A) In general.--The Secretary shall establish a 
                process--
                            ``(i) to review the accuracy, clarity of 
                        presentation, timeliness, and comprehensiveness 
                        of information reported on such website as of 
                        the day before the date of the enactment of 
                        this subsection; and
                            ``(ii) not later than 1 year after the date 
                        of the enactment of this subsection, to modify 
                        or revamp such website in accordance with the 
                        review conducted under clause (i).
                    ``(B) Consultation.--In conducting the review under 
                subparagraph (A)(i), the Secretary shall consult with--
                            ``(i) State long-term care ombudsman 
                        programs;
                            ``(ii) consumer advocacy groups;
                            ``(iii) provider stakeholder groups; and
                            ``(iv) any other representatives of 
                        programs or groups the Secretary determines 
                        appropriate.''.
            (2) Timeliness of submission of survey and certification 
        information.--
                    (A) In general.--Section 1819(g)(5) of the Social 
                Security Act (42 U.S.C. 1395i-3(g)(5)) is amended by 
                adding at the end the following new subparagraph:
                    ``(E) Submission of survey and certification 
                information to the secretary.--In order to improve the 
                timeliness of information made available to the public 
                under subparagraph (A) and provided on the Nursing Home 
                Compare Medicare website under subsection (i), each 
                State shall submit information respecting any survey or 
                certification recommendation made respecting a skilled 
                nursing facility (including any enforcement actions 
                taken by the State or any Federal enforcement action 
                recommended by the State) to the Secretary not later 
                than the date on which the State sends such information 
                to the facility. The Secretary shall use the 
                information submitted under the preceding sentence to 
                update the information provided on the Nursing Home 
                Compare Medicare website as expeditiously as 
                practicable but not less frequently than quarterly.''.
                    (B) Effective date.--The amendment made by this 
                paragraph shall take effect 1 year after the date of 
                the enactment of this Act.
            (3) Special focus facility program.--Section 1819(f) of 
        such Act is amended by adding at the end the following new 
        paragraph:
            ``(8) Special focus facility program.--
                    ``(A) In general.--The Secretary shall conduct a 
                special focus facility program for enforcement of 
                requirements for skilled nursing facilities that the 
                Secretary has identified as having a poor compliance 
                history or that substantially failed to meet applicable 
                requirements of this Act
                    ``(B) Periodic surveys.--Under such program the 
                Secretary shall conduct surveys of each facility in the 
                program not less than once every 6 months.''.
    (b) Nursing Facilities.--
            (1) In general.--Section 1919 of the Social Security Act 
        (42 U.S.C. 1396r) is amended--
                    (A) by redesignating subsection (i) as subsection 
                (j); and
                    (B) by inserting after subsection (h) the following 
                new subsection:
    ``(i) Nursing Home Compare Website.--
            ``(1) Inclusion of additional information.--
                    ``(A) In general.--The Secretary shall ensure that 
                the Department of Health and Human Services includes, 
                as part of the information provided for comparison of 
                nursing homes on the official internet website of the 
                Federal Government for Medicare beneficiaries (commonly 
                referred to as the `Nursing Home Compare' Medicare 
                website) (or a successor website), the following 
                information in a manner that is prominent, easily 
                accessible, readily understandable to consumers of 
                long-term care services, and searchable:
                            ``(i) Information that is reported to the 
                        Secretary under section 1124(c)(4)
                            ``(ii) Information on the `Special Focus 
                        Facility program' (or a successor program) 
                        established by the Centers for Medicare & 
                        Medicaid Services, according to procedures 
                        established by the Secretary. Such procedures 
                        shall provide for the inclusion of information 
                        with respect to, and the names and locations 
                        of, those facilities that, since the previous 
                        quarter--
                                    ``(I) were newly enrolled in the 
                                program;
                                    ``(II) are enrolled in the program 
                                and have failed to significantly 
                                improve;
                                    ``(III) are enrolled in the program 
                                and have significantly improved;
                                    ``(IV) have graduated from the 
                                program; and
                                    ``(V) have closed voluntarily or no 
                                longer participate under this title.
                            ``(iii) Staffing data for each facility 
                        (including resident census data and data on the 
                        hours of care provided per resident per day) 
                        based on data submitted under subsection 
                        (b)(8)(C)(ii), including information on 
                        staffing turnover and tenure, in a format that 
                        is clearly understandable to consumers of long-
                        term care services and allows such consumers to 
                        compare differences in staffing between 
                        facilities and State and national averages for 
                        the facilities. Such format shall include--
                                    ``(I) concise explanations of how 
                                to interpret the data (such as plain 
                                English explanation of data reflecting 
                                `nursing home staff hours per resident 
                                day');
                                    ``(II) differences in types of 
                                staff (such as training associated with 
                                different categories of staff);
                                    ``(III) the relationship between 
                                nurse staffing levels and quality of 
                                care; and
                                    ``(IV) an explanation that 
                                appropriate staffing levels vary based 
                                on patient case mix.
                            ``(iv) Links to State internet websites 
                        with information regarding State survey and 
                        certification programs, links to Form 2567 
                        State inspection reports (or a successor form) 
                        on such websites, information to guide 
                        consumers in how to interpret and understand 
                        such reports, and the facility plan of 
                        correction or other response to such report.
                            ``(v) The standardized complaint form 
                        developed under subsection (f)(10), including 
                        explanatory material on what complaint forms 
                        are, how they are used, and how to file a 
                        complaint with the State survey and 
                        certification program and the State long-term 
                        care ombudsman program.
                            ``(vi) Summary information on the number, 
                        type, severity, and outcome of substantiated 
                        complaints.
                            ``(vii) The number of adjudicated instances 
                        of criminal violations by employees of a 
                        nursing facility--
                                    ``(I) that were committed inside of 
                                the facility; and
                                    ``(II) with respect to such 
                                instances of violations or crimes 
                                committed inside of the facility that 
                                were the violations or crimes of abuse, 
                                neglect, and exploitation, criminal 
                                sexual abuse, or other violations or 
                                crimes that resulted in serious bodily 
                                injury.
                            ``(viii) the number of civil monetary 
                        penalties levied against the facility, 
                        employees, contractors, and other agents.
                            ``(ix) Any other information that the 
                        Secretary determines appropriate.
                The facility shall not make available under clause (ii) 
                identifying information about complainants or 
                residents.
                    ``(B) Deadline for provision of information.--
                            ``(i) In general.--Except as provided in 
                        clause (ii), the Secretary shall ensure that 
                        the information described in subparagraph (A) 
                        is included on such website (or a successor 
                        website) not later than 1 year after the date 
                        of the enactment of this subsection.
                            ``(ii) Exception.--The Secretary shall 
                        ensure that the information described in 
                        subparagraph (A)(i) and (A)(iii) is included on 
                        such website (or a successor website) not later 
                        than 1 year after the dates on which the data 
                        are submitted to the Secretary pursuant to 
                        section 1124(c)(4) and subsection (b)(8)(C), 
                        respectively.
            ``(2) Review and modification of website.--
                    ``(A) In general.--The Secretary shall establish a 
                process--
                            ``(i) to review the accuracy, clarity of 
                        presentation, timeliness, and comprehensiveness 
                        of information reported on such website as of 
                        the day before the date of the enactment of 
                        this subsection; and
                            ``(ii) not later than 1 year after the date 
                        of the enactment of this subsection, to modify 
                        or revamp such website in accordance with the 
                        review conducted under clause (i).
                    ``(B) Consultation.--In conducting the review under 
                subparagraph (A)(i), the Secretary shall consult with--
                            ``(i) State long-term care ombudsman 
                        programs;
                            ``(ii) consumer advocacy groups;
                            ``(iii) provider stakeholder groups;
                            ``(iv) skilled nursing facility employees 
                        and their representatives; and
                            ``(v) any other representatives of programs 
                        or groups the Secretary determines 
                        appropriate.''.
            (2) Timeliness of submission of survey and certification 
        information.--
                    (A) In general.--Section 1919(g)(5) of the Social 
                Security Act (42 U.S.C. 1396r(g)(5)) is amended by 
                adding at the end the following new subparagraph:
                    ``(E) Submission of survey and certification 
                information to the secretary.--In order to improve the 
                timeliness of information made available to the public 
                under subparagraph (A) and provided on the Nursing Home 
                Compare Medicare website under subsection (i), each 
                State shall submit information respecting any survey or 
                certification recommendation made respecting a nursing 
                facility (including any enforcement actions taken by 
                the State or any Federal enforcement action recommended 
                by the State) to the Secretary not later than the date 
                on which the State sends such information to the 
                facility. The Secretary shall use the information 
                submitted under the preceding sentence to update the 
                information provided on the Nursing Home Compare 
                Medicare website as expeditiously as practicable but 
                not less frequently than quarterly.''.
                    (B) Effective date.--The amendment made by this 
                paragraph shall take effect 1 year after the date of 
                the enactment of this Act.
            (3) Special focus facility program.--Section 1919(f) of 
        such Act is amended by adding at the end of the following new 
        paragraph:
            ``(10) Special focus facility program.--
                    ``(A) In general.--The Secretary shall conduct a 
                special focus facility program for enforcement of 
                requirements for nursing facilities that the Secretary 
                has identified as having a poor compliance history or 
                that substantially failed to meet applicable 
                requirements of this Act
                    ``(B) Periodic surveys.--Under such program the 
                Secretary shall conduct surveys of each facility in the 
                program not less often than once every 6 months.''.
    (c) Availability of Reports on Surveys, Certifications, and 
Complaint Investigations.--
            (1) Skilled nursing facilities.--Section 1819(d)(1) of the 
        Social Security Act (42 U.S.C. 1395i-3(d)(1)), as amended by 
        sections 1411 and 1412, is amended by adding at the end the 
        following new subparagraph:
                    ``(D) Availability of survey, certification, and 
                complaint investigation reports.--A skilled nursing 
                facility must--
                            ``(i) have reports with respect to any 
                        surveys, certifications, and complaint 
                        investigations made respecting the facility 
                        during the 3 preceding years available for any 
                        individual to review upon request; and
                            ``(ii) post notice of the availability of 
                        such reports in areas of the facility that are 
                        prominent and accessible to the public.
                The facility shall not make available under clause (i) 
                identifying information about complainants or 
                residents.''.
            (2) Nursing facilities.--Section 1919(d)(1) of the Social 
        Security Act (42 U.S.C. 1396r(d)(1)), as amended by sections 
        1411 and 1412, is amended by adding at the end the following 
        new subparagraph:
                    ``(D) Availability of survey, certification, and 
                complaint investigation reports.--A nursing facility 
                must--
                            ``(i) have reports with respect to any 
                        surveys, certifications, and complaint 
                        investigations made respecting the facility 
                        during the 3 preceding years available for any 
                        individual to review upon request; and
                            ``(ii) post notice of the availability of 
                        such reports in areas of the facility that are 
                        prominent and accessible to the public.
                The facility shall not make available under clause (i) 
                identifying information about complainants or 
                residents.''.
            (3) Effective date.--The amendments made by this subsection 
        shall take effect 1 year after the date of the enactment of 
        this Act.
    (d) Guidance to States on Form 2567 State Inspection Reports and 
Complaint Investigation Reports.--
            (1) Guidance.--The Secretary of Health and Human Services 
        (in this subtitle referred to as the ``Secretary'') shall 
        provide guidance to States on how States can establish 
        electronic links to Form 2567 State inspection reports (or a 
        successor form), complaint investigation reports, and a 
        facility's plan of correction or other response to such Form 
        2567 State inspection reports (or a successor form) on the 
        Internet website of the State that provides information on 
        skilled nursing facilities and nursing facilities and the 
        Secretary shall, if possible, include such information on 
        Nursing Home Compare.
            (2) Requirement.--Section 1902(a)(9) of the Social Security 
        Act (42 U.S.C. 1396a(a)(9)) is amended--
                    (A) by striking ``and'' at the end of subparagraph 
                (B);
                    (B) by striking the semicolon at the end of 
                subparagraph (C) and inserting ``, and''; and
                    (C) by adding at the end the following new 
                subparagraph:
                    ``(D) that the State maintain a consumer-oriented 
                website providing useful information to consumers 
                regarding all skilled nursing facilities and all 
                nursing facilities in the State, including for each 
                facility, Form 2567 State inspection reports (or a 
                successor form), complaint investigation reports, the 
                facility's plan of correction, and such other 
                information that the State or the Secretary considers 
                useful in assisting the public to assess the quality of 
                long term care options and the quality of care provided 
                by individual facilities;''.
            (3) Definitions.--In this subsection:
                    (A) Nursing facility.--The term ``nursing 
                facility'' has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a)).
                    (B) Secretary.--The term ``Secretary'' means the 
                Secretary of Health and Human Services.
                    (C) Skilled nursing facility.--The term ``skilled 
                nursing facility'' has the meaning given such term in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395i-3(a)).

SEC. 1414. REPORTING OF EXPENDITURES.

    Section 1888 of the Social Security Act (42 U.S.C. 1395yy) is 
amended by adding at the end the following new subsection:
    ``(f) Reporting of Direct Care Expenditures.--
            ``(1) In general.--For cost reports submitted under this 
        title for cost reporting periods beginning on or after the date 
        that is no more than two years after the redesign of the report 
        specified in subparagraph (2), skilled nursing facilities 
        shall--
                    ``(A) separately report expenditures for wages and 
                benefits for direct care staff (breaking out (at a 
                minimum) registered nurses, licensed professional 
                nurses, certified nurse assistants, and other medical 
                and therapy staff); and
                    ``(B) take into account agency and contract staff 
                in a manner to be determined by the Administrator.
            ``(2) Modification of form.--The Secretary, in consultation 
        with private sector accountants experienced with skilled 
        nursing facility cost reports, shall redesign such reports to 
        meet the requirement of paragraph (1) not later than 2 years 
        after the date of the enactment of this subsection.
            ``(3) Categorization by functional accounts.--Beginning 
        with cost reports submitted under paragraph (1) , the 
        Secretary, working in consultation with the Medicare Payment 
        Advisory Commission, the Inspector General of the Department of 
        Health and Human Services, and other expert parties the 
        Secretary determines appropriate, shall categorize the 
        expenditures listed on cost reports, as modified under 
        paragraph (1), submitted by skilled nursing facilities, 
        regardless of any source of payment for such expenditures, for 
        each skilled nursing facility into the following functional 
        accounts on an annual basis:
                    ``(A) Spending on direct care services (including 
                nursing, therapy, and medical services).
                    ``(B) Spending on indirect care (including 
                housekeeping and dietary services).
                    ``(C) Capital assets (including building and land 
                costs).
                    ``(D) Administrative services costs.
            ``(4) Availability of information submitted.--The Secretary 
        shall establish procedures to make information on expenditures 
        submitted under this subsection readily available to interested 
        parties upon request, subject to such requirements as the 
        Secretary may specify under the procedures established under 
        this paragraph.''.

SEC. 1415. STANDARDIZED COMPLAINT FORM.

    (a) Skilled Nursing Facilities.--
            (1) Development by the secretary.--Section 1819(f) of the 
        Social Security Act (42 U.S.C. 1395i-3(f)), as amended by 
        section 1413(a)(3), is amended by adding at the end the 
        following new paragraph:
            ``(9) Standardized complaint form.--The Secretary shall 
        develop a standardized complaint form for use by a resident (or 
        a person acting on the resident's behalf) in filing a complaint 
        with a State survey and certification agency and a State long-
        term care ombudsman program with respect to a skilled nursing 
        facility.''.
            (2) State requirements.--Section 1819(e) of the Social 
        Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the 
        end the following new paragraph:
            ``(6) Complaint processes and whistle-blower protection.--
                    ``(A) Complaint forms.--The State must make the 
                standardized complaint form developed under subsection 
                (f)(9) available upon request to--
                            ``(i) a resident of a skilled nursing 
                        facility;
                            ``(ii) any person acting on the resident's 
                        behalf; and
                            ``(iii) any person who works at a skilled 
                        nursing facility or is a representative of such 
                        a worker.
                    ``(B) Complaint resolution process.--The State must 
                establish a complaint resolution process in order to 
                ensure that a resident, the legal representative of a 
                resident of a skilled nursing facility, or other 
                responsible party is not retaliated against if the 
                resident, legal representative, or responsible party 
                has complained, in good faith, about the quality of 
                care or other issues relating to the skilled nursing 
                facility, that the legal representative of a resident 
                of a skilled nursing facility or other responsible 
                party is not denied access to such resident or 
                otherwise retaliated against if such representative 
                party has complained, in good faith, about the quality 
                of care provided by the facility or other issues 
                relating to the facility, and that a person who works 
                at a skilled nursing facility is not retaliated against 
                if the worker has complained, in good faith, about 
                quality of care or services or an issue relating to the 
                quality of care or services provided at the facility, 
                whether the resident, legal representative, other 
                responsible party, or worker used the form developed 
                under subsection (f)(9) or some other method for 
                submitting the complaint. Such complaint resolution 
                process shall include--
                            ``(i) procedures to assure accurate 
                        tracking of complaints received, including 
                        notification to the complainant that a 
                        complaint has been received;
                            ``(ii) procedures to determine the likely 
                        severity of a complaint and for the 
                        investigation of the complaint;
                            ``(iii) deadlines for responding to a 
                        complaint and for notifying the complainant of 
                        the outcome of the investigation; and
                            ``(iv) procedures to ensure that the 
                        identity of the complainant will be kept 
                        confidential.
                    ``(C) Whistleblower protection.--
                            ``(i) Prohibition against retaliation.--No 
                        person who works at a skilled nursing facility 
                        may be penalized, discriminated, or retaliated 
                        against with respect to any aspect of 
                        employment, including discharge, promotion, 
                        compensation, terms, conditions, or privileges 
                        of employment, or have a contract for services 
                        terminated, because the person (or anyone 
                        acting at the person's request) complained, in 
                        good faith, about the quality of care or 
                        services provided by a skilled nursing facility 
                        or about other issues relating to quality of 
                        care or services, whether using the form 
                        developed under subsection (f)(9) or some other 
                        method for submitting the complaint.
                            ``(ii) Retaliatory reporting.--A skilled 
                        nursing facility may not file a complaint or a 
                        report against a person who works (or has 
                        worked at the facility) with the appropriate 
                        State professional disciplinary agency because 
                        the person (or anyone acting at the person's 
                        request) complained in good faith, as described 
                        in clause (i).
                            ``(iii) Relief.--Any person aggrieved by a 
                        violation of clause (i) or clause (ii) may, in 
                        a civil action, obtain all appropriate relief, 
                        including reinstatement, reimbursement of lost 
                        wages, compensation, and benefits, and 
                        exemplary damages where warranted, and such 
                        other relief as the court deems appropriate, as 
                        well as costs of suit and reasonable attorney 
                        and expert witness fees.
                            ``(iv) Rights not waivable.--The rights 
                        protected by this paragraph may not be 
                        diminished by contract or other agreement, and 
                        nothing in this paragraph shall be construed to 
                        diminish any greater or additional protection 
                        provided by Federal or State law or by contract 
                        or other agreement.
                            ``(v) Requirement to post notice of 
                        employee rights.--Each skilled nursing facility 
                        shall post conspicuously in an appropriate 
                        location a sign (in a form specified by the 
                        Secretary) specifying the rights of persons 
                        under this paragraph and including a statement 
                        that an employee may file a complaint with the 
                        Secretary against a skilled nursing facility 
                        that violates the provisions of this paragraph 
                        and information with respect to the manner of 
                        filing such a complaint.
                    ``(D) Rule of construction.--Nothing in this 
                paragraph shall be construed as preventing a resident 
                of a skilled nursing facility (or a person acting on 
                the resident's behalf) from submitting a complaint in a 
                manner or format other than by using the standardized 
                complaint form developed under subsection (f)(9) 
                (including submitting a complaint orally).
                    ``(E) Good faith defined.--For purposes of this 
                paragraph, an individual shall be deemed to be acting 
                in good faith with respect to the filing of a complaint 
                if the individual reasonably believes--
                            ``(i) the information reported or disclosed 
                        in the complaint is true; and
                            ``(ii) the violation of this title has 
                        occurred or may occur in relation to such 
                        information.''.
    (b) Nursing Facilities.--
            (1) Development by the secretary.--Section 1919(f) of the 
        Social Security Act (42 U.S.C. 1395i-3(f)), as amended by 
        section 1413(b), is amended by adding at the end the following 
        new paragraph:
            ``(11) Standardized complaint form.--The Secretary shall 
        develop a standardized complaint form for use by a resident (or 
        a person acting on the resident's behalf) in filing a complaint 
        with a State survey and certification agency and a State long-
        term care ombudsman program with respect to a nursing 
        facility.''.
            (2) State requirements.--Section 1919(e) of the Social 
        Security Act (42 U.S.C. 1395i-3(e)) is amended by adding at the 
        end the following new paragraph:
            ``(8) Complaint processes and whistleblower protection.--
                    ``(A) Complaint forms.--The State must make the 
                standardized complaint form developed under subsection 
                (f)(11) available upon request to--
                            ``(i) a resident of a nursing facility;
                            ``(ii) any person acting on the resident's 
                        behalf; and
                            ``(iii) any person who works at a nursing 
                        facility or a representative of such a worker.
                    ``(B) Complaint resolution process.--The State must 
                establish a complaint resolution process in order to 
                ensure that a resident, the legal representative of a 
                resident of a nursing facility, or other responsible 
                party is not retaliated against if the resident, legal 
                representative, or responsible party has complained, in 
                good faith, about the quality of care or other issues 
                relating to the nursing facility, that the legal 
                representative of a resident of a nursing facility or 
                other responsible party is not denied access to such 
                resident or otherwise retaliated against if such 
                representative party has complained, in good faith, 
                about the quality of care provided by the facility or 
                other issues relating to the facility, and that a 
                person who works at a nursing facility is not 
                retaliated against if the worker has complained, in 
                good faith, about quality of care or services or an 
                issue relating to the quality of care or services 
                provided at the facility, whether the resident, legal 
                representative, other responsible party, or worker used 
                the form developed under subsection (f)(11) or some 
                other method for submitting the complaint. Such 
                complaint resolution process shall include--
                            ``(i) procedures to assure accurate 
                        tracking of complaints received, including 
                        notification to the complainant that a 
                        complaint has been received;
                            ``(ii) procedures to determine the likely 
                        severity of a complaint and for the 
                        investigation of the complaint;
                            ``(iii) deadlines for responding to a 
                        complaint and for notifying the complainant of 
                        the outcome of the investigation; and
                            ``(iv) procedures to ensure that the 
                        identity of the complainant will be kept 
                        confidential.
                    ``(C) Whistleblower protection.--
                            ``(i) Prohibition against retaliation.--No 
                        person who works at a nursing facility may be 
                        penalized, discriminated, or retaliated against 
                        with respect to any aspect of employment, 
                        including discharge, promotion, compensation, 
                        terms, conditions, or privileges of employment, 
                        or have a contract for services terminated, 
                        because the person (or anyone acting at the 
                        person's request) complained, in good faith, 
                        about the quality of care or services provided 
                        by a nursing facility or about other issues 
                        relating to quality of care or services, 
                        whether using the form developed under 
                        subsection (f)(11) or some other method for 
                        submitting the complaint.
                            ``(ii) Retaliatory reporting.--A nursing 
                        facility may not file a complaint or a report 
                        against a person who works (or has worked at 
                        the facility with the appropriate State 
                        professional disciplinary agency because the 
                        person (or anyone acting at the person's 
                        request) complained in good faith, as described 
                        in clause (i).
                            ``(iii) Relief.--Any person aggrieved by a 
                        violation of clause (i) or clause (ii) may, in 
                        a civil action, obtain all appropriate relief, 
                        including reinstatement, reimbursement of lost 
                        wages, compensation, and benefits, and 
                        exemplary damages where warranted, and such 
                        other relief as the court deems appropriate, as 
                        well as costs of suit and reasonable attorney 
                        and expert witness fees.
                            ``(iv) Rights not waivable.--The rights 
                        protected by this paragraph may not be 
                        diminished by contract or other agreement, and 
                        nothing in this paragraph shall be construed to 
                        diminish any greater or additional protection 
                        provided by Federal or State law or by contract 
                        or other agreement.
                            ``(v) Requirement to post notice of 
                        employee rights.--Each nursing facility shall 
                        post conspicuously in an appropriate location a 
                        sign (in a form specified by the Secretary) 
                        specifying the rights of persons under this 
                        paragraph and including a statement that an 
                        employee may file a complaint with the 
                        Secretary against a nursing facility that 
                        violates the provisions of this paragraph and 
                        information with respect to the manner of 
                        filing such a complaint.
                    ``(D) Rule of construction.--Nothing in this 
                paragraph shall be construed as preventing a resident 
                of a nursing facility (or a person acting on the 
                resident's behalf) from submitting a complaint in a 
                manner or format other than by using the standardized 
                complaint form developed under subsection (f)(11) 
                (including submitting a complaint orally).
                    ``(E) Good faith defined.--For purposes of this 
                paragraph, an individual shall be deemed to be acting 
                in good faith with respect to the filing of a complaint 
                if the individual reasonably believes--
                            ``(i) the information reported or disclosed 
                        in the complaint is true; and
                            ``(ii) the violation of this title has 
                        occurred or may occur in relation to such 
                        information.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of the enactment of this Act.

SEC. 1416. ENSURING STAFFING ACCOUNTABILITY.

    (a) Skilled Nursing Facilities.--Section 1819(b)(8) of the Social 
Security Act (42 U.S.C. 1395i-3(b)(8)) is amended by adding at the end 
the following new subparagraph:
                    ``(C) Submission of staffing information based on 
                payroll data in a uniform format.--On and after the 
                first day of the first calendar quarter beginning after 
                the date that is 2 years after the date of enactment of 
                this subparagraph, and after consulting with State 
                long-term care ombudsman programs, consumer advocacy 
                groups, provider stakeholder groups, employees and 
                their representatives, and other parties the Secretary 
                deems appropriate, the Secretary shall require a 
                skilled nursing facility to electronically submit to 
                the Secretary direct care staffing information 
                (including information with respect to agency and 
                contract staff) based on payroll and other verifiable 
                and auditable data in a uniform format (according to 
                specifications established by the Secretary in 
                consultation with such programs, groups, and parties). 
                Such specifications shall require that the information 
                submitted under the preceding sentence--
                            ``(i) specify the category of work a 
                        certified employee performs (such as whether 
                        the employee is a registered nurse, licensed 
                        practical nurse, licensed vocational nurse, 
                        certified nursing assistant, therapist, or 
                        other medical personnel);
                            ``(ii) include resident census data and 
                        information on resident case mix;
                            ``(iii) include a regular reporting 
                        schedule; and
                            ``(iv) include information on employee 
                        turnover and tenure and on the hours of care 
                        provided by each category of certified 
                        employees referenced in clause (i) per resident 
                        per day.
                Nothing in this subparagraph shall be construed as 
                preventing the Secretary from requiring submission of 
                such information with respect to specific categories, 
                such as nursing staff, before other categories of 
                certified employees. Information under this 
                subparagraph with respect to agency and contract staff 
                shall be kept separate from information on employee 
                staffing.''.
    (b) Nursing Facilities.--Section 1919(b)(8) of the Social Security 
Act (42 U.S.C. 1396r(b)(8)) is amended by adding at the end the 
following new subparagraph:
                    ``(C) Submission of staffing information based on 
                payroll data in a uniform format.--On and after the 
                first day of the first calendar quarter beginning after 
                the date that is 2 years after the date of enactment of 
                this subparagraph, and after consulting with State 
                long-term care ombudsman programs, consumer advocacy 
                groups, provider stakeholder groups, employees and 
                their representatives, and other parties the Secretary 
                deems appropriate, the Secretary shall require a 
                nursing facility to electronically submit to the 
                Secretary direct care staffing information (including 
                information with respect to agency and contract staff) 
                based on payroll and other verifiable and auditable 
                data in a uniform format (according to specifications 
                established by the Secretary in consultation with such 
                programs, groups, and parties). Such specifications 
                shall require that the information submitted under the 
                preceding sentence--
                            ``(i) specify the category of work a 
                        certified employee performs (such as whether 
                        the employee is a registered nurse, licensed 
                        practical nurse, licensed vocational nurse, 
                        certified nursing assistant, therapist, or 
                        other medical personnel);
                            ``(ii) include resident census data and 
                        information on resident case mix;
                            ``(iii) include a regular reporting 
                        schedule; and
                            ``(iv) include information on employee 
                        turnover and tenure and on the hours of care 
                        provided by each category of certified 
                        employees referenced in clause (i) per resident 
                        per day.
                Nothing in this subparagraph shall be construed as 
                preventing the Secretary from requiring submission of 
                such information with respect to specific categories, 
                such as nursing staff, before other categories of 
                certified employees. Information under this 
                subparagraph with respect to agency and contract staff 
                shall be kept separate from information on employee 
                staffing.''.

SEC. 1417. NATIONWIDE PROGRAM FOR NATIONAL AND STATE BACKGROUND CHECKS 
              ON DIRECT PATIENT ACCESS EMPLOYEES OF LONG-TERM CARE 
              FACILITIES AND PROVIDERS.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary''), shall establish a 
program to identify efficient, effective, and economical procedures for 
long term care facilities or providers to conduct background checks on 
prospective direct patient access employees on a nationwide basis (in 
this subsection, such program shall be referred to as the ``nationwide 
program''). The Secretary shall carry out the nationwide program under 
similar terms and conditions as the pilot program under section 307 of 
the Medicare Prescription Drug, Improvement, and Modernization Act of 
2003 (Public Law 108-173; 117 Stat. 2257), including the prohibition on 
hiring abusive workers and the authorization of the imposition of 
penalties by a participating State under subsections (b)(3)(A) and 
(b)(6), respectively, of such section 307. The program under this 
subsection shall contain the following modifications to such pilot 
program:
            (1) Agreements.--
                    (A) Newly participating states.--The Secretary 
                shall enter into agreements with each State--
                            (i) that the Secretary has not entered into 
                        an agreement with under subsection (c)(1) of 
                        such section 307;
                            (ii) that agrees to conduct background 
                        checks under the nationwide program on a 
                        Statewide basis; and
                            (iii) that submits an application to the 
                        Secretary containing such information and at 
                        such time as the Secretary may specify.
                    (B) Certain previously participating states.--The 
                Secretary shall enter into agreements with each State--
                            (i) that the Secretary has entered into an 
                        agreement with under such subsection (c)(1);
                            (ii) that agrees to conduct background 
                        checks under the nationwide program on a 
                        Statewide basis; and
                            (iii) that submits an application to the 
                        Secretary containing such information and at 
                        such time as the Secretary may specify.
            (2) Nonapplication of selection criteria.--The selection 
        criteria required under subsection (c)(3)(B) of such section 
        307 shall not apply.
            (3) Required fingerprint check as part of criminal 
        background check.--The procedures established under subsection 
        (b)(1) of such section 307 shall--
                    (A) require that the long-term care facility or 
                provider (or the designated agent of the long-term care 
                facility or provider) obtain State and national 
                criminal or other background checks on the prospective 
                employee through such means as the Secretary determines 
                appropriate that utilize a search of State-based abuse 
                and neglect registries and databases, including the 
                abuse and neglect registries of another State in the 
                case where a prospective employee previously resided in 
                that State, State criminal history records, the records 
                of any proceedings in the State that may contain 
                disqualifying information about prospective employees 
                (such as proceedings conducted by State professional 
                licensing and disciplinary boards and State Medicaid 
                Fraud Control Units), and Federal criminal history 
                records, including a fingerprint check using the 
                Integrated Automated Fingerprint Identification System 
                of the Federal Bureau of Investigation; and
                    (B) require States to describe and test methods 
                that reduce duplicative fingerprinting, including 
                providing for the development of ``rap back'' 
                capability by the State such that, if a direct patient 
                access employee of a long-term care facility or 
                provider is convicted of a crime following the initial 
                criminal history background check conducted with 
                respect to such employee, and the employee's 
                fingerprints match the prints on file with the State 
                law enforcement department, the department will 
                immediately inform the State and the State will 
                immediately inform the long-term care facility or 
                provider which employs the direct patient access 
                employee of such conviction.
            (4) State requirements.--An agreement entered into under 
        paragraph (1) shall require that a participating State--
                    (A) be responsible for monitoring compliance with 
                the requirements of the nationwide program;
                    (B) have procedures in place to--
                            (i) conduct screening and criminal or other 
                        background checks under the nationwide program 
                        in accordance with the requirements of this 
                        section;
                            (ii) monitor compliance by long-term care 
                        facilities and providers with the procedures 
                        and requirements of the nationwide program;
                            (iii) as appropriate, provide for a 
                        provisional period of employment by a long-term 
                        care facility or provider of a direct patient 
                        access employee, not to exceed 60 days, pending 
                        completion of the required criminal history 
                        background check and, in the case where the 
                        employee has appealed the results of such 
                        background check, pending completion of the 
                        appeals process, during which the employee 
                        shall be subject to direct on-site supervision 
                        (in accordance with procedures established by 
                        the State to ensure that a long-term care 
                        facility or provider furnishes such direct on-
                        site supervision);
                            (iv) provide an independent process by 
                        which a provisional employee or an employee may 
                        appeal or dispute the accuracy of the 
                        information obtained in a background check 
                        performed under the nationwide program, 
                        including the specification of criteria for 
                        appeals for direct patient access employees 
                        found to have disqualifying information which 
                        shall include consideration of the passage of 
                        time, extenuating circumstances, demonstration 
                        of rehabilitation, and relevancy of the 
                        particular disqualifying information with 
                        respect to the current employment of the 
                        individual;
                            (v) provide for the designation of a single 
                        State agency as responsible for--
                                    (I) overseeing the coordination of 
                                any State and national criminal history 
                                background checks requested by a long-
                                term care facility or provider (or the 
                                designated agent of the long-term care 
                                facility or provider) utilizing a 
                                search of State and Federal criminal 
                                history records, including a 
                                fingerprint check of such records;
                                    (II) overseeing the design of 
                                appropriate privacy and security 
                                safeguards for use in the review of the 
                                results of any State or national 
                                criminal history background checks 
                                conducted regarding a prospective 
                                direct patient access employee to 
                                determine whether the employee has any 
                                conviction for a relevant crime;
                                    (III) immediately reporting to the 
                                long-term care facility or provider 
                                that requested the criminal history 
                                background check the results of such 
                                review; and
                                    (IV) in the case of an employee 
                                with a conviction for a relevant crime 
                                that is subject to reporting under 
                                section 1128E of the Social Security 
                                Act (42 U.S.C. 1320a-7e), reporting the 
                                existence of such conviction to the 
                                database established under that 
                                section;
                            (vi) determine which individuals are direct 
                        patient access employees (as defined in 
                        paragraph (6)(B)) for purposes of the 
                        nationwide program;
                            (vii) as appropriate, specify offenses, 
                        including convictions for violent crimes, for 
                        purposes of the nationwide program; and
                            (viii) describe and test methods that 
                        reduce duplicative fingerprinting, including 
                        providing for the development of ``rap back'' 
                        capability such that, if a direct patient 
                        access employee of a long-term care facility or 
                        provider is convicted of a crime following the 
                        initial criminal history background check 
                        conducted with respect to such employee, and 
                        the employee's fingerprints match the prints on 
                        file with the State law enforcement 
                        department--
                                    (I) the department will immediately 
                                inform the State agency designated 
                                under clause (v) and such agency will 
                                immediately inform the facility or 
                                provider which employs the direct 
                                patient access employee of such 
                                conviction; and
                                    (II) the State will provide, or 
                                will require the facility to provide, 
                                to the employee a copy of the results 
                                of the criminal history background 
                                check conducted with respect to the 
                                employee at no charge in the case where 
                                the individual requests such a copy.
                        Background checks and screenings under this 
                        subsection shall be valid for a period of no 
                        longer than 2 years, as determined by the State 
                        and approved by the Secretary.
            (5) Payments.--
                    (A) Newly participating states.--
                            (i) In general.--As part of the application 
                        submitted by a State under paragraph 
                        (1)(A)(iii), the State shall guarantee, with 
                        respect to the costs to be incurred by the 
                        State in carrying out the nationwide program, 
                        that the State will make available (directly or 
                        through donations from public or private 
                        entities) a particular amount of non-Federal 
                        contributions, as a condition of receiving the 
                        Federal match under clause (ii).
                            (ii) Federal match.--The payment amount to 
                        each State that the Secretary enters into an 
                        agreement with under paragraph (1)(A) shall be 
                        3 times the amount that the State guarantees to 
                        make available under clause (i).
                    (B) Previously participating states.--
                            (i) In general.--As part of the application 
                        submitted by a State under paragraph 
                        (1)(B)(iii), the State shall guarantee, with 
                        respect to the costs to be incurred by the 
                        State in carrying out the nationwide program, 
                        that the State will make available (directly or 
                        through donations from public or private 
                        entities) a particular amount of non-Federal 
                        contributions, as a condition of receiving the 
                        Federal match under clause (ii).
                            (ii) Federal match.--The payment amount to 
                        each State that the Secretary enters into an 
                        agreement with under paragraph (1)(B) shall be 
                        3 times the amount that the State guarantees to 
                        make available under clause (i).
            (6) Definitions.--Under the nationwide program:
                    (A) Long-term care facility or provider.--The term 
                ``long-term care facility or provider'' means the 
                following facilities or providers which receive payment 
                for services under title XVIII or XIX of the Social 
                Security Act:
                            (i) A skilled nursing facility (as defined 
                        in section 1819(a) of the Social Security Act 
                        (42 U.S.C. 1395i-3(a))).
                            (ii) A nursing facility (as defined in 
                        section 1919(a) of such Act (42 U.S.C. 
                        1396r(a))).
                            (iii) A home health agency.
                            (iv) A provider of hospice care (as defined 
                        in section 1861(dd)(1) of such Act (42 U.S.C. 
                        1395x(dd)(1))).
                            (v) A long-term care hospital (as described 
                        in section 1886(d)(1)(B)(iv) of such Act (42 
                        U.S.C. 1395ww(d)(1)(B)(iv))).
                            (vi) A provider of personal care services.
                            (vii) A provider of adult day care.
                            (viii) A residential care provider that 
                        arranges for, or directly provides, long-term 
                        care services, including an assisted living 
                        facility that provides a nursing home level of 
                        care conveyed by State licensure or State 
                        definition.
                            (ix) An intermediate care facility for the 
                        mentally retarded (as defined in section 
                        1905(d) of such Act (42 U.S.C. 1396d(d))).
                            (x) Any other facility or provider of long-
                        term care services under such titles as the 
                        participating State determines appropriate.
                    (B) Direct patient access employee.--The term 
                ``direct patient access employee'' means any individual 
                who has access to a patient or resident of a long-term 
                care facility or provider through employment or through 
                a contract with such facility or provider and has 
                duties that involve (or may involve) one-on-one contact 
                with a patient or resident of the facility or provider, 
                as determined by the State for purposes of the 
                nationwide program. Such term does not include a 
                volunteer unless the volunteer has duties that are 
                equivalent to the duties of a direct patient access 
                employee and those duties involve (or may involve) one-
                on-one contact with a patient or resident of the long-
                term care facility or provider.
            (7) Evaluation and report.--
                    (A) Evaluation.--The Inspector General of the 
                Department of Health and Human Services shall conduct 
                an evaluation of the nationwide program. Such 
                evaluation shall include--
                            (i) a review of the various procedures 
                        implemented by participating States for long-
                        term care facilities or providers, including 
                        staffing agencies, to conduct background checks 
                        of direct patient access employees and identify 
                        the most efficient, effective, and economical 
                        procedures for conducting such background 
                        checks;
                            (ii) an assessment of the costs of 
                        conducting such background checks (including 
                        start-up and administrative costs);
                            (iii) a determination of the extent to 
                        which conducting such background checks leads 
                        to any unintended consequences, including a 
                        reduction in the available workforce for such 
                        facilities or providers;
                            (iv) an assessment of the impact of the 
                        program on reducing the number of incidents of 
                        neglect, abuse, and misappropriation of 
                        resident property to the extent practicable; 
                        and
                            (v) an evaluation of other aspects of the 
                        program, as determined appropriate by the 
                        Secretary.
                    (B) Report.--Not later than 180 days after the 
                completion of the nationwide program, the Inspector 
                General of the Department of Health and Human Services 
                shall submit a report to Congress containing the 
                results of the evaluation conducted under subparagraph 
                (A).
    (b) Funding.--
            (1) Notification.--The Secretary of Health and Human 
        Services shall notify the Secretary of the Treasury of the 
        amount necessary to carry out the nationwide program under this 
        section, including costs for the Department of Health and Human 
        Services to administer and evaluate the program, for the period 
        of fiscal years 2010 through 2012, except that in no case shall 
        such amount exceed $160,000,000.
            (2) Transfer of funds.--Out of any funds in the Treasury 
        not otherwise appropriated, the Secretary of the Treasury shall 
        provide for the transfer to the Secretary of Health and Human 
        Services of the amount specified as necessary to carry out the 
        nationwide program under paragraph (1). Such amount shall 
        remain available until expended.

                     PART 2--TARGETING ENFORCEMENT

SEC. 1421. CIVIL MONEY PENALTIES.

    (a) Skilled Nursing Facilities.--
            (1) In general.--Section 1819(h)(2)(B)(ii) of the Social 
        Security Act (42 U.S.C. 1395i-3(h)(2)(B)(ii)) is amended to 
        read as follows:
                            ``(ii) Authority with respect to civil 
                        money penalties.--
                                    ``(I) Amount.--The Secretary may 
                                impose a civil money penalty in the 
                                applicable per instance or per day 
                                amount (as defined in subclause (II) 
                                and (III)) for each day or instance, 
                                respectively, of noncompliance (as 
                                determined appropriate by the 
                                Secretary).
                                    ``(II) Applicable per instance 
                                amount.--In this clause, the term 
                                `applicable per instance amount' 
                                means--
                                            ``(aa) in the case where 
                                        the deficiency is found to be a 
                                        direct proximate cause of death 
                                        of a resident of the facility, 
                                        an amount not to exceed 
                                        $100,000.
                                            ``(bb) in each case of a 
                                        deficiency where the facility 
                                        is cited for actual harm or 
                                        immediate jeopardy, an amount 
                                        not less than $3,050 and not 
                                        more than $25,000; and
                                            ``(cc) in each case of any 
                                        other deficiency, an amount not 
                                        less than $250 and not to 
                                        exceed $3050.
                                    ``(III) Applicable per day 
                                amount.--In this clause, the term 
                                `applicable per day amount' means--
                                            ``(aa) in each case of a 
                                        deficiency where the facility 
                                        is cited for actual harm or 
                                        immediate jeopardy, an amount 
                                        not less than $3,050 and not 
                                        more than $25,000 and
                                            ``(bb) in each case of any 
                                        other deficiency, an amount not 
                                        less than $250 and not to 
                                        exceed $3,050.
                                    ``(IV) Reduction of civil money 
                                penalties in certain circumstances.--
                                Subject to subclauses (V) and (VI), in 
                                the case where a facility self-reports 
                                and promptly corrects a deficiency for 
                                which a penalty was imposed under this 
                                clause not later than 10 calendar days 
                                after the date of such imposition, the 
                                Secretary may reduce the amount of the 
                                penalty imposed by not more than 50 
                                percent.
                                    ``(V) Prohibition on reduction for 
                                certain deficiencies.--
                                            ``(aa) Repeat 
                                        deficiencies.--The Secretary 
                                        may not reduce under subclause 
                                        (IV) the amount of a penalty if 
                                        the deficiency is a repeat 
                                        deficiency.
                                            ``(bb) Certain other 
                                        deficiencies.--The Secretary 
                                        may not reduce under subclause 
                                        (IV) the amount of a penalty if 
                                        the penalty is imposed for a 
                                        deficiency described in 
                                        subclause (II)(aa) or (III)(aa) 
                                        and the actual harm or 
                                        widespread harm immediately 
                                        jeopardizes the health or 
                                        safety of a resident or 
                                        residents of the facility, or 
                                        if the penalty is imposed for a 
                                        deficiency described in 
                                        subclause (II)(bb).
                                    ``(VI) Limitation on aggregate 
                                reductions.--The aggregate reduction in 
                                a penalty under subclause (IV) may not 
                                exceed 35 percent on the basis of self-
                                reporting, on the basis of a waiver of 
                                an appeal (as provided for under 
                                regulations under section 488.436 of 
                                title 42, Code of Federal Regulations), 
                                or on the basis of both.
                                    ``(VII) Collection of civil money 
                                penalties.--In the case of a civil 
                                money penalty imposed under this 
                                clause, the Secretary--
                                            ``(aa) subject to item 
                                        (cc), shall, not later than 30 
                                        days after the date of 
                                        imposition of the penalty, 
                                        provide the opportunity for the 
                                        facility to participate in an 
                                        independent informal dispute 
                                        resolution process, established 
                                        by the State survey agency, 
                                        which generates a written 
                                        record prior to the collection 
                                        of such penalty, but such 
                                        opportunity shall not affect 
                                        the responsibility of the State 
                                        survey agency for making final 
                                        recommendations for such 
                                        penalties;
                                            ``(bb) in the case where 
                                        the penalty is imposed for each 
                                        day of noncompliance, shall not 
                                        impose a penalty for any day 
                                        during the period beginning on 
                                        the initial day of the 
                                        imposition of the penalty and 
                                        ending on the day on which the 
                                        informal dispute resolution 
                                        process under item (aa) is 
                                        completed;
                                            ``(cc) may provide for the 
                                        collection of such civil money 
                                        penalty and the placement of 
                                        such amounts collected in an 
                                        escrow account under the 
                                        direction of the Secretary on 
                                        the earlier of the date on 
                                        which the informal dispute 
                                        resolution process under item 
                                        (aa) is completed or the date 
                                        that is 90 days after the date 
                                        of the imposition of the 
                                        penalty;
                                            ``(dd) may provide that 
                                        such amounts collected are kept 
                                        in such account pending the 
                                        resolution of any subsequent 
                                        appeals;
                                            ``(ee) in the case where 
                                        the facility successfully 
                                        appeals the penalty, may 
                                        provide for the return of such 
                                        amounts collected (plus 
                                        interest) to the facility; and
                                            ``(ff) in the case where 
                                        all such appeals are 
                                        unsuccessful, may provide that 
                                        some portion of such amounts 
                                        collected may be used to 
                                        support activities that benefit 
                                        residents, including assistance 
                                        to support and protect 
                                        residents of a facility that 
                                        closes (voluntarily or 
                                        involuntarily) or is 
                                        decertified (including 
                                        offsetting costs of relocating 
                                        residents to home and 
                                        community-based settings or 
                                        another facility), projects 
                                        that support resident and 
                                        family councils and other 
                                        consumer involvement in 
                                        assuring quality care in 
                                        facilities, and facility 
                                        improvement initiatives 
                                        approved by the Secretary 
                                        (including joint training of 
                                        facility staff and surveyors, 
                                        technical assistance for 
                                        facilities under quality 
                                        assurance programs, the 
                                        appointment of temporary 
                                        management, and other 
                                        activities approved by the 
                                        Secretary).
                                    ``(VIII) Procedure.--The provisions 
                                of section 1128A (other than 
                                subsections (a) and (b) and except to 
                                the extent that such provisions require 
                                a hearing prior to the imposition of a 
                                civil money penalty) shall apply to a 
                                civil money penalty under this clause 
                                in the same manner as such provisions 
                                apply to a penalty or proceeding under 
                                section 1128A(a).''.
            (2) Conforming amendment.--The second sentence of section 
        1819(h)(5) of the Social Security Act (42 U.S.C. 1395i-3(h)(5)) 
        is amended by inserting ``(ii),''after ``(i),''.
    (b) Nursing Facilities.--
            (1) Penalties imposed by the state.--
                    (A) In general.--Section 1919(h)(2) of the Social 
                Security Act (42 U.S.C. 1396r(h)(2)) is amended--
                            (i) in subparagraph (A)(ii), by striking 
                        the first sentence and inserting the following: 
                        ``A civil money penalty in accordance with 
                        subparagraph (G).''; and
                            (ii) by adding at the end the following new 
                        subparagraph:
                    ``(G) Civil money penalties.--
                            ``(i) In general.--The State may impose a 
                        civil money penalty under subparagraph (A)(ii) 
                        in the applicable per instance or per day 
                        amount (as defined in subclause (II) and (III)) 
                        for each day or instance, respectively, of 
                        noncompliance (as determined appropriate by the 
                        Secretary).
                            ``(ii) Applicable per instance amount.--In 
                        this subparagraph, the term `applicable per 
                        instance amount' means--
                                    ``(I) in the case where the 
                                deficiency is found to be a direct 
                                proximate cause of death of a resident 
                                of the facility, an amount not to 
                                exceed $100,000.
                                    ``(II) in each case of a deficiency 
                                where the facility is cited for actual 
                                harm or immediate jeopardy, an amount 
                                not less than $3,050 and not more than 
                                $25,000; and
                                    ``(III) in each case of any other 
                                deficiency, an amount not less than 
                                $250 and not to exceed $3050.
                            ``(iii) Applicable per day amount.--In this 
                        subparagraph, the term `applicable per day 
                        amount' means--
                                    ``(I) in each case of a deficiency 
                                where the facility is cited for actual 
                                harm or immediate jeopardy, an amount 
                                not less than $3,050 and not more than 
                                $25,000 and
                                    ``(II) in each case of any other 
                                deficiency, an amount not less than 
                                $250 and not to exceed $3,050.
                            ``(iv) Reduction of civil money penalties 
                        in certain circumstances.--Subject to clauses 
                        (v) and (vi), in the case where a facility 
                        self-reports and promptly corrects a deficiency 
                        for which a penalty was imposed under 
                        subparagraph (A)(ii) not later than 10 calendar 
                        days after the date of such imposition, the 
                        State may reduce the amount of the penalty 
                        imposed by not more than 50 percent.
                            ``(v) Prohibition on reduction for certain 
                        deficiencies.--
                                    ``(I) Repeat deficiencies.--The 
                                State may not reduce under clause (iv) 
                                the amount of a penalty if the State 
                                had reduced a penalty imposed on the 
                                facility in the preceding year under 
                                such clause with respect to a repeat 
                                deficiency.
                                    ``(II) Certain other 
                                deficiencies.--The State may not reduce 
                                under clause (iv) the amount of a 
                                penalty if the penalty is imposed for a 
                                deficiency described in clause (ii)(II) 
                                or (iii)(I) and the actual harm or 
                                widespread harm that immediately 
                                jeopardizes the health or safety of a 
                                resident or residents of the facility, 
                                or if the penalty is imposed for a 
                                deficiency described in clause (ii)(I).
                                    ``(III) Limitation on aggregate 
                                reductions.--The aggregate reduction in 
                                a penalty under clause (iv) may not 
                                exceed 35 percent on the basis of self-
                                reporting, on the basis of a waiver of 
                                an appeal (as provided for under 
                                regulations under section 488.436 of 
                                title 42, Code of Federal Regulations), 
                                or on the basis of both.
                            ``(vi) Collection of civil money 
                        penalties.--In the case of a civil money 
                        penalty imposed under subparagraph (A)(ii), the 
                        State--
                                    ``(I) subject to subclause (III), 
                                shall, not later than 30 days after the 
                                date of imposition of the penalty, 
                                provide the opportunity for the 
                                facility to participate in an 
                                independent informal dispute resolution 
                                process, established by the State 
                                survey agency, which generates a 
                                written record prior to the collection 
                                of such penalty, but such opportunity 
                                shall not affect the responsibility of 
                                the State survey agency for making 
                                final recommendations for such 
                                penalties;
                                    ``(II) in the case where the 
                                penalty is imposed for each day of 
                                noncompliance, shall not impose a 
                                penalty for any day during the period 
                                beginning on the initial day of the 
                                imposition of the penalty and ending on 
                                the day on which the informal dispute 
                                resolution process under subclause (I) 
                                is completed;
                                    ``(III) may provide for the 
                                collection of such civil money penalty 
                                and the placement of such amounts 
                                collected in an escrow account under 
                                the direction of the State on the 
                                earlier of the date on which the 
                                informal dispute resolution process 
                                under subclause (I) is completed or the 
                                date that is 90 days after the date of 
                                the imposition of the penalty;
                                    ``(IV) may provide that such 
                                amounts collected are kept in such 
                                account pending the resolution of any 
                                subsequent appeals;
                                    ``(V) in the case where the 
                                facility successfully appeals the 
                                penalty, may provide for the return of 
                                such amounts collected (plus interest) 
                                to the facility; and
                                    ``(VI) in the case where all such 
                                appeals are unsuccessful, may provide 
                                that such funds collected shall be used 
                                for the purposes described in the 
                                second sentence of subparagraph 
                                (A)(ii).''.
                    (B) Conforming amendment.--The second sentence of 
                section 1919(h)(2)(A)(ii) of the Social Security Act 
                (42 U.S.C. 1396r(h)(2)(A)(ii)) is amended by inserting 
                before the period at the end the following: ``, and 
                some portion of such funds may be used to support 
                activities that benefit residents, including assistance 
                to support and protect residents of a facility that 
                closes (voluntarily or involuntarily) or is decertified 
                (including offsetting costs of relocating residents to 
                home and community-based settings or another facility), 
                projects that support resident and family councils and 
                other consumer involvement in assuring quality care in 
                facilities, and facility improvement initiatives 
                approved by the Secretary (including joint training of 
                facility staff and surveyors, providing technical 
                assistance to facilities under quality assurance 
                programs, the appointment of temporary management, and 
                other activities approved by the Secretary)''.
            (2) Penalties imposed by the secretary.--
                    (A) In general.--Section 1919(h)(3)(C)(ii) of the 
                Social Security Act (42 U.S.C. 1396r(h)(3)(C)) is 
                amended to read as follows:
                            ``(ii) Authority with respect to civil 
                        money penalties.--
                                    ``(I) Amount.--Subject to subclause 
                                (II), the Secretary may impose a civil 
                                money penalty in an amount not to 
                                exceed $10,000 for each day or each 
                                instance of noncompliance (as 
                                determined appropriate by the 
                                Secretary).
                                    ``(II) Reduction of civil money 
                                penalties in certain circumstances.--
                                Subject to subclause (III), in the case 
                                where a facility self-reports and 
                                promptly corrects a deficiency for 
                                which a penalty was imposed under this 
                                clause not later than 10 calendar days 
                                after the date of such imposition, the 
                                Secretary may reduce the amount of the 
                                penalty imposed by not more than 50 
                                percent.
                                    ``(III) Prohibition on reduction 
                                for repeat deficiencies.--The Secretary 
                                may not reduce the amount of a penalty 
                                under subclause (II) if the Secretary 
                                had reduced a penalty imposed on the 
                                facility in the preceding year under 
                                such subclause with respect to a repeat 
                                deficiency.
                                    ``(IV) Collection of civil money 
                                penalties.--In the case of a civil 
                                money penalty imposed under this 
                                clause, the Secretary--
                                            ``(aa) subject to item 
                                        (bb), shall, not later than 30 
                                        days after the date of 
                                        imposition of the penalty, 
                                        provide the opportunity for the 
                                        facility to participate in an 
                                        independent informal dispute 
                                        resolution process which 
                                        generates a written record 
                                        prior to the collection of such 
                                        penalty;
                                            ``(bb) in the case where 
                                        the penalty is imposed for each 
                                        day of noncompliance, shall not 
                                        impose a penalty for any day 
                                        during the period beginning on 
                                        the initial day of the 
                                        imposition of the penalty and 
                                        ending on the day on which the 
                                        informal dispute resolution 
                                        process under item (aa) is 
                                        completed;
                                            ``(cc) may provide for the 
                                        collection of such civil money 
                                        penalty and the placement of 
                                        such amounts collected in an 
                                        escrow account under the 
                                        direction of the Secretary on 
                                        the earlier of the date on 
                                        which the informal dispute 
                                        resolution process under item 
                                        (aa) is completed or the date 
                                        that is 90 days after the date 
                                        of the imposition of the 
                                        penalty;
                                            ``(dd) may provide that 
                                        such amounts collected are kept 
                                        in such account pending the 
                                        resolution of any subsequent 
                                        appeals;
                                            ``(ee) in the case where 
                                        the facility successfully 
                                        appeals the penalty, may 
                                        provide for the return of such 
                                        amounts collected (plus 
                                        interest) to the facility; and
                                            ``(ff) in the case where 
                                        all such appeals are 
                                        unsuccessful, may provide that 
                                        some portion of such amounts 
                                        collected may be used to 
                                        support activities that benefit 
                                        residents, including assistance 
                                        to support and protect 
                                        residents of a facility that 
                                        closes (voluntarily or 
                                        involuntarily) or is 
                                        decertified (including 
                                        offsetting costs of relocating 
                                        residents to home and 
                                        community-based settings or 
                                        another facility), projects 
                                        that support resident and 
                                        family councils and other 
                                        consumer involvement in 
                                        assuring quality care in 
                                        facilities, and facility 
                                        improvement initiatives 
                                        approved by the Secretary 
                                        (including joint training of 
                                        facility staff and surveyors, 
                                        technical assistance for 
                                        facilities under quality 
                                        assurance programs, the 
                                        appointment of temporary 
                                        management, and other 
                                        activities approved by the 
                                        Secretary).
                                    ``(V) Procedure.--The provisions of 
                                section 1128A (other than subsections 
                                (a) and (b) and except to the extent 
                                that such provisions require a hearing 
                                prior to the imposition of a civil 
                                money penalty) shall apply to a civil 
                                money penalty under this clause in the 
                                same manner as such provisions apply to 
                                a penalty or proceeding under section 
                                1128A(a).''.
                    (B) Conforming amendment.--Section 1919(h)(8) of 
                the Social Security Act (42 U.S.C. 1396r(h)(5)(8)) is 
                amended by inserting ``and in paragraph (3)(C)(ii)'' 
                after ``paragraph (2)(A)''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of the enactment of this Act.

SEC. 1422. NATIONAL INDEPENDENT MONITOR PILOT PROGRAM.

    (a) Establishment.--
            (1) In general.--The Secretary, in consultation with the 
        Inspector General of the Department of Health and Human 
        Services, shall establish a pilot program (in this section 
        referred to as the ``pilot program'') to develop, test, and 
        implement use of an independent monitor to oversee interstate 
        and large intrastate chains of skilled nursing facilities and 
        nursing facilities.
            (2) Selection.--The Secretary shall select chains of 
        skilled nursing facilities and nursing facilities described in 
        paragraph (1) to participate in the pilot program from among 
        those chains that submit an application to the Secretary at 
        such time, in such manner, and containing such information as 
        the Secretary may require.
            (3) Duration.--The Secretary shall conduct the pilot 
        program for a two-year period.
            (4) Implementation.--The Secretary shall implement the 
        pilot program not later than one year after the date of the 
        enactment of this Act.
    (b) Requirements.--The Secretary shall evaluate chains selected to 
participate in the pilot program based on criteria selected by the 
Secretary, including where evidence suggests that one or more 
facilities of the chain are experiencing serious safety and quality of 
care problems. Such criteria may include the evaluation of a chain that 
includes one or more facilities participating in the ``Special Focus 
Facility'' program (or a successor program) or one or more facilities 
with a record of repeated serious safety and quality of care 
deficiencies.
    (c) Responsibilities of the Independent Monitor.--An independent 
monitor that enters into a contract with the Secretary to participate 
in the conduct of such program shall--
            (1) conduct periodic reviews and prepare root-cause quality 
        and deficiency analyses of a chain to assess if facilities of 
        the chain are in compliance with State and Federal laws and 
        regulations applicable to the facilities;
            (2) undertake sustained oversight of the chain, whether 
        publicly or privately held, to involve the owners of the chain 
        and the principal business partners of such owners in 
        facilitating compliance by facilities of the chain with State 
        and Federal laws and regulations applicable to the facilities;
            (3) analyze the management structure, distribution of 
        expenditures, and nurse staffing levels of facilities of the 
        chain in relation to resident census, staff turnover rates, and 
        tenure;
            (4) report findings and recommendations with respect to 
        such reviews, analyses, and oversight to the chain and 
        facilities of the chain, to the Secretary and to relevant 
        States; and
            (5) publish the results of such reviews, analyses, and 
        oversight.
    (d) Implementation of Recommendations.--
            (1) Receipt of finding by chain.--Not later than 10 days 
        after receipt of a finding of an independent monitor under 
        subsection (c)(4), a chain participating in the pilot program 
        shall submit to the independent monitor a report--
                    (A) outlining corrective actions the chain will 
                take to implement the recommendations in such report; 
                or
                    (B) indicating that the chain will not implement 
                such recommendations and why it will not do so.
            (2) Receipt of report by independent monitor.--Not later 
        than 10 days after the date of receipt of a report submitted by 
        a chain under paragraph (1), an independent monitor shall 
        finalize its recommendations and submit a report to the chain 
        and facilities of the chain, the Secretary, and the State (or 
        States) involved, as appropriate, containing such final 
        recommendations.
    (e) Cost of Appointment.--A chain shall be responsible for a 
portion of the costs associated with the appointment of independent 
monitors under the pilot program. The chain shall pay such portion to 
the Secretary (in an amount and in accordance with procedures 
established by the Secretary).
    (f) Waiver Authority.--The Secretary may waive such requirements of 
titles XVIII and XIX of the Social Security Act (42 U.S.C. 1395 et 
seq.; 1396 et seq.) as may be necessary for the purpose of carrying out 
the pilot program.
    (g) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as may be necessary to carry out this section.
    (h) Definitions.--In this section:
            (1) Facility.--The term ``facility'' means a skilled 
        nursing facility or a nursing facility.
            (2) Nursing facility.--The term ``nursing facility'' has 
        the meaning given such term in section 1919(a) of the Social 
        Security Act (42 U.S.C. 1396r(a)).
            (3) Secretary.--The term ``Secretary'' means the Secretary 
        of Health and Human Services, acting through the Assistant 
        Secretary for Planning and Evaluation.
            (4) Skilled nursing facility.--The term ``skilled nursing 
        facility'' has the meaning given such term in section 1819(a) 
        of the Social Security Act (42 U.S.C. 1395(a)).
    (i) Evaluation and Report.--
            (1) Evaluation.--The Inspector General of the Department of 
        Health and Human Services shall evaluate the pilot program. 
        Such evaluation shall--
                    (A) determine whether the independent monitor 
                program should be established on a permanent basis; and
                    (B) if the Inspector General determines that the 
                independent monitor program should be established on a 
                permanent basis, recommend appropriate procedures and 
                mechanisms for such establishment.
            (2) Report.--Not later than 180 days after the completion 
        of the pilot program, the Inspector General shall submit to 
        Congress and the Secretary a report containing the results of 
        the evaluation conducted under paragraph (1), together with 
        recommendations for such legislation and administrative action 
        as the Inspector General determines appropriate.

SEC. 1423. NOTIFICATION OF FACILITY CLOSURE.

    (a) Skilled Nursing Facilities.--
            (1) In general.--Section 1819(c) of the Social Security Act 
        (42 U.S.C. 1395i-3(c)) is amended by adding at the end the 
        following new paragraph:
            ``(7) Notification of facility closure.--
                    ``(A) In general.--Any individual who is the 
                administrator of a skilled nursing facility must--
                            ``(i) submit to the Secretary, the State 
                        long-term care ombudsman, residents of the 
                        facility, and the legal representatives of such 
                        residents or other responsible parties, written 
                        notification of an impending closure--
                                    ``(I) subject to subclause (II), 
                                not later than the date that is 60 days 
                                prior to the date of such closure; and
                                    ``(II) in the case of a facility 
                                where the Secretary terminates the 
                                facility's participation under this 
                                title, not later than the date that the 
                                Secretary determines appropriate;
                            ``(ii) ensure that the facility does not 
                        admit any new residents on or after the date on 
                        which such written notification is submitted; 
                        and
                            ``(iii) include in the notice a plan for 
                        the transfer and adequate relocation of the 
                        residents of the facility by a specified date 
                        prior to closure that has been approved by the 
                        State, including assurances that the residents 
                        will be transferred to the most appropriate 
                        facility or other setting in terms of quality, 
                        services, and location, taking into 
                        consideration the needs and best interests of 
                        each resident.
                    ``(B) Relocation.--
                            ``(i) In general.--The State shall ensure 
                        that, before a facility closes, all residents 
                        of the facility have been successfully 
                        relocated to another facility or an alternative 
                        home and community-based setting.
                            ``(ii) Continuation of payments until 
                        residents relocated.--The Secretary may, as the 
                        Secretary determines appropriate, continue to 
                        make payments under this title with respect to 
                        residents of a facility that has submitted a 
                        notification under subparagraph (A) during the 
                        period beginning on the date such notification 
                        is submitted and ending on the date on which 
                        the resident is successfully relocated.''.
            (2) Conforming amendments.--Section 1819(h)(4) of the 
        Social Security Act (42 U.S.C. 1395i-3(h)(4)) is amended--
                    (A) in the first sentence, by striking ``the 
                Secretary shall terminate'' and inserting ``the 
                Secretary, subject to subsection (c)(7), shall 
                terminate''; and
                    (B) in the second sentence, by striking 
                ``subsection (c)(2)'' and inserting ``paragraphs (2) 
                and (7) of subsection (c)''.
    (b) Nursing Facilities.--
            (1) In general.--Section 1919(c) of the Social Security Act 
        (42 U.S.C. 1396r(c)) is amended by adding at the end the 
        following new paragraph:
            ``(9) Notification of facility closure.--
                    ``(A) In general.--Any individual who is an 
                administrator of a nursing facility must--
                            ``(i) submit to the Secretary, the State 
                        long-term care ombudsman, residents of the 
                        facility, and the legal representatives of such 
                        residents or other responsible parties, written 
                        notification of an impending closure--
                                    ``(I) subject to subclause (II), 
                                not later than the date that is 60 days 
                                prior to the date of such closure; and
                                    ``(II) in the case of a facility 
                                where the Secretary terminates the 
                                facility's participation under this 
                                title, not later than the date that the 
                                Secretary determines appropriate;
                            ``(ii) ensure that the facility does not 
                        admit any new residents on or after the date on 
                        which such written notification is submitted; 
                        and
                            ``(iii) include in the notice a plan for 
                        the transfer and adequate relocation of the 
                        residents of the facility by a specified date 
                        prior to closure that has been approved by the 
                        State, including assurances that the residents 
                        will be transferred to the most appropriate 
                        facility or other setting in terms of quality, 
                        services, and location, taking into 
                        consideration the needs and best interests of 
                        each resident.
                    ``(B) Relocation.--
                            ``(i) In general.--The State shall ensure 
                        that, before a facility closes, all residents 
                        of the facility have been successfully 
                        relocated to another facility or an alternative 
                        home and community-based setting.
                            ``(ii) Continuation of payments until 
                        residents relocated.--The Secretary may, as the 
                        Secretary determines appropriate, continue to 
                        make payments under this title with respect to 
                        residents of a facility that has submitted a 
                        notification under subparagraph (A) during the 
                        period beginning on the date such notification 
                        is submitted and ending on the date on which 
                        the resident is successfully relocated.''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of the enactment of this Act.

                    PART 3--IMPROVING STAFF TRAINING

SEC. 1431. DEMENTIA AND ABUSE PREVENTION TRAINING.

    (a) Skilled Nursing Facilities.--Section 1819(f)(2)(A)(i)(I) of the 
Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(I)) is amended by 
inserting ``(including, in the case of initial training and, if the 
Secretary determines appropriate, in the case of ongoing training, 
dementia management training and resident abuse prevention training)'' 
after ``curriculum''.
    (b) Nursing Facilities.--Section 1919(f)(2)(A)(i)(I) of the Social 
Security Act (42 U.S.C. 1396r(f)(2)(A)(i)(I)) is amended by inserting 
``(including, in the case of initial training and, if the Secretary 
determines appropriate, in the case of ongoing training, dementia 
management training and resident abuse prevention training)'' after 
``curriculum''.
    (c) Effective Date.--The amendments made by this section shall take 
effect 1 year after the date of the enactment of this Act.

SEC. 1432. STUDY AND REPORT ON TRAINING REQUIRED FOR CERTIFIED NURSE 
              AIDES AND SUPERVISORY STAFF.

    (a) Study.--
            (1) In general.--The Secretary shall conduct a study on the 
        content of training for certified nurse aides and supervisory 
        staff of skilled nursing facilities and nursing facilities. The 
        study shall include an analysis of the following:
                    (A) Whether the number of initial training hours 
                for certified nurse aides required under sections 
                1819(f)(2)(A)(i)(II) and 1919(f)(2)(A)(i)(II) of the 
                Social Security Act (42 U.S.C. 1395i-3(f)(2)(A)(i)(II); 
                1396r(f)(2)(A)(i)(II)) should be increased from 75 and, 
                if so, what the required number of initial training 
                hours should be, including any recommendations for the 
                content of such training (including training related to 
                dementia).
                    (B) Whether requirements for ongoing training under 
                such sections 1819(f)(2)(A)(i)(II) and 
                1919(f)(2)(A)(i)(II) should be increased from 12 hours 
                per year, including any recommendations for the content 
                of such training.
            (2) Consultation.--In conducting the analysis under 
        paragraph (1)(A), the Secretary shall consult with States that, 
        as of the date of the enactment of this Act, require more than 
        75 hours of training for certified nurse aides.
            (3) Definitions.--In this section:
                    (A) Nursing facility.--The term ``nursing 
                facility'' has the meaning given such term in section 
                1919(a) of the Social Security Act (42 U.S.C. 
                1396r(a)).
                    (B) Secretary.--The term ``Secretary'' means the 
                Secretary of Health and Human Services, acting through 
                the Assistant Secretary for Planning and Evaluation.
                    (C) Skilled nursing facility.--The term ``skilled 
                nursing facility'' has the meaning given such term in 
                section 1819(a) of the Social Security Act (42 U.S.C. 
                1395(a)).
    (b) Report.--Not later than 2 years after the date of the enactment 
of this Act, the Secretary shall submit to Congress a report containing 
the results of the study conducted under subsection (a), together with 
recommendations for such legislation and administrative action as the 
Secretary determines appropriate.

SEC. 1433. QUALIFICATION OF DIRECTOR OF FOOD SERVICES OF A SKILLED 
              NURSING FACILITY OR NURSING FACILITY.

    (a) Medicare.--Section 1819(b)(4)(A) of the Social Security Act (42 
U.S.C. 1395i-3(b)(4)(A)) is amended by adding at the end the following: 
``With respect to meeting the staffing requirement imposed by the 
Secretary to carry out clause (iv), the full-time director of food 
services of the facility, if not a qualified dietitian (as defined in 
section 483.35(a)(2) of title 42, Code of Federal Regulations, as in 
effect as of the date of the enactment of this sentence), shall be a 
Certified Dietary Manager meeting the requirements of the Certifying 
Board for Dietary Managers, or a Dietetic Technician, Registered 
meeting the requirements of the Commission on Dietetic Registration or 
have equivalent military, academic, or other qualifications (as 
specified by the Secretary).''.
    (b) Medicaid.--Section 1919(b)(4)(A) of the Social Security Act (42 
U.S.C. 1396r(b)(4)(A)) is amended by adding at the end the following: 
``With respect to meeting the staffing requirement imposed by the 
Secretary to carry out clause (iv), the full-time director of food 
services of the facility, if not a qualified dietitian (as defined in 
section 483.35(a)(2) of title 42, Code of Federal Regulations, as in 
effect as of the date of the enactment of this sentence), shall be a 
Certified Dietary Manager meeting the requirements of the Certifying 
Board for Dietary Managers, or a Dietetic Technician, Registered 
meeting the requirements of the Commission on Dietetic Registration or 
have equivalent military, academic, or other qualifications (as 
specified by the Secretary).''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on the date that is 180 days after the date of enactment of this 
Act.

                    Subtitle C--Quality Measurements

SEC. 1441. ESTABLISHMENT OF NATIONAL PRIORITIES FOR QUALITY 
              IMPROVEMENT.

    Title XI of the Social Security Act, as amended by section 1401(a), 
is further amended by adding at the end the following new part:

                     ``Part E--Quality Improvement

   ``establishment of national priorities for performance improvement

    ``Sec. 1191.  (a) Establishment of National Priorities by the 
Secretary.--The Secretary shall establish and periodically update, not 
less frequently than triennially, national priorities for performance 
improvement.
    ``(b) Recommendations for National Priorities.--In establishing and 
updating national priorities under subsection (a), the Secretary shall 
solicit and consider recommendations from multiple outside 
stakeholders.
    ``(c) Considerations in Setting National Priorities.--With respect 
to such priorities, the Secretary shall ensure that priority is given 
to areas in the delivery of health care services in the United States 
that--
            ``(1) contribute to a large burden of disease, including 
        those that address the health care provided to patients with 
        prevalent, high-cost chronic diseases;
            ``(2) have the greatest potential to decrease morbidity and 
        mortality in this country, including those that are designed to 
        eliminate harm to patients;
            ``(3) have the greatest potential for improving the 
        performance, affordability, and patient-centeredness of health 
        care, including those due to variations in care;
            ``(4) address health disparities across groups and areas; 
        and
            ``(5) have the potential for rapid improvement due to 
        existing evidence, standards of care or other reasons.
    ``(d) Definitions.--In this part:
            ``(1) Consensus-based entity.--The term `consensus-based 
        entity' means an entity with a contract with the Secretary 
        under section 1890.
            ``(2) Quality measure.--The term `quality measure' means a 
        national consensus standard for measuring the performance and 
        improvement of population health, or of institutional providers 
        of services, physicians, and other health care practitioners in 
        the delivery of health care services.
    ``(e) Funding.--
            ``(1) In general.--The Secretary shall provide for the 
        transfer, from the Federal Hospital Insurance Trust Fund under 
        section 1817 and the Federal Supplementary Medical Insurance 
        Trust Fund under section 1841 (in such proportion as the 
        Secretary determines appropriate), of $2,000,000, for the 
        activities under this section for each of the fiscal years 2010 
        through 2014.
            ``(2) Authorization of appropriations.--For purposes of 
        carrying out the provisions of this section, in addition to 
        funds otherwise available, out of any funds in the Treasury not 
        otherwise appropriated, there are appropriated to the Secretary 
        of Health and Human Services $2,000,000 for each of the fiscal 
        years 2010 through 2014.''.

SEC. 1442. DEVELOPMENT OF NEW QUALITY MEASURES; GAO EVALUATION OF DATA 
              COLLECTION PROCESS FOR QUALITY MEASUREMENT.

    Part E of title XI of the Social Security Act, as added by section 
1441, is amended by adding at the end the following new sections:

``SEC. 1192. DEVELOPMENT OF NEW QUALITY MEASURES.

    ``(a) Agreements With Qualified Entities.--
            ``(1) In general.--The Secretary shall enter into 
        agreements with qualified entities to develop quality measures 
        for the delivery of health care services in the United States.
            ``(2) Form of agreements.--The Secretary may carry out 
        paragraph (1) by contract, grant, or otherwise.
            ``(3) Recommendations of consensus-based entity.--In 
        carrying out this section, the Secretary shall--
                    ``(A) seek public input; and
                    ``(B) take into consideration recommendations of 
                the consensus-based entity with a contract with the 
                Secretary under section 1890(a).
    ``(b) Determination of Areas Where Quality Measures Are Required.--
Consistent with the national priorities established under this part and 
with the programs administered by the Centers for Medicare & Medicaid 
Services and in consultation with other relevant Federal agencies, the 
Secretary shall determine areas in which quality measures for assessing 
health care services in the United States are needed.
    ``(c) Development of Quality Measures.--
            ``(1) Patient-centered and population-based measures.--In 
        entering into agreements under subsection (a), the Secretary 
        shall give priority to the development of quality measures that 
        allow the assessment of--
                    ``(A) health outcomes, presence of impairment, and 
                functional status of patients;
                    ``(B) the continuity and coordination of care and 
                care transitions for patients across providers and 
                health care settings, including end of life care;
                    ``(C) patient experience and patient engagement;
                    ``(D) the safety, effectiveness, and timeliness of 
                care;
                    ``(E) health disparities including those associated 
                with individual race, ethnicity, age, gender, place of 
                residence or language; and
                    ``(F) the efficiency and resource use in the 
                provision of care.
            ``(2) Use of funds.--An entity that enters into an 
        agreement under subsection (a) shall develop quality measures 
        that--
                    ``(A) to the extent feasible, have the ability to 
                be collected through the use of health information 
                technologies supporting better delivery of health care 
                services; and
                    ``(B) are available free of charge to users for the 
                use of such measures.
            ``(3) Availability of measures.--The Secretary shall make 
        quality measures developed under this section available to the 
        public.
            ``(4) Testing of proposed measures.--The Secretary may use 
        amounts made available under subsection (f) to fund the testing 
        of proposed quality measures by qualified entities. Testing 
        funded under this paragraph shall include testing of the 
        feasibility and usability of proposed measures.
            ``(5) Updating of endorsed measures.--The Secretary may use 
        amounts made available under subsection (f) to fund the 
        updating (and testing, if applicable) by consensus-based 
        entities of quality measures that have been previously endorsed 
        by such an entity as new evidence is developed, in a manner 
        consistent with section 1890(b)(3).
    ``(d) Qualified Entities.--Before entering into agreements with a 
qualified entity, the Secretary shall ensure that the entity is a 
public, private, or academic institution with technical expertise in 
the area of health quality measurement.
    ``(e) Application for Grant.--A grant may be made under this 
section only if an application for the grant is submitted to the 
Secretary and the application is in such form, is made in such manner, 
and contains such agreements, assurances, and information as the 
Secretary determines to be necessary to carry out this section.
    ``(f) Funding.--
            ``(1) In general.--The Secretary shall provide for the 
        transfer, from the Federal Hospital Insurance Trust Fund under 
        section 1817 and the Federal Supplementary Medical Insurance 
        Trust Fund under section 1841 (in such proportion as the 
        Secretary determines appropriate), of $25,000,000, to the 
        Secretary for purposes of carrying out this section for each of 
        the fiscal years 2010 through 2014.
            ``(2) Authorization of appropriations.--For purposes of 
        carrying out the provisions of this section, in addition to 
        funds otherwise available, out of any funds in the Treasury not 
        otherwise appropriated, there are appropriated to the Secretary 
        of Health and Human Services $25,000,000 for each of the fiscal 
        years 2010 through 2014.

``SEC. 1193. GAO EVALUATION OF DATA COLLECTION PROCESS FOR QUALITY 
              MEASUREMENT.

    ``(a) GAO Evaluations.--The Comptroller General of the United 
States shall conduct periodic evaluations of the implementation of the 
data collection processes for quality measures used by the Secretary.
    ``(b) Considerations.--In carrying out the evaluation under 
subsection (a), the Comptroller General shall determine--
            ``(1) whether the system for the collection of data for 
        quality measures provides for validation of data as relevant 
        and scientifically credible;
            ``(2) whether data collection efforts under the system use 
        the most efficient and cost-effective means in a manner that 
        minimizes administrative burden on persons required to collect 
        data and that adequately protects the privacy of patients' 
        personal health information and provides data security;
            ``(3) whether standards under the system provide for an 
        appropriate opportunity for physicians and other clinicians and 
        institutional providers of services to review and correct 
        findings; and
            ``(4) the extent to which quality measures are consistent 
        with section 1192(c)(1) or result in direct or indirect costs 
        to users of such measures.
    ``(c) Report.--The Comptroller General shall submit reports to 
Congress and to the Secretary containing a description of the findings 
and conclusions of the results of each such evaluation.''.

SEC. 1443. MULTI-STAKEHOLDER PRE-RULEMAKING INPUT INTO SELECTION OF 
              QUALITY MEASURES.

    Section 1808 of the Social Security Act (42 U.S.C. 1395b-9) is 
amended by adding at the end the following new subsection:
    ``(d) Multi-stakeholder Pre-rulemaking Input Into Selection of 
Quality Measures.--
            ``(1) List of measures.--Not later than December 1 before 
        each year (beginning with 2011), the Secretary shall make 
        public a list of measures being considered for selection for 
        quality measurement by the Secretary in rulemaking with respect 
        to payment systems under this title beginning in the payment 
        year beginning in such year and for payment systems beginning 
        in the calendar year following such year, as the case may be.
            ``(2) Consultation on selection of endorsed quality 
        measures.--A consensus-based entity that has entered into a 
        contract under section 1890 shall, as part of such contract, 
        convene multi-stakeholder groups to provide recommendations on 
        the selection of individual or composite quality measures, for 
        use in reporting performance information to the public or for 
        use in public health care programs.
            ``(3) Multi-stakeholder input.--Not later than February 1 
        of each year (beginning with 2011), the consensus-based entity 
        described in paragraph (2) shall transmit to the Secretary the 
        recommendations of multi-stakeholder groups provided under 
        paragraph (2). Such recommendations shall be included in the 
        transmissions the consensus-based entity makes to the Secretary 
        under the contract provided for under section 1890.
            ``(4) Requirement for transparency in process.--
                    ``(A) In general.--In convening multi-stakeholder 
                groups under paragraph (2) with respect to the 
                selection of quality measures, the consensus-based 
                entity described in such paragraph shall provide for an 
                open and transparent process for the activities 
                conducted pursuant to such convening.
                    ``(B) Selection of organizations participating in 
                multi-stakeholder groups.--The process under paragraph 
                (2) shall ensure that the selection of representatives 
                of multi-stakeholder groups includes provision for 
                public nominations for, and the opportunity for public 
                comment on, such selection.
            ``(5) Use of input.--The respective proposed rule shall 
        contain a summary of the recommendations made by the multi-
        stakeholder groups under paragraph (2), as well as other 
        comments received regarding the proposed measures, and the 
        extent to which such proposed rule follows such recommendations 
        and the rationale for not following such recommendations.
            ``(6) Multi-stakeholder groups.--For purposes of this 
        subsection, the term `multi-stakeholder groups' means, with 
        respect to a quality measure, a voluntary collaborative of 
        organizations representing persons interested in or affected by 
        the use of such quality measure, such as the following:
                    ``(A) Hospitals and other institutional providers.
                    ``(B) Physicians.
                    ``(C) Health care quality alliances.
                    ``(D) Nurses and other health care practitioners.
                    ``(E) Health plans.
                    ``(F) Patient advocates and consumer groups.
                    ``(G) Employers.
                    ``(H) Public and private purchasers of health care 
                items and services.
                    ``(I) Labor organizations.
                    ``(J) Relevant departments or agencies of the 
                United States.
                    ``(K) Biopharmaceutical companies and manufacturers 
                of medical devices.
                    ``(L) Licensing, credentialing, and accrediting 
                bodies.
            ``(7) Funding.--
                    ``(A) In general.--The Secretary shall provide for 
                the transfer, from the Federal Hospital Insurance Trust 
                Fund under section 1817 and the Federal Supplementary 
                Medical Insurance Trust Fund under section 1841 (in 
                such proportion as the Secretary determines 
                appropriate), of $1,000,000, to the Secretary for 
                purposes of carrying out this subsection for each of 
                the fiscal years 2010 through 2014.
                    ``(B) Authorization of appropriations.--For 
                purposes of carrying out the provisions of this 
                subsection, in addition to funds otherwise available, 
                out of any funds in the Treasury not otherwise 
                appropriated, there are appropriated to the Secretary 
                of Health and Human Services $1,000,000 for each of the 
                fiscal years 2010 through 2014.''.

SEC. 1444. APPLICATION OF QUALITY MEASURES.

    (a) Inpatient Hospital Services.--Section 1886(b)(3)(B) of such Act 
(42 U.S.C. 1395ww(b)(3)(B)) is amended by adding at the end the 
following new clause:
    ``(x)(I) Subject to subclause (II), for purposes of reporting data 
on quality measures for inpatient hospital services furnished during 
fiscal year 2012 and each subsequent fiscal year, the quality measures 
specified under clause (viii) shall be measures selected by the 
Secretary from measures that have been endorsed by the entity with a 
contract with the Secretary under section 1890(a).
    ``(II) In the case of a specified area or medical topic determined 
appropriate by the Secretary for which a feasible and practical quality 
measure has not been endorsed by the entity with a contract under 
section 1890(a), the Secretary may specify a measure that is not so 
endorsed as long as due consideration is given to measures that have 
been endorsed or adopted by a consensus organization identified by the 
Secretary. The Secretary shall submit such a non-endorsed measure to 
the entity for consideration for endorsement. If the entity considers 
but does not endorse such a measure and if the Secretary does not 
phase-out use of such measure, the Secretary shall include the 
rationale for continued use of such a measure in rulemaking.''.
    (b) Outpatient Hospital Services.--Section 1833(t)(17) of such Act 
(42 U.S.C. 1395l(t)(17)) is amended by adding at the end the following 
new subparagraph:
                    ``(F) Use of endorsed quality measures.--The 
                provisions of clause (x) of section 1886(b)(3)(C) shall 
                apply to quality measures for covered OPD services 
                under this paragraph in the same manner as such 
                provisions apply to quality measures for inpatient 
                hospital services.''.
    (c) Physicians' Services.--Section 1848(k)(2)(C)(ii) of such Act 
(42 U.S.C. 1395w-4(k)(2)(C)(ii)) is amended by adding at the end the 
following: ``The Secretary shall submit such a non-endorsed measure to 
the entity for consideration for endorsement. If the entity considers 
but does not endorse such a measure and if the Secretary does not 
phase-out use of such measure, the Secretary shall include the 
rationale for continued use of such a measure in rulemaking.''.
    (d) Renal Dialysis Services.--Section 1881(h)(2)(B)(ii) of such Act 
(42 U.S.C. 1395rr(h)(2)(B)(ii)) is amended by adding at the end the 
following: ``The Secretary shall submit such a non-endorsed measure to 
the entity for consideration for endorsement. If the entity considers 
but does not endorse such a measure and if the Secretary does not 
phase-out use of such measure, the Secretary shall include the 
rationale for continued use of such a measure in rulemaking.''.
    (e) Endorsement of Standards.--Section 1890(b)(2) of the Social 
Security Act (42 U.S.C. 1395aaa(b)(2)) is amended by adding after and 
below subparagraph (B) the following:
        ``If the entity does not endorse a measure, such entity shall 
        explain the reasons and provide suggestions about changes to 
        such measure that might make it a potentially endorsable 
        measure.''.
    (f) Effective Date.--Except as otherwise provided, the amendments 
made by this section shall apply to quality measures applied for 
payment years beginning with 2012 or fiscal year 2012, as the case may 
be.

SEC. 1445. CONSENSUS-BASED ENTITY FUNDING.

    Section 1890(d) of the Social Security Act (42 U.S.C. 1395aaa(d)) 
is amended by striking ``for each of fiscal years 2009 through 2012'' 
and inserting ``for fiscal year 2009, and $12,000,000 for each of the 
fiscal years 2010 through 2012''

           Subtitle D--Physician Payments Sunshine Provision

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.

    (a) In General.--Part A of title XI of the Social Security Act (42 
U.S.C. 1301 et seq.), as amended by section 1631(a), is further amended 
by inserting after section 1128G the following new section:

``SEC. 1128H. FINANCIAL REPORTS ON PHYSICIANS' FINANCIAL RELATIONSHIPS 
              WITH MANUFACTURERS AND DISTRIBUTORS OF COVERED DRUGS, 
              DEVICES, BIOLOGICALS, OR MEDICAL SUPPLIES UNDER MEDICARE, 
              MEDICAID, OR CHIP AND WITH ENTITIES THAT BILL FOR 
              SERVICES UNDER MEDICARE.

    ``(a) Reporting of Payments or Other Transfers of Value.--
            ``(1) In general.--Except as provided in this subsection, 
        not later than March 31, 2011, and annually thereafter, each 
        applicable manufacturer or distributor that provides a payment 
        or other transfer of value to a covered recipient, or to an 
        entity or individual at the request of or designated on behalf 
        of a covered recipient, shall submit to the Secretary, in such 
        electronic form as the Secretary shall require, the following 
        information with respect to the preceding calendar year:
                    ``(A) With respect to the covered recipient, the 
                recipient's name, business address, physician 
                specialty, and national provider identifier.
                    ``(B) With respect to the payment or other transfer 
                of value, other than a drug sample--
                            ``(i) its value and date;
                            ``(ii) the name of the related drug, 
                        device, or supply, if available, to the level 
                        of specificity available; and
                            ``(iii) a description of its form, 
                        indicated (as appropriate for all that apply) 
                        as--
                                    ``(I) cash or a cash equivalent;
                                    ``(II) in-kind items or services;
                                    ``(III) stock, a stock option, or 
                                any other ownership interest, dividend, 
                                profit, or other return on investment; 
                                or
                                    ``(IV) any other form (as defined 
                                by the Secretary).
                    ``(C) With respect to a drug sample, the name, 
                number, date, and dosage units of the sample.
            ``(2) Aggregate reporting.--Information submitted by an 
        applicable manufacturer or distributor under paragraph (1) 
        shall include the aggregate amount of all payments or other 
        transfers of value provided by the manufacturer or distributor 
        to covered recipients (and to entities or individuals at the 
        request of or designated on behalf of a covered recipient) 
        during the year involved, including all payments and transfers 
        of value regardless of whether such payments or transfer of 
        value were individually disclosed.
            ``(3) Special rule for certain payments or other transfers 
        of value.--In the case where an applicable manufacturer or 
        distributor provides a payment or other transfer of value to an 
        entity or individual at the request of or designated on behalf 
        of a covered recipient, the manufacturer or distributor shall 
        disclose that payment or other transfer of value under the name 
        of the covered recipient.
            ``(4) Delayed reporting for payments made pursuant to 
        product development agreements.--In the case of a payment or 
        other transfer of value made to a covered recipient by an 
        applicable manufacturer or distributor pursuant to a product 
        development agreement for services furnished in connection with 
        the development of a new drug, device, biological, or medical 
        supply, the applicable manufacturer or distributor may report 
        the value and recipient of such payment or other transfer of 
        value in the first reporting period under this subsection in 
        the next reporting deadline after the earlier of the following:
                    ``(A) The date of the approval or clearance of the 
                covered drug, device, biological, or medical supply by 
                the Food and Drug Administration.
                    ``(B) Two calendar years after the date such 
                payment or other transfer of value was made.
            ``(5) Delayed reporting for payments made pursuant to 
        clinical investigations.--In the case of a payment or other 
        transfer of value made to a covered recipient by an applicable 
        manufacturer or distributor in connection with a clinical 
        investigation regarding a new drug, device, biological, or 
        medical supply, the applicable manufacturer or distributor may 
        report as required under this section in the next reporting 
        period under this subsection after the earlier of the 
        following:
                    ``(A) The date that the clinical investigation is 
                registered on the website maintained by the National 
                Institutes of Health pursuant to section 671 of the 
                Food and Drug Administration Amendments Act of 2007.
                    ``(B) Two calendar years after the date such 
                payment or other transfer of value was made.
            ``(6) Confidentiality.--Information described in paragraph 
        (4) or (5) shall be considered confidential and shall not be 
        subject to disclosure under section 552 of title 5, United 
        States Code, or any other similar Federal, State, or local law, 
        until or after the date on which the information is made 
        available to the public under such paragraph.
            ``(7) Physicians in self-insured health plans.--Nothing in 
        this subsection shall be construed to require the disclosure of 
        a payment or other transfer of value to a physician by a self-
        insured health plan.
    ``(b) Reporting of Ownership Interest by Physicians.--
            ``(1) Hospitals and other entities that bill medicare.--Not 
        later than March 31 of each year (beginning with 2011), each 
        hospital or other health care entity (not including a Medicare 
        Advantage organization) that bills the Secretary under part A 
        or part B of title XVIII for services shall report on the 
        ownership shares (other than ownership shares described in 
        section 1877(c)) of each physician who, directly or indirectly, 
        owns an interest in the entity.
            ``(2) Additional physician ownership.--Not later than March 
        31 of each year (beginning with 2011), in addition to the 
        requirement under subsection (a)(1), any applicable 
        manufacturer, applicable group purchasing organization, or 
        applicable distributor shall submit to the Secretary, in such 
        electronic form as the Secretary shall require, the following 
        information regarding any ownership or investment interest 
        (other than an ownership or investment interest in a publicly 
        traded security and mutual fund, as described in section 
        1877(c)) held by a physician (or an immediate family member of 
        such physician (as defined for purposes of section 1877(a))) in 
        the applicable manufacturer, applicable group purchasing 
        organization or applicable distributor during the preceding 
        year:
                    ``(A) The dollar amount invested by each physician 
                holding such an ownership or investment interest.
                    ``(B) The value and terms of each such ownership or 
                investment interest.
                    ``(C) Any payment or other transfer of value 
                provided to a physician holding such an ownership or 
                investment interest (or to an entity or individual at 
                the request of or designated on behalf of a physician 
                holding such an ownership or investment interest), 
                including the information described in clauses (i) 
                through (iii) of paragraph (a)(1)(B), and information 
                described in subsection (f)(8)(A) and (f)(8)(B).
                    ``(D) Any other information regarding the ownership 
                or investment interest the Secretary determines 
                appropriate.
            ``(3) Definitions.--In this subsection:
                    ``(A) Physician.--The term `physician' includes a 
                physician's immediate family members (as defined for 
                purposes of section 1877(a)).
                    ``(B) Applicable group purchasing organization.--
                The term `applicable group purchasing organization' 
                means any organization or other entity (as defined by 
                the Secretary) that purchases, arranges for, or 
                negotiates the purchase of a covered drug, device, 
                biological, or medical supply.
            ``(4) Study of practice patterns in advanced diagnostic 
        imaging and radiation oncology services.--The Comptroller 
        General of the United States shall conduct a study to evaluate 
        the extent of use of physician self-referral arrangements and 
        the effects of such arrangements on the cost of providing 
        advanced diagnostic imaging and radiation oncology services to 
        Medicare beneficiaries under title XVIII. The study shall be 
        completed and submitted to Congress not later than July 1, 
        2011.
    ``(c) Public Availability.--
            ``(1) In general.--The Secretary shall establish procedures 
        to ensure that, not later than September 30, 2011, and on June 
        30 of each year beginning thereafter, the information submitted 
        under subsections (a) and (b), other than information regard 
        drug samples, with respect to the preceding calendar year is 
        made available through an Internet website that--
                    ``(A) is searchable and is in a format that is 
                clear and understandable;
                    ``(B) contains information that is presented by the 
                name of the applicable manufacturer or distributor, the 
                name of the covered recipient, the business address of 
                the covered recipient, the specialty (if applicable) of 
                the covered recipient, the value of the payment or 
                other transfer of value, the date on which the payment 
                or other transfer of value was provided to the covered 
                recipient, the form of the payment or other transfer of 
                value, indicated (as appropriate) under subsection 
                (a)(1)(B)(ii), the nature of the payment or other 
                transfer of value, indicated (as appropriate) under 
                subsection (a)(1)(B)(iii), and the name of the covered 
                drug, device, biological, or medical supply, as 
                applicable;
                    ``(C) contains information that is able to be 
                easily aggregated and downloaded;
                    ``(D) contains a description of any enforcement 
                actions taken to carry out this section, including any 
                penalties imposed under subsection (d), during the 
                preceding year;
                    ``(E) contains background information on industry-
                physician relationships;
                    ``(F) in the case of information submitted with 
                respect to a payment or other transfer of value 
                described in subsection (a)(5), lists such information 
                separately from the other information submitted under 
                subsection (a) and designates such separately listed 
                information as funding for clinical research;
                    ``(G) contains any other information the Secretary 
                determines would be helpful to the average consumer; 
                and
                    ``(H) provides the covered recipient an opportunity 
                to submit corrections to the information made available 
                to the public with respect to the covered recipient.
            ``(2) Accuracy of reporting.--The accuracy of the 
        information that is submitted under subsections (a) and (b) and 
        made available under paragraph (1) shall be the responsibility 
        of the reporting entity reporting under subsection (a) or (b), 
        as applicable. The Secretary shall establish procedures to 
        ensure that the covered recipient is provided with an 
        opportunity to submit corrections to the applicable reporting 
        entity with regard to information made public with respect to 
        the covered recipient and, under such procedures, the 
        corrections shall be transmitted to the Secretary.
            ``(3) Special rule for drug samples.--Information relating 
        to drug samples provided under subsection (a) shall not be made 
        available to the public by the Secretary but may be made 
        available outside the Department of Health and Human Services 
        by the Secretary for research or legitimate business purposes 
        pursuant to data use agreements.
            ``(4) Special rule for national provider identifiers.--
        Information relating to national provider identifiers provided 
        under subsection (a) shall not be made available to the public 
        by the Secretary but may be made available outside the 
        Department of Health and Human Services by the Secretary for 
        research or legitimate business purposes pursuant to data use 
        agreements.
    ``(d) Penalties for Noncompliance.--
            ``(1) Failure to report.--
                    ``(A) In general.--Subject to subparagraph (B), 
                except as provided in paragraph (2), any reporting 
                entity that fails to submit information required under 
                subsection (a) or (b), as applicable, in a timely 
                manner in accordance with regulations promulgated to 
                carry out such applicable subsection shall be subject 
                to a civil money penalty of not less than $1,000, but 
                not more than $10,000, for each payment or other 
                transfer of value or ownership or investment interest 
                not reported as required under such subsection. Such 
                penalty shall be imposed and collected in the same 
                manner as civil money penalties under subsection (a) of 
                section 1128A are imposed and collected under that 
                section.
                    ``(B) Limitation.--The total amount of civil money 
                penalties imposed under subparagraph (A), with respect 
                to each annual submission of information under 
                subsection (a) by a reporting entity, shall not exceed 
                $150,000.
            ``(2) Knowing failure to report.--
                    ``(A) In general.--Subject to subparagraph (B), any 
                reporting entity that knowingly fails to submit 
                information required under subsection (a) or (b), as 
                applicable, in a timely manner in accordance with 
                regulations promulgated to carry out such applicable 
                subsection, shall be subject to a civil money penalty 
                of not less than $10,000, but not more than $100,000, 
                for each payment or other transfer of value or 
                ownership or investment interest not reported as 
                required under such subsection. Such penalty shall be 
                imposed and collected in the same manner as civil money 
                penalties under subsection (a) of section 1128A are 
                imposed and collected under that section.
                    ``(B) Limitation.--The total amount of civil money 
                penalties imposed under subparagraph (A) with respect 
                to each annual submission of information under 
                subsection (a) or (b) by an applicable reporting entity 
                shall not exceed $1,000,000, or, if greater, 0.1 
                percentage of the total annual revenues of the 
                reporting entity.
            ``(3) Use of funds.--Funds collected by the Secretary as a 
        result of the imposition of a civil money penalty under this 
        subsection shall be used to carry out this section.
            ``(4) Enforcement through state attorneys general.--The 
        attorney general of a State, after providing notice to the 
        Secretary of an intent to proceed under this paragraph in a 
        specific case and providing the Secretary with an opportunity 
        to bring an action under this subsection and the Secretary 
        declining such opportunity, may proceed under this subsection 
        against an applicable manufacturer or distributor in the State.
    ``(e) Annual Report to Congress.--Not later than April 1 of each 
year beginning with 2011, the Secretary shall submit to Congress a 
report that includes the following:
            ``(1) The information submitted under this section during 
        the preceding year, aggregated for each applicable reporting 
        entity that submitted such information during such year.
            ``(2) A description of any enforcement actions taken to 
        carry out this section, including any penalties imposed under 
        subsection (d), during the preceding year.
    ``(f) Definitions.--In this section:
            ``(1) Applicable distributor.--The term `applicable 
        distributor' means--
                    ``(A) any entity, other than an applicable group 
                purchasing organization, that buys and resells, or 
                receives a commission or other similar form of payment, 
                from another seller, for selling or arranging for the 
                sale of a covered drug, device, biological, or medical 
                supply; or
                    ``(B) any entity under common ownership with such 
                an entity described in subparagraph (A) and which 
                provides assistance or support to such entity so 
                described with respect to the production, preparation, 
                propagation, compounding, conversion, processing, 
                marketing, or distribution of a covered drug, device, 
                biological, or medical supply.
        Such term does not include a wholesale pharmaceutical 
        distributor.
            ``(2) Applicable manufacturer.--The term `applicable 
        manufacturer' means any entity which is engaged in the 
        production, preparation, propagation, compounding, conversion, 
        processing, marketing, or manufacturer-direct distribution of a 
        covered drug, device, biological, or medical supply (or any 
        entity under common ownership with such entity and which 
        provides assistance or support to such entity with respect to 
        the production, preparation, propagation, compounding, 
        conversion, processing, marketing, or distribution or a covered 
        drug, device, biological, or medical supply). For purposes of 
        this section only, such term does not include a retail pharmacy 
        licensed under State law.
            ``(3) Clinical investigation.--The term `clinical 
        investigation' means any experiment involving one or more human 
        subjects, or materials derived from human subjects, in which a 
        drug or device is administered, dispensed, or used.
            ``(4) Covered drug, device, biological, or medical 
        supply.--The term `covered' means, with respect to a drug, 
        device, biological, or medical supply, such a drug, device, 
        biological, or medical supply for which payment is available 
        under title XVIII or a State plan under title XIX or XXI (or a 
        waiver of such a plan).
            ``(5) Covered recipient.--The term `covered recipient' 
        means the following:
                    ``(A) A physician.
                    ``(B) A physician group practice.
                    ``(C) Any other prescriber of a covered drug, 
                device, biological, or medical supply.
                    ``(D) A pharmacy or pharmacist.
                    ``(E) A health insurance issuer, group health plan, 
                or other entity offering a health benefits plan, 
                including any employee of such an issuer, plan, or 
                entity.
                    ``(F) A pharmacy benefit manager, including any 
                employee of such a manager.
                    ``(G) A hospital.
                    ``(H) A medical school.
                    ``(I) A sponsor of a continuing medical education 
                program.
                    ``(J) A patient advocacy or disease specific group.
                    ``(K) A organization of health care professionals.
                    ``(L) A biomedical researcher.
                    ``(M) A group purchasing organization.
            ``(6) Employee.--The term `employee' has the meaning given 
        such term in section 1877(h)(2).
            ``(7) Knowingly.--The term `knowingly' has the meaning 
        given such term in section 3729(b) of title 31, United States 
        Code.
            ``(8) Payment or other transfer of value.--
                    ``(A) In general.--The term `payment or other 
                transfer of value' means a transfer of anything of 
                value for or of any of the following:
                            ``(i) Gift, food, or entertainment.
                            ``(ii) Travel or trip.
                            ``(iii) Honoraria.
                            ``(iv) Research funding or grant.
                            ``(v) Education or conference funding.
                            ``(vi) Consulting fees.
                            ``(vii) Ownership or investment interest 
                        and royalties or license fee.
                    ``(B) Inclusions.--Subject to subparagraph (C), the 
                term `payment or other transfer of value' includes any 
                compensation, gift, honorarium, speaking fee, 
                consulting fee, travel, services, dividend, profit 
                distribution, stock or stock option grant, or any 
                ownership or investment interest held by a physician in 
                a manufacturer (excluding a dividend or other profit 
                distribution from, or ownership or investment interest 
                in, a publicly traded security or mutual fund (as 
                described in section 1877(c))).
                    ``(C) Exclusions.--The term `payment or other 
                transfer of value' does not include the following:
                            ``(i) Any payment or other transfer of 
                        value provided by an applicable manufacturer or 
                        distributor to a covered recipient where the 
                        amount transferred to, requested by, or 
                        designated on behalf of the covered recipient 
                        does not exceed $5.
                            ``(ii) The loan of a covered device for a 
                        short-term trial period, not to exceed 90 days, 
                        to permit evaluation of the covered device by 
                        the covered recipient.
                            ``(iii) Items or services provided under a 
                        contractual warranty, including the replacement 
                        of a covered device, where the terms of the 
                        warranty are set forth in the purchase or lease 
                        agreement for the covered device.
                            ``(iv) A transfer of anything of value to a 
                        covered recipient when the covered recipient is 
                        a patient and not acting in the professional 
                        capacity of a covered recipient.
                            ``(v) In-kind items used for the provision 
                        of charity care.
                            ``(vi) A dividend or other profit 
                        distribution from, or ownership or investment 
                        interest in, a publicly traded security and 
                        mutual fund (as described in section 1877(c)).
                            ``(vii) Compensation paid by an applicable 
                        manufacturer or distributor to a covered 
                        recipient who is directly employed by and works 
                        solely for such manufacturer or distributor.
                            ``(viii) Payments made to a covered 
                        recipient by an applicable manufacturer or by a 
                        health plan affiliated with an applicable 
                        manufacturer for medical care provided to 
                        employees of such manufacturer or their 
                        dependents.
                            ``(ix) Any discount (including a rebate).
                            ``(x) Any payment or other transfer of 
                        value that is made to a covered recipient 
                        indirectly through an entity other than the 
                        applicable manufacturer in connection with an 
                        activity or service--
                                    ``(I) in which the applicable 
                                manufacturer is unaware of the identity 
                                of the covered recipient and is not 
                                using such activity or service to 
                                market its product to the covered 
                                recipient; and
                                    ``(II) that is not designed to 
                                market or promote the product to the 
                                covered recipient.
                            ``(xi) In the case of an applicable 
                        manufacturer who offers a self-insured plan, 
                        payments for the provision of health care to 
                        employees under the plan.
            ``(9) Physician.--The term `physician' has the meaning 
        given that term in section 1861(r). For purposes of this 
        section, such term does not include a physician who is an 
        employee of the applicable manufacturer that is required to 
        submit information under subsection (a).
            ``(10) Reporting entity.--The term `reporting entity' 
        means--
                    ``(A) with respect to the reporting requirement 
                under subsection (a), an applicable manufacturer or 
                distributor of a covered drug, device, biological, or 
                medical supply required to report under such 
                subsection; and
                    ``(B) with respect to the reporting requirement 
                under subsection (b), a hospital, other health care 
                entity, applicable manufacturer, applicable 
                distributor, or applicable group purchasing 
                organization required to report physician ownership 
                under such subsection.
    ``(g) Annual Reports to States.--Not later than April 1 of each 
year beginning with 2011, the Secretary shall submit to States a report 
that includes a summary of the information submitted under subsections 
(a), (b), and (e) during the preceding year with respect to covered 
recipients or other hospitals and entities in the State.
    ``(h) Relation to State Laws.--
            ``(1) In general.--Effective on January 1, 2011, subject to 
        paragraph (2), the provisions of this section shall preempt any 
        law or regulation of a State or of a political subdivision of a 
        State that requires an applicable manufacturer and applicable 
        distributor (as such terms are defined in subsection (f)) to 
        disclose or report, in any format, the type of information 
        (described in subsection (a)) regarding a payment or other 
        transfer of value provided by the manufacturer to a covered 
        recipient (as so defined).
            ``(2) No preemption of additional requirements.--Paragraph 
        (1) shall not preempt any statute or regulation of a State or 
        political subdivision of a State that requires any of the 
        following:
                    ``(A) The disclosure or reporting of information 
                not of the type required to be disclosed or reported 
                under this section.
                    ``(B) The disclosure or reporting, in any format, 
                of information described in subsection (f)(8)(C), 
                except in the case of information described in clause 
                (i) of subsection (f)(8)(C).
                    ``(C) The disclosure or reporting, in any format, 
                of the type of information by any person or entity 
                other than an applicable manufacturer (as so defined) 
                or a covered recipient (as defined in subsection (f)).
                    ``(D) The disclosure or reporting, in any format, 
                of the type of information required to be disclosed or 
                reported under this section to a Federal, State, or 
                local governmental agency for public health 
                surveillance, investigation, or other public health 
                purposes or health oversight purposes.
        Nothing in paragraph (1) shall be construed to limit the 
        discovery or admissibility of information described in this 
        paragraph in a criminal, civil, or administrative 
        proceeding.''.
    (b) Availability of Information From the Disclosure of Financial 
Relationship Report (DFRR).--The Secretary of Health and Human Services 
shall submit to Congress a report on the full results of the Disclosure 
of Physician Financial Relationships surveys required pursuant to 
section 5006 of the Deficit Reduction Act of 2005. Such report shall be 
submitted to Congress not later than the date that is 6 months after 
the date such surveys are collected and shall be made publicly 
available on an Internet website of the Department of Health and Human 
Services.
    (c) GAO Report.--Not later than December 31, 2012, the Comptroller 
General of the United States shall submit to Congress a report on 
section 1128H of the Social Security Act, as added by subsection (a). 
Such report shall address the extent to which important transfers of 
value are being adequately reported under such section (including 
unreported transfers required by such section as well as transfers not 
required to be reported by such section), the impact on States of the 
federal preemption provision under subsection (h) of such section, 
whether changes have occurred in the pattern of payments as a result of 
efforts to evade reporting requirements, a description of the financial 
relationships subject to delayed reporting under subsection (a) of such 
section, and any recommended improvements to the collection or the 
analysis of data reported under such section.

   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.

    (a) In General.--Title XI of the Social Security Act is amended by 
inserting after section 1138 the following section:

``SEC. 1138A. REQUIREMENT FOR PUBLIC REPORTING BY HOSPITALS AND 
              AMBULATORY SURGICAL CENTERS ON HEALTH CARE-ASSOCIATED 
              INFECTIONS.

    ``(a) Reporting Requirement.--
            ``(1) In general.--The Secretary shall provide that a 
        hospital (as defined in subsection (g)) or ambulatory surgical 
        center meeting the requirements of titles XVIII or XIX may 
        participate in the programs established under such titles only 
        if, in accordance with this section, the hospital or center 
        reports such information on health care-associated infections 
        that develop in the hospital or center (and such demographic 
        information associated with such infections) as the Secretary 
        specifies.
            ``(2) Reporting protocols.-- Such information shall be 
        reported in accordance with reporting protocols established by 
        the Secretary through the Director of the Centers for Disease 
        Control and Prevention (in this section referred to as the 
        `CDC') and to the National Healthcare Safety Network of the CDC 
        or under such another reporting system of such Centers as 
        determined appropriate by the Secretary in consultation with 
        such Director.
            ``(3) Coordination with hit.--The Secretary, through the 
        Director of the CDC and the Office of the National Coordinator 
        for Health Information Technology, shall ensure that the 
        transmission of information under this subsection is 
        coordinated with systems established under the HITECH Act, 
        where appropriate.
            ``(4) Procedures to ensure the validity of information.--
        The Secretary shall establish procedures regarding the validity 
        of the information submitted under this subsection in order to 
        ensure that such information is appropriately compared across 
        hospitals and centers. Such procedures shall address failures 
        to report as well as errors in reporting.
            ``(5) Implementation.--Not later than 1 year after the date 
        of enactment of this section, the Secretary, through the 
        Director of CDC, shall promulgate regulations to carry out this 
        section.
    ``(b) Public Posting of Information.--The Secretary shall promptly 
post, on the official public Internet site of the Department of Health 
and Human Services, the information reported under subsection (a). Such 
information shall be set forth in a manner that allows for the 
comparison of information on health care-associated infections--
            ``(1) among hospitals and ambulatory surgical centers; and
            ``(2) by demographic information.
    ``(c) Annual Report to Congress.--On an annual basis the Secretary 
shall submit to the Congress a report that summarizes each of the 
following:
            ``(1) The number and types of health care-associated 
        infections reported under subsection (a) in hospitals and 
        ambulatory surgical centers during such year.
            ``(2) Factors that contribute to the occurrence of such 
        infections, including health care worker immunization rates.
            ``(3) Based on the most recent information available to the 
        Secretary on the composition of the professional staff of 
        hospitals and ambulatory surgical centers, the number of 
        certified infection control professionals on the staff of 
        hospitals and ambulatory surgical centers.
            ``(4) The total increases or decreases in health care costs 
        that resulted from increases or decreases in the rates of 
        occurrence of each such type of infection during such year.
            ``(5) Recommendations, in coordination with the Center for 
        Quality Improvement established under section 931 of the Public 
        Health Service Act, for best practices to eliminate the rates 
        of occurrence of each such type of infection in hospitals and 
        ambulatory surgical centers.
    ``(d) Non-preemption of State Laws.--Nothing in this section shall 
be construed as preempting or otherwise affecting any provision of 
State law relating to the disclosure of information on health care-
associated infections or patient safety procedures for a hospital or 
ambulatory surgical center.
    ``(e) Health Care-associated Infection.--For purposes of this 
section:
            ``(1) In general.--The term `health care-associated 
        infection' means an infection that develops in a patient who 
        has received care in any institutional setting where health 
        care is delivered and is related to receiving health care.
            ``(2) Related to receiving health care.--The term `related 
        to receiving health care', with respect to an infection, means 
        that the infection was not incubating or present at the time 
        health care was provided.
    ``(f) Application to Critical Access Hospitals.--For purposes of 
this section, the term `hospital' includes a critical access hospital, 
as defined in section 1861(mm)(1).''.
    (b) Effective Date.--With respect to section 1138A of the Social 
Security Act (as inserted by subsection (a) of this section), the 
requirement under such section that hospitals and ambulatory surgical 
centers submit reports takes effect on such date (not later than 2 
years after the date of the enactment of this Act) as the Secretary of 
Health and Human Services shall specify. In order to meet such 
deadline, the Secretary may implement such section through guidance or 
other instructions.
    (c) GAO Report.--Not later than 18 months after the date of the 
enactment of this Act, the Comptroller General of the United States 
shall submit to Congress a report on the program established under 
section 1138A of the Social Security Act, as inserted by subsection 
(a). Such report shall include an analysis of the appropriateness of 
the types of information required for submission, compliance with 
reporting requirements, the success of the validity procedures 
established, and any conflict or overlap between the reporting required 
under such section and any other reporting systems mandated by either 
the States or the Federal Government.
    (d) Report on Additional Data.--Not later than 18 months after the 
date of the enactment of this Act, the Secretary of Health and Human 
Services shall submit to the Congress a report on the appropriateness 
of expanding the requirements under such section to include additional 
information (such as health care worker immunization rates), in order 
to improve health care quality and patient safety.

              TITLE V--MEDICARE GRADUATE MEDICAL EDUCATION

SEC. 1501. DISTRIBUTION OF UNUSED RESIDENCY POSITIONS.

    (a) In General.--Section 1886(h) of the Social Security Act (42 
U.S.C. 1395ww(h)) is amended--
            (1) in paragraph (4)(F)(i), by striking ``paragraph (7)'' 
        and inserting ``paragraphs (7) and (8)'';
            (2) in paragraph (4)(H)(i), by striking ``paragraph (7)'' 
        and inserting ``paragraphs (7) and (8)'';
            (3) in paragraph (7)(E), by inserting ``and paragraph (8)'' 
        after ``this paragraph''; and
            (4) by adding at the end the following new paragraph:
            ``(8) Additional redistribution of unused residency 
        positions.--
                    ``(A) Reductions in limit based on unused 
                positions.--
                            ``(i) Programs subject to reduction.--If a 
                        hospital's reference resident level (specified 
                        in clause (ii)) is less than the otherwise 
                        applicable resident limit (as defined in 
                        subparagraph (C)(ii)), effective for portions 
                        of cost reporting periods occurring on or after 
                        July 1, 2011, the otherwise applicable resident 
                        limit shall be reduced by 90 percent of the 
                        difference between such otherwise applicable 
                        resident limit and such reference resident 
                        level.
                            ``(ii) Reference resident level.--
                                    ``(I) In general.--Except as 
                                otherwise provided in a subsequent 
                                subclause, the reference resident level 
                                specified in this clause for a hospital 
                                is the highest resident level for any 
                                of the 3 most recent cost reporting 
                                periods (ending before the date of the 
                                enactment of this paragraph) of the 
                                hospital for which a cost report has 
                                been settled (or, if not, submitted 
                                (subject to audit)), as determined by 
                                the Secretary.
                                    ``(II) Use of most recent 
                                accounting period to recognize 
                                expansion of existing programs.--If a 
                                hospital submits a timely request to 
                                increase its resident level due to an 
                                expansion, or planned expansion, of an 
                                existing residency training program 
                                that is not reflected on the most 
                                recent settled or submitted cost 
                                report, after audit and subject to the 
                                discretion of the Secretary, subject to 
                                subclause (IV), the reference resident 
                                level for such hospital is the resident 
                                level that includes the additional 
                                residents attributable to such 
                                expansion or establishment, as 
                                determined by the Secretary. The 
                                Secretary is authorized to determine an 
                                alternative reference resident level 
                                for a hospital that submitted to the 
                                Secretary a timely request, before the 
                                start of the 2009-2010 academic year, 
                                for an increase in its reference 
                                resident level due to a planned 
                                expansion.
                                    ``(III) Special provider 
                                agreement.--In the case of a hospital 
                                described in paragraph (4)(H)(v), the 
                                reference resident level specified in 
                                this clause is the limitation 
                                applicable under subclause (I) of such 
                                paragraph.
                                    ``(IV) Previous redistribution.--
                                The reference resident level specified 
                                in this clause for a hospital shall be 
                                increased to the extent required to 
                                take into account an increase in 
                                resident positions made available to 
                                the hospital under paragraph (7)(B) 
                                that are not otherwise taken into 
                                account under a previous subclause.
                            ``(iii) Affiliation.--The provisions of 
                        clause (i) shall be applied to hospitals which 
                        are members of the same affiliated group (as 
                        defined by the Secretary under paragraph 
                        (4)(H)(ii)) and to the extent the hospitals can 
                        demonstrate that they are filling any 
                        additional  resident slots allocated to other 
                        hospitals through an affiliation agreement, the 
                        Secretary shall adjust the determination of 
                        available slots accordingly, or which the 
                        Secretary otherwise has permitted the resident 
                        positions (under section 402 of the Social 
                        Security Amendments of 1967) to be aggregated 
                        for purposes of applying the resident position 
                        limitations under this subsection.
                    ``(B) Redistribution.--
                            ``(i) In general.--The Secretary shall 
                        increase the otherwise applicable resident 
                        limit for each qualifying hospital that submits 
                        an application under this subparagraph by such 
                        number as the Secretary may approve for 
                        portions of cost reporting periods occurring on 
                        or after July 1, 2011. The estimated aggregate 
                        number of increases in the otherwise applicable 
                        resident limit under this subparagraph may not 
                        exceed the Secretary's estimate of the 
                        aggregate reduction in such limits attributable 
                        to subparagraph (A).
                            ``(ii) Requirements for qualifying 
                        hospitals.--A hospital is not a qualifying 
                        hospital for purposes of this paragraph unless 
                        the following requirements are met:
                                    ``(I) Maintenance of primary care 
                                resident level.--The hospital maintains 
                                the number of primary care residents at 
                                a level that is not less than the base 
                                level of primary care residents 
                                increased by the number of additional 
                                primary care resident positions 
                                provided to the hospital under this 
                                subparagraph. For purposes of this 
                                subparagraph, the `base level of 
                                primary care residents' for a hospital 
                                is the level of such residents as of a 
                                base period (specified by the 
                                Secretary), determined without regard 
                                to whether such positions were in 
                                excess of the otherwise applicable 
                                resident limit for such period but 
                                taking into account the application of 
                                subclauses (II) and (III) of 
                                subparagraph (A)(ii).
                                    ``(II) Dedicated assignment of 
                                additional resident positions to 
                                primary care.--The hospital assigns all 
                                such additional resident positions for 
                                primary care residents.
                                    ``(III) Accreditation.--The 
                                hospital's residency programs in 
                                primary care are fully accredited or, 
                                in the case of a residency training 
                                program not in operation as of the base 
                                year, the hospital is actively applying 
                                for such accreditation for the program 
                                for such additional resident positions 
                                (as determined by the Secretary).
                            ``(iii) Considerations in redistribution.--
                        In determining for which qualifying hospitals 
                        the increase in the otherwise applicable 
                        resident limit is provided under this 
                        subparagraph, the Secretary shall take into 
                        account the demonstrated likelihood of the 
                        hospital filling the positions within the first 
                        3 cost reporting periods beginning on or after 
                        July 1, 2011, made available under this 
                        subparagraph, as determined by the Secretary.
                            ``(iv) Priority for certain hospitals.--In 
                        determining for which qualifying hospitals the 
                        increase in the otherwise applicable resident 
                        limit is provided under this subparagraph, the 
                        Secretary shall distribute the increase to 
                        qualifying hospitals based on the following 
                        criteria:
                                    ``(I) The Secretary shall give 
                                preference to hospitals that had a 
                                reduction in resident training 
                                positions under subparagraph (A).
                                    ``(II) The Secretary shall give 
                                preference to hospitals with 3-year 
                                primary care residency training 
                                programs, such as family practice and 
                                general internal medicine.
                                    ``(III) The Secretary shall give 
                                preference to hospitals insofar as they 
                                have in effect formal arrangements (as 
                                determined by the Secretary) that place 
                                greater emphasis upon training in 
                                Federally qualified health centers, 
                                rural health clinics, and other 
                                nonprovider settings, and to hospitals 
                                that receive additional payments under 
                                subsection (d)(5)(F) and emphasize 
                                training in an outpatient department.
                                    ``(IV) The Secretary shall give 
                                preference to hospitals with a number 
                                of positions (as of July 1, 2009) in 
                                excess of the otherwise applicable 
                                resident limit for such period.
                                    ``(V) The Secretary shall give 
                                preference to hospitals that place 
                                greater emphasis upon training in a 
                                health professional shortage area 
                                (designated under section 332 of the 
                                Public Health Service Act) or a health 
                                professional needs area (designated 
                                under section 2211 of such Act).
                                    ``(VI) The Secretary shall give 
                                preference to hospitals in States that 
                                have low resident-to-population ratios 
                                (including a greater preference for 
                                those States with lower resident-to-
                                population ratios).
                            ``(v) Limitation.--In no case shall more 
                        than 20 full-time equivalent additional 
                        residency positions be made available under 
                        this subparagraph with respect to any hospital.
                            ``(vi) Application of per resident amounts 
                        for primary care.--With respect to additional 
                        residency positions in a hospital attributable 
                        to the increase provided under this 
                        subparagraph, the approved FTE resident amounts 
                        are deemed to be equal to the hospital per 
                        resident amounts for primary care and 
                        nonprimary care computed under paragraph (2)(D) 
                        for that hospital.
                            ``(vii) Distribution.--The Secretary shall 
                        distribute the increase in resident training 
                        positions to qualifying hospitals under this 
                        subparagraph not later than July 1, 2011.
                    ``(C) Resident level and limit defined.--In this 
                paragraph:
                            ``(i) The term `resident level' has the 
                        meaning given such term in paragraph (7)(C)(i).
                            ``(ii) The term `otherwise applicable 
                        resident limit' means, with respect to a 
                        hospital, the limit otherwise applicable under 
                        subparagraphs (F)(i) and (H) of paragraph (4) 
                        on the resident level for the hospital 
                        determined without regard to this paragraph but 
                        taking into account paragraph (7)(A).
                    ``(D) Maintenance of primary care resident level.--
                In carrying out this paragraph, the Secretary shall 
                require hospitals that receive additional resident 
                positions under subparagraph (B)--
                            ``(i) to maintain records, and periodically 
                        report to the Secretary, on the number of 
                        primary care residents in its residency 
                        training programs; and
                            ``(ii) as a condition of payment for a cost 
                        reporting period under this subsection for such 
                        positions, to maintain the level of such 
                        positions at not less than the sum of--
                                    ``(I) the base level of primary 
                                care resident positions (as determined 
                                under subparagraph (B)(ii)(I)) before 
                                receiving such additional positions; 
                                and
                                    ``(II) the number of such 
                                additional positions.''.
    (b) IME.--
            (1) In general.--Section 1886(d)(5)(B)(v) of the Social 
        Security Act (42 U.S.C. 1395ww(d)(5)(B)(v)), in the third 
        sentence, is amended--
                    (A) by striking ``subsection (h)(7)'' and inserting 
                ``subsections (h)(7) and (h)(8)''; and
                    (B) by striking ``it applies'' and inserting ``they 
                apply''.
            (2) Conforming provision.--Section 1886(d)(5)(B) of the 
        Social Security Act (42 U.S.C. 1395ww(d)(5)(B)) is amended by 
        adding at the end the following clause:
    ``(x) For discharges occurring on or after July 1, 2011, insofar as 
an additional payment amount under this subparagraph is attributable to 
resident positions distributed to a hospital under subsection 
(h)(8)(B), the indirect teaching adjustment factor shall be computed in 
the same manner as provided under clause (ii) with respect to such 
resident positions.''.
    (c) Conforming Amendment.--Section 422(b)(2) of the Medicare 
Prescription Drug, Improvement, and Modernization Act of 2003 (Public 
Law 108-173) is amended by striking ``section 1886(h)(7)'' and all that 
follows and inserting ``paragraphs (7) and (8) of subsection (h) of 
section 1886 of the Social Security Act.''.

SEC. 1502. INCREASING TRAINING IN NONPROVIDER SETTINGS.

    (a) Direct GME.--Section 1886(h)(4)(E) of the Social Security Act 
(42 U.S.C. 1395ww(h)) is amended--
            (1) by designating the first sentence as a clause (i) with 
        the heading ``In general.--'' and appropriate indentation;
            (2) by striking ``shall be counted and that all the time'' 
        and inserting ``shall be counted and that--
                                    ``(I) effective for cost reporting 
                                periods beginning before July 1, 2009, 
                                all the time'';
            (3) in subclause (I), as inserted by paragraph (1), by 
        striking the period at the end and inserting ``; and''; and
                    (A) by inserting after subclause (I), as so 
                inserted, the following:
                                    ``(II) effective for cost reporting 
                                periods beginning on or after July 1, 
                                2009, all the time so spent by a 
                                resident shall be counted towards the 
                                determination of full-time equivalency, 
                                without regard to the setting in which 
                                the activities are performed, if the 
                                hospital incurs the costs of the 
                                stipends and fringe benefits of the 
                                resident during the time the resident 
                                spends in that setting.
                        Any hospital claiming under this subparagraph 
                        for time spent in a nonprovider setting shall 
                        maintain and make available to the Secretary 
                        records regarding the amount of such time and 
                        such amount in comparison with amounts of such 
                        time in such base year as the Secretary shall 
                        specify.''.
    (b) IME.--Section 1886(d)(5)(B)(iv) of the Social Security Act (42 
U.S.C. 1395ww(d)(5)(B)(iv)) is amended--
            (1) by striking ``(iv) Effective for discharges occurring 
        on or after October 1, 1997'' and inserting ``(iv)(I) Effective 
        for discharges occurring on or after October 1, 1997, and 
        before July 1, 2009''; and
            (2) by inserting after subclause (I), as inserted by 
        paragraph (1), the following new subclause:
            ``(II) Effective for discharges occurring on or after July 
        1, 2009, all the time spent by an intern or resident in patient 
        care activities at an entity in a nonprovider setting shall be 
        counted towards the determination of full-time equivalency if 
        the hospital incurs the costs of the stipends and fringe 
        benefits of the intern or resident during the time the intern 
        or resident spends in that setting.''.
    (c) OIG Study on Impact on Training.--The Inspector General of the 
Department of Health and Human Services shall analyze the data 
collected by the Secretary of Health and Human Services from the 
records made available to the Secretary under section 1886(h)(4)(E) of 
the Social Security Act, as amended by subsection (a), in order to 
assess the extent to which there is an increase in time spent by 
medical residents in training in nonprovider settings as a result of 
the amendments made by this section. Not later than 4 years after the 
date of the enactment of this Act, the Inspector General shall submit a 
report to Congress on such analysis and assessment.
    (d) Demonstration Project for Approved Teaching Health Centers.--
            (1) In general.--The Secretary of Health and Human Services 
        shall conduct a demonstration project under which an approved 
        teaching health center (as defined in paragraph (3)) would be 
        eligible for payment under subsections (h) and (k) of section 
        1886 of the Social Security Act (42 U.S.C. 1395ww) of amounts 
        for its own direct costs of graduate medical education 
        activities for primary care residents, as well as for the 
        direct costs of graduate medical education activities of its 
        contracting hospital for such residents, in a manner similar to 
        the manner in which such payments would be made to a hospital 
        if the hospital were to operate such a program.
            (2) Conditions.--Under the demonstration project--
                    (A) an approved teaching health center shall 
                contract with an accredited teaching hospital to carry 
                out the inpatient responsibilities of the primary care 
                residency program of the hospital involved and is 
                responsible for payment to the hospital for the 
                hospital's costs of the salary and fringe benefits for 
                residents in the program;
                    (B) the number of primary care residents of the 
                center shall not count against the contracting 
                hospital's resident limit; and
                    (C) the contracting hospital shall agree not to 
                diminish the number of residents in its primary care 
                residency training program.
            (3) Approved teaching health center defined.--In this 
        subsection, the term ``approved teaching health center'' means 
        a nonprovider setting, such as a Federally qualified health 
        center or rural health clinic (as defined in section 1861(aa) 
        of the Social Security Act), that develops and operates an 
        accredited primary care residency program for which funding 
        would be available if it were operated by a hospital.

SEC. 1503. RULES FOR COUNTING RESIDENT TIME FOR DIDACTIC AND SCHOLARLY 
              ACTIVITIES AND OTHER ACTIVITIES.

    (a) Direct GME.--Section 1886(h) of the Social Security Act (42 
U.S.C. 1395ww(h)) is amended--
            (1) in paragraph (4)(E), as amended by section 1502(a)--
                    (A) in clause (i), by striking ``Such rules'' and 
                inserting ``Subject to clause (ii), such rules''; and
                    (B) by adding at the end the following new clause:
                            ``(ii) Treatment of certain nonprovider and 
                        didactic activities.--Such rules shall provide 
                        that all time spent by an intern or resident in 
                        an approved medical residency training program 
                        in a nonprovider setting that is primarily 
                        engaged in furnishing patient care (as defined 
                        in paragraph (5)(K)) in nonpatient care 
                        activities, such as didactic conferences and 
                        seminars, but not including research not 
                        associated with the treatment or diagnosis of a 
                        particular patient, as such time and activities 
                        are defined by the Secretary, shall be counted 
                        toward the determination of full-time 
                        equivalency.'';
            (2) in paragraph (4), by adding at the end the following 
        new subparagraph:
                    ``(I) Treatment of certain time in approved medical 
                residency training programing.--In determining the 
                hospital's number of full-time equivalent residents for 
                purposes of this subsection, all the time that is spent 
                by an intern or resident in an approved medical 
                residency training program on vacation, sick leave, or 
                other approved leave, as such time is defined by the 
                Secretary, and that does not prolong the total time the 
                resident is participating in the approved program 
                beyond the normal duration of the program shall be 
                counted toward the determination of full-time 
                equivalency.''; and
            (3) in paragraph (5), by adding at the end the following 
        new subparagraph:
                    ``(K) Nonprovider setting that is primarily engaged 
                in furnishing patient care.--The term `nonprovider 
                setting that is primarily engaged in furnishing patient 
                care' means a nonprovider setting in which the primary 
                activity is the care and treatment of patients, as 
                defined by the Secretary.''.
    (b) IME Determinations.--Section 1886(d)(5)(B) of such Act (42 
U.S.C. 1395ww(d)(5)(B)), as amended by section 1501(b), is amended by 
adding at the end the following new clause:
    ``(xi)(I) The provisions of subparagraph (I) of subsection (h)(4) 
shall apply under this subparagraph in the same manner as they apply 
under such subsection.
    ``(II) In determining the hospital's number of full-time equivalent 
residents for purposes of this subparagraph, all the time spent by an 
intern or resident in an approved medical residency training program in 
nonpatient care activities, such as didactic conferences and seminars, 
as such time and activities are defined by the Secretary, that occurs 
in the hospital shall be counted toward the determination of full-time 
equivalency if the hospital--
            ``(aa) is recognized as a subsection (d) hospital;
            ``(bb) is recognized as a subsection (d) Puerto Rico 
        hospital;
            ``(cc) is reimbursed under a reimbursement system 
        authorized under section 1814(b)(3); or
            ``(dd) is a provider-based hospital outpatient department.
    ``(III) In determining the hospital's number of full-time 
equivalent residents for purposes of this subparagraph, all the time 
spent by an intern or resident in an approved medical residency 
training program in research activities that are not associated with 
the treatment or diagnosis of a particular patient, as such time and 
activities are defined by the Secretary, shall not be counted toward 
the determination of full-time equivalency.''.
    (c) Effective Dates; Application.--
            (1) In general.--Except as otherwise provided, the 
        Secretary of Health and Human Services shall implement the 
        amendments made by this section in a manner so as to apply to 
        cost reporting periods beginning on or after January 1, 1983.
            (2) Direct gme.--Section 1886(h)(4)(E)(ii) of the Social 
        Security Act, as added by subsection (a)(1)(B), shall apply to 
        cost reporting periods beginning on or after July 1, 2008.
            (3) IME.--Section 1886(d)(5)(B)(x)(III) of the Social 
        Security Act, as added by subsection (b), shall apply to cost 
        reporting periods beginning on or after October 1, 2001. Such 
        section, as so added, shall not give rise to any inference on 
        how the law in effect prior to such date should be interpreted.
            (4) Application.--The amendments made by this section shall 
        not be applied in a manner that requires reopening of any 
        settled hospital cost reports as to which there is not a 
        jurisdictionally proper appeal pending as of the date of the 
        enactment of this Act on the issue of payment for indirect 
        costs of medical education under section 1886(d)(5)(B) of the 
        Social Security Act or for direct graduate medical education 
        costs under section 1886(h) of such Act.

SEC. 1504. PRESERVATION OF RESIDENT CAP POSITIONS FROM CLOSED 
              HOSPITALS.

    (a) Direct GME.--Section 1886(h)(4)(H) of the Social Security Act 
(42 U.S.C. Section 1395ww(h)(4)(H)) is amended by adding at the end the 
following new clause:
                            ``(vi) Redistribution of residency slots 
                        after a hospital closes.--
                                    ``(I) In general.--The Secretary 
                                shall, by regulation, establish a 
                                process consistent with subclauses (II) 
                                and (III) under which, in the case 
                                where a hospital (other than a hospital 
                                described in clause (v)) with an 
                                approved medical residency program in a 
                                State closes on or after the date that 
                                is 2 years before the date of the 
                                enactment of this clause, the Secretary 
                                shall increase the otherwise applicable 
                                resident limit under this paragraph for 
                                other hospitals in the State in 
                                accordance with this clause.
                                    ``(II) Process for hospitals in 
                                certain areas.--In determining for 
                                which hospitals the increase in the 
                                otherwise applicable resident limit 
                                described in subclause (I) is provided, 
                                the Secretary shall establish a process 
                                to provide for such increase to one or 
                                more hospitals located in the State. 
                                Such process shall take into 
                                consideration the recommendations 
                                submitted to the Secretary by the 
                                senior health official (as designated 
                                by the chief executive officer of such 
                                State) if such recommendations are 
                                submitted not later than 180 days after 
                                the date of the hospital closure 
                                involved (or, in the case of a hospital 
                                that closed after the date that is 2 
                                years before the date of the enactment 
                                of this clause, 180 days after such 
                                date of enactment).
                                    ``(III) Limitation.--The estimated 
                                aggregate number of increases in the 
                                otherwise applicable resident limits 
                                for hospitals under this clause shall 
                                be equal to the estimated number of 
                                resident positions in the approved 
                                medical residency programs that closed 
                                on or after the date described in 
                                subclause (I).''.
    (b) No Effect on Temporary FTE Cap Adjustments.--The amendments 
made by this section shall not effect any temporary adjustment to a 
hospital's FTE cap under section 413.79(h) of title 42, Code of Federal 
Regulations (as in effect on the date of enactment of this Act) and 
shall not affect the application of section 1886(h)(4)(H)(v) of the 
Social Security Act.
    (c) Conforming Amendments.--
            (1) Section 422(b)(2) of the Medicare Prescription Drug, 
        Improvement, and Modernization Act of 2003 (Public Law 108-
        173), as amended by section 1501(c), is amended by striking 
        ``(7) and'' and inserting ``(4)(H)(vi), (7), and''.
            (2) Section 1886(h)(7)(E) of the Social Security Act (42 
        U.S.C. 1395ww(h)(7)(E)) is amended by inserting ``or under 
        paragraph (4)(H)(vi)'' after ``under this paragraph''.

SEC. 1505. IMPROVING ACCOUNTABILITY FOR APPROVED MEDICAL RESIDENCY 
              TRAINING.

    (a) Specification of Goals for Approved Medical Residency Training 
Programs.--Section 1886(h)(1) of the Social Security Act (42 U.S.C. 
1395ww(h)(1)) is amended--
            (1) by designating the matter beginning with 
        ``Notwithstanding'' as a subparagraph (A) with the heading ``In 
        general.--'' and with appropriate indentation; and
            (2) by adding at the end the following new subparagraph:
                    ``(B) Goals and accountability for approved medical 
                residency training programs.--The goals of medical 
                residency training programs are to foster a physician 
                workforce so that physicians are trained to be able to 
                do the following:
                            ``(i) Work effectively in various health 
                        care delivery settings, such as nonprovider 
                        settings.
                            ``(ii) Coordinate patient care within and 
                        across settings relevant to their specialties.
                            ``(iii) Understand the relevant cost and 
                        value of various diagnostic and treatment 
                        options.
                            ``(iv) Work in inter-professional teams and 
                        multi-disciplinary team-based models in 
                        provider and nonprovider settings to enhance 
                        safety and improve quality of patient care.
                            ``(v) Be knowledgeable in methods of 
                        identifying systematic errors in health care 
                        delivery and in implementing systematic 
                        solutions in case of such errors, including 
                        experience and participation in continuous 
                        quality improvement projects to improve health 
                        outcomes of the population the physicians 
                        serve.
                            ``(vi) Be meaningful EHR users (as 
                        determined under section 1848(o)(2)) in the 
                        delivery of care and in improving the quality 
                        of the health of the community and the 
                        individuals that the hospital serves.''
    (b) GAO Study on Evaluation of Training Programs.--
            (1) In general.--The Comptroller General of the United 
        States shall conduct a study to evaluate the extent to which 
        medical residency training programs--
                    (A) are meeting the goals described in section 
                1886(h)(1)(B) of the Social Security Act, as added by 
                subsection (a), in a range of residency programs, 
                including primary care and other specialties; and
                    (B) have the appropriate faculty expertise to teach 
                the topics required to achieve such goals.
            (2) Report.--Not later than 18 months after the date of the 
        enactment of this Act, the Comptroller General shall submit to 
        Congress a report on such study and shall include in such 
        report recommendations as to how medical residency training 
        programs could be further encouraged to meet such goals through 
        means such as--
                    (A) development of curriculum requirements; and
                    (B) assessment of the accreditation processes of 
                the Accreditation Council for Graduate Medical 
                Education and the American Osteopathic Association and 
                effectiveness of those processes in accrediting medical 
                residency programs that meet the goals referred to in 
                paragraph (1)(A).

                      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.

    (a) In General.--Section 1817(k) of the Social Security Act (42 
U.S.C. 1395i(k)) is amended--
            (1) by adding at the end the following new paragraph:
            ``(7) Additional funding.--In addition to the funds 
        otherwise appropriated to the Account from the Trust Fund under 
        paragraphs (3) and (4) and for purposes described in paragraphs 
        (3)(C) and (4)(A), there are hereby appropriated an additional 
        $100,000,000 to such Account from such Trust Fund for each 
        fiscal year beginning with 2011. The funds appropriated under 
        this paragraph shall be allocated in the same proportion as the 
        total funding appropriated with respect to paragraphs (3)(A) 
        and (4)(A) was allocated with respect to fiscal year 2010, and 
        shall be available without further appropriation until 
        expended.''.
            (2) in paragraph (4)(A)--
                    (A) by inserting ``for activities described in 
                paragraph (3)(C) and'' after ``necessary''; and
                    (B) by inserting ``until expended'' after 
                ``appropriation''.
    (b) Flexibility in Pursuing Fraud and Abuse.--Section 1893(a) of 
the Social Security Act (42 U.S.C. 1395ddd(a)) is amended by inserting 
``, or otherwise,'' after ``entities''.

           Subtitle B--Enhanced Penalties for Fraud and Abuse

SEC. 1611. ENHANCED PENALTIES FOR FALSE STATEMENTS ON PROVIDER OR 
              SUPPLIER ENROLLMENT APPLICATIONS.

    (a) In General.--Section 1128A(a) of the Social Security Act (42 
U.S.C. 1320a-7a(a)) is amended--
            (1) in paragraph (1)(D), by striking all that follows ``in 
        which the person was excluded'' and inserting ``under Federal 
        law from the Federal health care program under which the claim 
        was made, or'';
            (2) by striking ``or'' at the end of paragraph (6);
            (3) in paragraph (7), by inserting at the end ``or'';
            (4) by inserting after paragraph (7) the following new 
        paragraph:
            ``(8) knowingly makes or causes to be made any false 
        statement, omission, or misrepresentation of a material fact in 
        any application, agreement, bid, or contract to participate or 
        enroll as a provider of services or supplier under a Federal 
        health care program, including managed care organizations under 
        title XIX, Medicare Advantage organizations under part C of 
        title XVIII, prescription drug plan sponsors under part D of 
        title XVIII, and entities that apply to participate as 
        providers of services or suppliers in such managed care 
        organizations and such plans;'';
            (5) in the matter following paragraph (8), as inserted by 
        paragraph (4), by striking ``or in cases under paragraph (7), 
        $50,000 for each such act)'' and inserting ``in cases under 
        paragraph (7), $50,000 for each such act, or in cases under 
        paragraph (8), $50,000 for each false statement, omission, or 
        misrepresentation of a material fact)''; and
            (6) in the second sentence, by striking ``for a lawful 
        purpose)'' and inserting ``for a lawful purpose, or in cases 
        under paragraph (8), an assessment of not more than 3 times the 
        amount claimed as the result of the false statement, omission, 
        or misrepresentation of material fact claimed by a provider of 
        services or supplier whose application to participate contained 
        such false statement, omission, or misrepresentation)''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to acts committed on or after January 1, 2010.

SEC. 1612. ENHANCED PENALTIES FOR SUBMISSION OF FALSE STATEMENTS 
              MATERIAL TO A FALSE CLAIM.

    (a) In General.--Section 1128A(a) of the Social Security Act (42 
U.S.C. 1320a-7a(a)), as amended by section 1611, is further amended--
            (1) in paragraph (7), by striking ``or'' at the end;
            (2) in paragraph (8), by inserting ``or'' at the end; and
            (3) by inserting after paragraph (8), the following new 
        paragraph:
            ``(9) knowingly makes, uses, or causes to be made or used, 
        a false record or statement material to a false or fraudulent 
        claim for payment for items and services furnished under a 
        Federal health care program;''; and
            (4) in the matter following paragraph (9), as inserted by 
        paragraph (3)--
                    (A) by striking ``or in cases under paragraph (8)'' 
                and inserting ``in cases under paragraph (8)''; and
                    (B) by striking ``a material fact)'' and inserting 
                ``a material fact, in cases under paragraph (9), 
                $50,000 for each false record or statement)''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to acts committed on or after January 1, 2010.

SEC. 1613. ENHANCED PENALTIES FOR DELAYING INSPECTIONS.

    (a) In General.--Section 1128A(a) of the Social Security Act (42 
U.S.C. 1320a-7a(a)), as amended by sections 1611 and 1612, is further 
amended--
            (1) in paragraph (8), by striking ``or'' at the end;
            (2) in paragraph (9), by inserting ``or'' at the end;
            (3) by inserting after paragraph (9) the following new 
        paragraph:
            ``(10) fails to grant timely access, upon reasonable 
        request (as defined by the Secretary in regulations), to the 
        Inspector General of the Department of Health and Human 
        Services, for the purpose of audits, investigations, 
        evaluations, or other statutory functions of the Inspector 
        General of the Department of Health and Human Services;''; and
            (4) in the matter following paragraph (10), as inserted by 
        paragraph (3), by inserting ``, or in cases under paragraph 
        (10), $15,000 for each day of the failure described in such 
        paragraph'' after ``false record or statement''.
    (b) Ensuring Timely Inspections Relating to Contracts With MA 
Organizations.--Section 1857(d)(2) of such Act (42 U.S.C. 1395w-
27(d)(2)) is amended--
            (1) in subparagraph (A), by inserting ``timely'' before 
        ``inspect''; and
            (2) in subparagraph (B), by inserting ``timely'' before 
        ``audit and inspect''.
    (c) Effective Date.--The amendments made by subsection (a) shall 
apply to violations committed on or after January 1, 2010.

SEC. 1614. ENHANCED HOSPICE PROGRAM SAFEGUARDS.

    (a) Medicare.--Part A of title XVIII of the Social Security Act is 
amended by inserting after section 1819 the following new section:

``SEC. 1819A. ASSURING QUALITY OF CARE IN HOSPICE CARE.

    ``(a) In General.--If the Secretary determines on the basis of a 
survey or otherwise, that a hospice program that is certified for 
participation under this title has demonstrated a substandard quality 
of care and failed to meet such other requirements as the Secretary may 
find necessary in the interest of the health and safety of the 
individuals who are provided care and services by the agency or 
organization involved and determines--
            ``(1) that the deficiencies involved immediately jeopardize 
        the health and safety of the individuals to whom the program 
        furnishes items and services, the Secretary shall take 
        immediate action to remove the jeopardy and correct the 
        deficiencies through the remedy specified in subsection 
        (b)(2)(A)(iii) or terminate the certification of the program, 
        and may provide, in addition, for 1 or more of the other 
        remedies described in subsection (b)(2)(A); or
            ``(2) that the deficiencies involved do not immediately 
        jeopardize the health and safety of the individuals to whom the 
        program furnishes items and services, the Secretary may--
                    ``(A) impose intermediate sanctions developed 
                pursuant to subsection (b), in lieu of terminating the 
                certification of the program; and
                    ``(B) if, after such a period of intermediate 
                sanctions, the program is still not in compliance with 
                such requirements, the Secretary shall terminate the 
                certification of the program.
        If the Secretary determines that a hospice program that is 
        certified for participation under this title is in compliance 
        with such requirements but, as of a previous period, was not in 
        compliance with such requirements, the Secretary may provide 
        for a civil money penalty under subsection (b)(2)(A)(i) for the 
        days in which it finds that the program was not in compliance 
        with such requirements.
    ``(b) Intermediate Sanctions.--
            ``(1) Development and implementation.--The Secretary shall 
        develop and implement, by not later than July 1, 2012--
                    ``(A) a range of intermediate sanctions to apply to 
                hospice programs under the conditions described in 
                subsection (a), and
                    ``(B) appropriate procedures for appealing 
                determinations relating to the imposition of such 
                sanctions.
            ``(2) Specified sanctions.--
                    ``(A) In general.--The intermediate sanctions 
                developed under paragraph (1) may include--
                            ``(i) civil money penalties in an amount 
                        not to exceed $10,000 for each day of 
                        noncompliance or, in the case of a per instance 
                        penalty applied by the Secretary, not to exceed 
                        $25,000,
                            ``(ii) denial of all or part of the 
                        payments to which a hospice program would 
                        otherwise be entitled under this title with 
                        respect to items and services furnished by a 
                        hospice program on or after the date on which 
                        the Secretary determines that intermediate 
                        sanctions should be imposed pursuant to 
                        subsection (a)(2),
                            ``(iii) the appointment of temporary 
                        management to oversee the operation of the 
                        hospice program and to protect and assure the 
                        health and safety of the individuals under the 
                        care of the program while improvements are 
                        made,
                            ``(iv) corrective action plans, and
                            ``(v) in-service training for staff.
                The provisions of section 1128A (other than subsections 
                (a) and (b)) shall apply to a civil money penalty under 
                clause (i) in the same manner as such provisions apply 
                to a penalty or proceeding under section 1128A(a). The 
                temporary management under clause (iii) shall not be 
                terminated until the Secretary has determined that the 
                program has the management capability to ensure 
                continued compliance with all requirements referred to 
                in that clause.
                    ``(B) Clarification.--The sanctions specified in 
                subparagraph (A) are in addition to sanctions otherwise 
                available under State or Federal law and shall not be 
                construed as limiting other remedies, including any 
                remedy available to an individual at common law.
                    ``(C) Commencement of payment.--A denial of payment 
                under subparagraph (A)(ii) shall terminate when the 
                Secretary determines that the hospice program no longer 
                demonstrates a substandard quality of care and meets 
                such other requirements as the Secretary may find 
                necessary in the interest of the health and safety of 
                the individuals who are provided care and services by 
                the agency or organization involved.
            ``(3) Secretarial authority.--The Secretary shall develop 
        and implement, by not later than July 1, 2011, specific 
        procedures with respect to the conditions under which each of 
        the intermediate sanctions developed under paragraph (1) is to 
        be applied, including the amount of any fines and the severity 
        of each of these sanctions. Such procedures shall be designed 
        so as to minimize the time between identification of 
        deficiencies and imposition of these sanctions and shall 
        provide for the imposition of incrementally more severe fines 
        for repeated or uncorrected deficiencies.''.
    (b) Application to Medicaid.--Section 1905(o) of the Social 
Security Act (42 U.S.C. 1396d(o)) is amended by adding at the end the 
following new paragraph:
    ``(4) The provisions of section 1819A shall apply to a hospice 
program providing hospice care under this title in the same manner as 
such provisions apply to a hospice program providing hospice care under 
title XVIII.''.
    (c) Application to CHIP.--Title XXI of the Social Security Act is 
amended by adding at the end the following new section:

``SEC. 2114. ASSURING QUALITY OF CARE IN HOSPICE CARE.

    ``The provisions of section 1819A shall apply to a hospice program 
providing hospice care under this title in the same manner such 
provisions apply to a hospice program providing hospice care under 
title XVIII.''.

SEC. 1615. ENHANCED PENALTIES FOR INDIVIDUALS EXCLUDED FROM PROGRAM 
              PARTICIPATION.

    (a) In General.--Section 1128A(a) of the Social Security Act (42 
U.S.C. 1320a-7a(a)), as amended by the previous sections, is further 
amended--
            (1) by striking ``or'' at the end of paragraph (9);
            (2) by inserting ``or'' at the end of paragraph (10);
            (3) by inserting after paragraph (10) the following new 
        paragraph:
            ``(11) orders or prescribes an item or service, including 
        without limitation home health care, diagnostic and clinical 
        lab tests, prescription drugs, durable medical equipment, 
        ambulance services, physical or occupational therapy, or any 
        other item or service, during a period when the person has been 
        excluded from participation in a Federal health care program, 
        and the person knows or should know that a claim for such item 
        or service will be presented to such a program;''; and
            (4) in the matter following paragraph (11), as inserted by 
        paragraph (2), by striking ``$15,000 for each day of the 
        failure described in such paragraph'' and inserting ``$15,000 
        for each day of the failure described in such paragraph, or in 
        cases under paragraph (11), $50,000 for each order or 
        prescription for an item or service by an excluded 
        individual''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to violations committed on or after January 1, 2010.

SEC. 1616. ENHANCED PENALTIES FOR PROVISION OF FALSE INFORMATION BY 
              MEDICARE ADVANTAGE AND PART D PLANS.

    (a) In General.--Section 1857(g)(2)(A) of the Social Security Act 
(42 U.S.C. 1395w--27(g)(2)(A)) is amended by inserting ``except with 
respect to a determination under subparagraph (E), an assessment of not 
more than 3 times the amount claimed by such plan or plan sponsor based 
upon the misrepresentation or falsified information involved,'' after 
``for each such determination,''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to violations committed on or after January 1, 2010.

SEC. 1617. ENHANCED PENALTIES FOR MEDICARE ADVANTAGE AND PART D 
              MARKETING VIOLATIONS.

    (a) In General.--Section 1857(g)(1) of the Social Security Act (42 
U.S.C. 1395w--27(g)(1)), as amended by section 1221(b), is amended--
            (1) in subparagraph (G), by striking ``or'' at the end;
            (2) by inserting after subparagraph (H) the following new 
        subparagraphs:
                    ``(I) except as provided under subparagraph (C) or 
                (D) of section 1860D-1(b)(1), enrolls an individual in 
                any plan under this part without the prior consent of 
                the individual or the designee of the individual;
                    ``(J) transfers an individual enrolled under this 
                part from one plan to another without the prior consent 
                of the individual or the designee of the individual or 
                solely for the purpose of earning a commission;
                    ``(K) fails to comply with marketing restrictions 
                described in subsections (h) and (j) of section 1851 or 
                applicable implementing regulations or guidance; or
                    ``(L) employs or contracts with any individual or 
                entity who engages in the conduct described in 
                subparagraphs (A) through (K) of this paragraph;''; and
            (3) by adding at the end the following new sentence: ``The 
        Secretary may provide, in addition to any other remedies 
        authorized by law, for any of the remedies described in 
        paragraph (2), if the Secretary determines that any employee or 
        agent of such organization, or any provider or supplier who 
        contracts with such organization, has engaged in any conduct 
        described in subparagraphs (A) through (L) of this paragraph.''
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to violations committed on or after January 1, 2010.

SEC. 1618. ENHANCED PENALTIES FOR OBSTRUCTION OF PROGRAM AUDITS.

    (a) In General.--Section 1128(b)(2) of the Social Security Act (42 
U.S.C. 1320a-7(b)(2)) is amended--
            (1) in the heading, by inserting ``or audit'' after 
        ``investigation''; and
            (2) by striking ``investigation into'' and all that follows 
        through the period and inserting ``investigation or audit 
        related to--''
                            ``(i) any offense described in paragraph 
                        (1) or in subsection (a); or
                            ``(ii) the use of funds received, directly 
                        or indirectly, from any Federal health care 
                        program (as defined in section 1128B(f)).''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to violations committed on or after January 1, 2010.

SEC. 1619. EXCLUSION OF CERTAIN INDIVIDUALS AND ENTITIES FROM 
              PARTICIPATION IN MEDICARE AND STATE HEALTH CARE PROGRAMS.

    (a) In General.--Section 1128(c) of the Social Security Act, as 
previously amended by this division, is further amended--
            (1) in the heading, by striking ``and Period'' and 
        inserting ``Period, and Effect''; and
            (2) by adding at the end the following new paragraph:
    ``(4)(A) For purposes of this Act, subject to subparagraph (C), the 
effect of exclusion is that no payment may be made by any Federal 
health care program (as defined in section 1128B(f)) with respect to 
any item or service furnished--
            ``(i) by an excluded individual or entity; or
            ``(ii) at the medical direction or on the prescription of a 
        physician or other authorized individual when the person 
        submitting a claim for such item or service knew or had reason 
        to know of the exclusion of such individual.
    ``(B) For purposes of this section and sections 1128A and 1128B, 
subject to subparagraph (C), an item or service has been furnished by 
an individual or entity if the individual or entity directly or 
indirectly provided, ordered, manufactured, distributed, prescribed, or 
otherwise supplied the item or service regardless of how the item or 
service was paid for by a Federal health care program or to whom such 
payment was made.
    ``(C)(i) Payment may be made under a Federal health care program 
for emergency items or services (not including items or services 
furnished in an emergency room of a hospital) furnished by an excluded 
individual or entity, or at the medical direction or on the 
prescription of an excluded physician or other authorized individual 
during the period of such individual's exclusion.
    ``(ii) In the case that an individual eligible for benefits under 
title XVIII or XIX submits a claim for payment for items or services 
furnished by an excluded individual or entity, and such individual 
eligible for such benefits did not know or have reason to know that 
such excluded individual or entity was so excluded, then, 
notwithstanding such exclusion, payment shall be made for such items or 
services. In such case the Secretary shall notify such individual 
eligible for such benefits of the exclusion of the individual or entity 
furnishing the items or services. Payment shall not be made for items 
or services furnished by an excluded individual or entity to an 
individual eligible for such benefits after a reasonable time (as 
determined by the Secretary in regulations) after the Secretary has 
notified the individual eligible for such benefits of the exclusion of 
the individual or entity furnishing the items or services.
    ``(iii) In the case that a claim for payment for items or services 
furnished by an excluded individual or entity is submitted by an 
individual or entity other than an individual eligible for benefits 
under title XVIII or XIX or the excluded individual or entity, and the 
Secretary determines that the individual or entity that submitted the 
claim took reasonable steps to learn of the exclusion and reasonably 
relied upon inaccurate or misleading information from the relevant 
Federal health care program or its contractor, the Secretary may waive 
repayment of the amount paid in violation of the exclusion to the 
individual or entity that submitted the claim for the items or services 
furnished by the excluded individual or entity. If a Federal health 
care program contractor provided inaccurate or misleading information 
that resulted in the waiver of an overpayment under this clause, the 
Secretary shall take appropriate action to recover the improperly paid 
amount from the contractor.''.

SEC. 1620. OIG AUTHORITY TO EXCLUDE FROM FEDERAL HEALTH CARE PROGRAMS 
              OFFICERS AND OWNERS OF ENTITIES CONVICTED OF FRAUD.

    Section 1128(b)(15)(A) of the Social Security Act (42 U.S.C. 1320a-
7(b)(15)(A)) is amended--
            (1) in clause (i)--
                    (A) by striking ``has'' and inserting ``had''; and
                    (B) by striking ``sanctioned entity and who knows 
                or should know (as defined in section 1128A(i)(6)) of'' 
                and inserting ``sanctioned entity at the time of, and 
                who knew or should have known (as defined in section 
                1128A(i)(6)) of,'' ; and
            (2) in clause (ii)--
                    (A) by striking ``is an officer'' and inserting 
                ``was an officer''; and
                    (B) by inserting before the period the following: 
                ``at the time of the action constituting the basis for 
                the conviction or exclusion described in subparagraph 
                (B)''.

SEC. 1621. SELF-REFERRAL DISCLOSURE PROTOCOL.

    (a) Development of Self-referral Disclosure Protocol.--
            (1) In general.--The Secretary of Health and Human 
        Services, in cooperation with the Inspector General of the 
        Department of Health and Human Services, shall establish, not 
        later than 6 months after the date of the enactment of this 
        Act, a protocol to enable health care providers of services and 
        suppliers to disclose an actual or potential violation of 
        section 1877 of the Social Security Act (42 U.S.C. 1395nn) 
        pursuant to a self-referral disclosure protocol (in this 
        section referred to as an ``SRDP''). The SRDP shall include 
        direction to health care providers of services and suppliers 
        on--
                    (A) a specific person, official, or office to whom 
                such disclosures shall be made; and
                    (B) instruction on the implication of the SRDP on 
                corporate integrity agreements and corporate compliance 
                agreements.
            (2) Publication on internet website of srdp information.--
        The Secretary shall post information on the public Internet 
        website of the Centers for Medicare & Medicaid Services to 
        inform relevant stakeholders of how to disclose actual or 
        potential violations pursuant to an SRDP.
            (3) Relation to advisory opinions.--The SRDP shall be 
        separate from the advisory opinion process set forth in 
        regulations implementing section 1877(g) of the Social Security 
        Act.
    (b) Reduction in Amounts Owed.--The Secretary is authorized to 
reduce the amount due and owing for all violations under section 1877 
of the Social Security Act to an amount less than that specified in 
subsection (g) of such section. In establishing such amount for a 
violation, the Secretary may consider the following factors:
            (1) The nature and extent of the improper or illegal 
        practice.
            (2) The timeliness of such self-disclosure.
            (3) The cooperation in providing additional information 
        related to the disclosure.
            (4) Such other factors as the Secretary considers 
        appropriate.
    (c) Report.--Not later than 18 months after the date on which the 
SRDP protocol is established under subsection (a)(1), the Secretary 
shall submit to Congress a report on the implementation of this 
section. Such report shall include--
            (1) the number of health care providers of services and 
        suppliers making disclosures pursuant to an SRDP;
            (2) the amounts collected pursuant to the SRDP;
            (3) the types of violations reported under the SRDP; and
            (4) such other information as may be necessary to evaluate 
        the impact of this section.
    (d) Relation to Other Law and Regulation.--Nothing in this section 
shall affect the application of section 1128G(c) of the Social Security 
Act, as added by section 1641, except, in the case of a health care 
provider of services or supplier who is a person (as defined in 
paragraph (4) of such section 1128G(c)) who discloses an overpayment 
(as defined in such paragraph) to the Secretary of Health and Human 
Services pursuant to a SRDP established under this section, the 60-day 
period described in paragraph (2) of such section 1128G(c) shall be 
extended with respect to the return of an overpayment to the extent 
necessary for the Secretary to determine pursuant to the SRDP the 
amount due and owing.

         Subtitle C--Enhanced Program and Provider Protections

SEC. 1631. ENHANCED CMS PROGRAM PROTECTION AUTHORITY.

    (a) In General.--Title XI of the Social Security Act (42 U.S.C. 
1301 et seq.) is amended by inserting after section 1128F the following 
new section:

``SEC. 1128G. ENHANCED PROGRAM AND PROVIDER PROTECTIONS IN THE 
              MEDICARE, MEDICAID, AND CHIP PROGRAMS.

    ``(a) Certain Authorized Screening, Enhanced Oversight Periods, and 
Enrollment Moratoria.--
            ``(1) In general.--For periods beginning after January 1, 
        2011, in the case that the Secretary determines there is a 
        significant risk of fraudulent activity (as determined by the 
        Secretary based on relevant complaints, reports, referrals by 
        law enforcement or other sources, data analysis, trending 
        information, or claims submissions by providers of services and 
        suppliers) with respect to a category of provider of services 
        or supplier of items or services, including a category within a 
        geographic area, under title XVIII, XIX, or XXI, the Secretary 
        may impose any of the following requirements with respect to a 
        provider of services or a supplier (whether such provider or 
        supplier is initially enrolling in the program or is renewing 
        such enrollment):
                    ``(A) Screening under paragraph (2).
                    ``(B) Enhanced oversight periods under paragraph 
                (3).
                    ``(C) Enrollment moratoria under paragraph (4).
        In applying this subsection for purposes of title XIX and XXI 
        the Secretary may require a State to carry out the provisions 
        of this subsection as a requirement of the State plan under 
        title XIX or the child health plan under title XXI. Actions 
        taken and determinations made under this subsection shall not 
        be subject to review by a judicial tribunal.
            ``(2) Screening.--For purposes of paragraph (1), the 
        Secretary shall establish procedures under which screening is 
        conducted with respect to providers of services and suppliers 
        described in such paragraph. Such screening may include--
                    ``(A) licensing board checks;
                    ``(B) screening against the list of individuals and 
                entities excluded from the program under title XVIII, 
                XIX, or XXI;
                    ``(C) the excluded provider list system;
                    ``(D) background checks; and
                    ``(E) unannounced pre-enrollment or other site 
                visits.
            ``(3) Enhanced oversight period.--For purposes of paragraph 
        (1), the Secretary shall establish procedures to provide for a 
        period of not less than 30 days and not more than 365 days 
        during which providers of services and suppliers described in 
        such paragraph, as the Secretary determines appropriate, would 
        be subject to enhanced oversight, such as required or 
        unannounced (or required and unannounced) site visits or 
        inspections, prepayment review, enhanced review of claims, and 
        such other actions as specified by the Secretary, under the 
        programs under titles XVIII, XIX, and XXI. Under such 
        procedures, the Secretary may extend such period for more than 
        365 days if the Secretary determines that after the initial 
        period such additional period of oversight is necessary.
            ``(4) Moratorium on enrollment of providers and 
        suppliers.--For purposes of paragraph (1), the Secretary, based 
        upon a finding of a risk of serious ongoing fraud within a 
        program under title XVIII, XIX, or XXI, may impose a moratorium 
        on the enrollment of providers of services and suppliers within 
        a category of providers of services and suppliers (including a 
        category within a specific geographic area) under such title. 
        Such a moratorium may only be imposed if the Secretary makes a 
        determination that the moratorium would not adversely impact 
        access of individuals to care under such program.
            ``(5) Clarification.--Nothing in this subsection shall be 
        interpreted to preclude or limit the ability of a State to 
        engage in provider screening or enhanced provider oversight 
        activities beyond those required by the Secretary.''.
    (b) Conforming Amendments.--
            (1) Medicaid.--Section 1902(a) of the Social Security Act 
        (42 U.S.C. 42 U.S.C. 1396a(a)) is amended--
                    (A) in paragraph (23), by inserting before the 
                semicolon at the end the following: ``or by a person to 
                whom or entity to which a moratorium under section 
                1128G(a)(4) is applied during the period of such 
                moratorium'';
                    (B) in paragraph (72); by striking at the end 
                ``and'';
                    (C) in paragraph (73), by striking the period at 
                the end and inserting ``; and''; and
                    (D) by adding after paragraph (73) the following 
                new paragraph:
            ``(74) provide that the State will enforce any 
        determination made by the Secretary under subsection (a) of 
        section 1128G (relating to a significant risk of fraudulent 
        activity with respect to a category of provider or supplier 
        described in such subsection (a) through use of the appropriate 
        procedures described in such subsection (a)), and that the 
        State will carry out any activities as required by the 
        Secretary for purposes of such subsection (a).''.
            (2) CHIP.--Section 2102 of such Act (42 U.S.C. 1397bb) is 
        amended by adding at the end the following new subsection:
    ``(d) Program Integrity.--A State child health plan shall include a 
description of the procedures to be used by the State--
            ``(1) to enforce any determination made by the Secretary 
        under subsection (a) of section 1128G (relating to a 
        significant risk of fraudulent activity with respect to a 
        category of provider or supplier described in such subsection 
        through use of the appropriate procedures described in such 
        subsection); and
            ``(2) to carry out any activities as required by the 
        Secretary for purposes of such subsection.''.
            (3) Medicare.--Section 1866(j) of such Act (42 U.S.C. 
        1395cc(j)) is amended by adding at the end the following new 
        paragraph:
            ``(3) Program integrity.--The provisions of section 
        1128G(a) apply to enrollments and renewals of enrollments of 
        providers of services and suppliers under this title.''.

SEC. 1632. ENHANCED MEDICARE, MEDICAID, AND CHIP PROGRAM DISCLOSURE 
              REQUIREMENTS RELATING TO PREVIOUS AFFILIATIONS.

    (a) In General.--Section 1128G of the Social Security Act, as 
inserted by section 1631, is amended by adding at the end the following 
new subsection:
    ``(b) Enhanced Program Disclosure Requirements.--
            ``(1) Disclosure.--A provider of services or supplier who 
        submits on or after July 1, 2011, an application for enrollment 
        and renewing enrollment in a program under title XVIII, XIX, or 
        XXI shall disclose (in a form and manner determined by the 
        Secretary) any current affiliation or affiliation within the 
        previous 10-year period with a provider of services or supplier 
        that has uncollected debt or with a person or entity that has 
        been suspended or excluded under such program, subject to a 
        payment suspension, or has had its billing privileges revoked.
            ``(2) Enhanced safeguards.--If the Secretary determines 
        that such previous affiliation of such provider or supplier 
        poses a risk of fraud, waste, or abuse, the Secretary may apply 
        such enhanced safeguards as the Secretary determines necessary 
        to reduce such risk associated with such provider or supplier 
        enrolling or participating in the program under title XVIII, 
        XIX, or XXI. Such safeguards may include enhanced oversight, 
        such as enhanced screening of claims, required or unannounced 
        (or required and unannounced) site visits or inspections, 
        additional information reporting requirements, and conditioning 
        such enrollment on the provision of a surety bond.
            ``(3) Authority to deny participation.--If the Secretary 
        determines that there has been at least one such affiliation 
        and that such affiliation or affiliations, as applicable, of 
        such provider or supplier poses a serious risk of fraud, waste, 
        or abuse, the Secretary may deny the application of such 
        provider or supplier.''.
    (b) Conforming Amendments.--
            (1) Medicaid.--Paragraph (74) of section 1902(a) of such 
        Act (42 U.S.C. 1396a(a)), as added by section 1631(b)(1), is 
        amended--
                    (A) by inserting ``or subsection (b) of such 
                section (relating to disclosure requirements)'' before 
                ``, and that the State''; and
                    (B) by inserting before the period the following: 
                ``and apply any enhanced safeguards, with respect to a 
                provider or supplier described in such subsection (b), 
                as the Secretary determines necessary under such 
                subsection (b)''.
            (2) CHIP.--Subsection (d) of section 2102 of such Act (42 
        U.S.C. 1397bb), as added by section 1631(b)(2), is amended--
                    (A) in paragraph (1), by striking at the end 
                ``and'';
                    (B) in paragraph (2) by striking the period at the 
                end and inserting ``; and''' and
                    (C) by adding at the end the following new 
                paragraph:
            ``(3) to enforce any determination made by the Secretary 
        under subsection (b) of section 1128G (relating to disclosure 
        requirements) and to apply any enhanced safeguards, with 
        respect to a provider or supplier described in such subsection, 
        as the Secretary determines necessary under such subsection.''.

SEC. 1633. REQUIRED INCLUSION OF PAYMENT MODIFIER FOR CERTAIN 
              EVALUATION AND MANAGEMENT SERVICES.

    Section 1848 of the Social Security Act (42 U.S.C. 1395w-4), as 
amended by section 4101 of the HITECH Act (Public Law 111-5), is 
amended by adding at the end the following new subsection:
    ``(p) Payment Modifier for Certain Evaluation and Management 
Services.--The Secretary shall establish a payment modifier under the 
fee schedule under this section for evaluation and management services 
(as specified in section 1842(b)(16)(B)(ii)) that result in the 
ordering of additional services (such as lab tests), the prescription 
of drugs, the furnishing or ordering of durable medical equipment in 
order to enable better monitoring of claims for payment for such 
additional services under this title, or the ordering, furnishing, or 
prescribing of other items and services determined by the Secretary to 
pose a high risk of waste, fraud, and abuse. The Secretary may require 
providers of services or suppliers to report such modifier in claims 
submitted for payment.''.

SEC. 1634. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICARE INTEGRITY 
              PROGRAM.

    (a) In General.--Section 1893(c) of the Social Security Act (42 
U.S.C. 1395ddd(c)) is amended--
            (1) in paragraph (3), by striking at the end ``and'';
            (2) by redesignating paragraph (4) as paragraph (5); and
            (3) by inserting after paragraph (3) the following new 
        paragraph:
            ``(4) for the contract year beginning in 2011 and each 
        subsequent contract year, the entity provides assurances to the 
        satisfaction of the Secretary that the entity will conduct 
        periodic evaluations of the effectiveness of the activities 
        carried out by such entity under the Program and will submit to 
        the Secretary an annual report on such activities; and''.
    (b) Reference to Medicaid Integrity Program.--For a similar 
provision with respect to the Medicaid Integrity Program, see section 
1752.

SEC. 1635. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE 
              WASTE, FRAUD, AND ABUSE.

    (a) In General.--Section 1866(j) of the Social Security Act (42 
U.S.C. 42 U.S.C. 1395cc(j)), as amended by section 1631(d)(3), is 
further amended by adding at the end the following new paragraph:
            ``(4) Compliance programs for providers of services and 
        suppliers.--
                    ``(A) In general.--The Secretary may not enroll (or 
                renew the enrollment of) a provider of services or a 
                supplier (other than a physician or a skilled nursing 
                facility) under this title if such provider of services 
                or supplier fails to, subject to subparagraph (E), 
                establish a compliance program that contains the core 
                elements established under subparagraph (B) and certify 
                in a manner determined by the Secretary, that the 
                provider or suppler has established such a program.
                    ``(B) Establishment of core elements.--The 
                Secretary, in consultation with the Inspector General 
                of the Department of Health and Human Services, shall 
                establish core elements for a compliance program under 
                subparagraph (A). Such elements may include written 
                policies, procedures, and standards of conduct, a 
                designated compliance officer and a compliance 
                committee; effective training and education pertaining 
                to fraud, waste, and abuse for the organization's 
                employees, and contractors; a confidential or anonymous 
                mechanism, such as a hotline, to receive compliance 
                questions and reports of fraud, waste, or abuse; 
                disciplinary guidelines for enforcement of standards; 
                internal monitoring and auditing procedures, including 
                monitoring and auditing of contractors; procedures for 
                ensuring prompt responses to detected offenses and 
                development of corrective action initiatives, including 
                responses to potential offenses; and procedures to 
                return all identified overpayments to the programs 
                under this title, title XIX, and title XXI.
                    ``(C) Timeline for implementation.--The Secretary 
                shall determine a timeline for the establishment of the 
                core elements under subparagraph (B) and the date on 
                which a provider of services and suppliers (other than 
                physicians and skilled nursing facilities) shall be 
                required to have established such a program for 
                purposes of this subsection.
                    ``(D) Pilot program.--The Secretary may conduct a 
                pilot program on the application of this subsection 
                with respect to a category of providers of services or 
                suppliers (other than physicians and skilled nursing 
                facilities) that the Secretary determines to be a 
                category which is at high risk for waste, fraud, and 
                abuse before implementing the requirements of this 
                subsection to all providers of services and suppliers 
                described in subparagraph (C).
                    ``(E) Treatment of skilled nursing facilities.--For 
                the requirement for skilled nursing facilities to 
                establish compliance and ethics programs see section 
                1819(d)(1)(C).
                    ``(F) Construction.--Nothing in this subsection 
                exempts a physician from participating in a compliance 
                program established by a health care provider or other 
                entity with which the physician is employed, under 
                contract, or affiliated if such compliance is required 
                by such provider or entity.''.
    (b) Reference to Similar Medicaid Provision.--For a similar 
provision with respect to the Medicaid program under title XIX of the 
Social Security Act, see section 1753.

SEC. 1636. MAXIMUM PERIOD FOR SUBMISSION OF MEDICARE CLAIMS REDUCED TO 
              NOT MORE THAN 12 MONTHS.

    (a) Purpose.--In general, the 36-month period currently allowed for 
claims filing under parts A, B, C, and, D of title XVIII of the Social 
Security Act presents opportunities for fraud schemes in which 
processing patterns of the Centers for Medicare & Medicaid Services can 
be observed and exploited. Narrowing the window for claims processing 
will not overburden providers and will reduce fraud and abuse.
    (b) Reducing Maximum Period for Submission.--
            (1) Part a.--Section 1814(a) of the Social Security Act (42 
        U.S.C. 1395f(a)) is amended--
                    (A) in paragraph (1), by striking ``period of 3 
                calendar years'' and all that follows and inserting 
                ``period of 1 calendar year from which such services 
                are furnished; and''; and
                    (B) by adding at the end the following new 
                sentence: ``In applying paragraph (1), the Secretary 
                may specify exceptions to the 1 calendar year period 
                specified in such paragraph.''.
            (2) Part b.--Section 1835(a) of such Act (42 U.S.C. 
        1395n(a)) is amended--
                    (A) in paragraph (1), by striking ``period of 3 
                calendar years'' and all that follows and inserting 
                ``period of 1 calendar year from which such services 
                are furnished; and''; and
                    (B) by adding at the end the following new 
                sentence: ``In applying paragraph (1), the Secretary 
                may specify exceptions to the 1 calendar year period 
                specified in such paragraph.''.
            (3) Parts c and d.--Section 1857(d) of such Act is amended 
        by adding at the end the following new paragraph:
            ``(7) Period for submission of claims.--The contract shall 
        require an MA organization or PDP sponsor to require any 
        provider of services under contract with, in partnership with, 
        or affiliated with such organization or sponsor to ensure that, 
        with respect to items and services furnished by such provider 
        to an enrollee of such organization, written request, signed by 
        such enrollee, except in cases in which the Secretary finds it 
        impracticable for the enrollee to do so, is filed for payment 
        for such items and services in such form, in such manner, and 
        by such person or persons as the Secretary may by regulation 
        prescribe, no later than the close of the 1 calendar year 
        period after such items and services are furnished. In applying 
        the previous sentence, the Secretary may specify exceptions to 
        the 1 calendar year period specified.''.
    (c) Effective Date.--The amendments made by subsection (b) shall be 
effective for items and services furnished on or after January 1, 2011.

SEC. 1637. PHYSICIANS WHO ORDER DURABLE MEDICAL EQUIPMENT OR HOME 
              HEALTH SERVICES REQUIRED TO BE MEDICARE ENROLLED 
              PHYSICIANS OR ELIGIBLE PROFESSIONALS.

    (a) DME.--Section 1834(a)(11)(B) of the Social Security Act (42 
U.S.C. 1395m(a)(11)(B)) is amended by striking ``physician'' and 
inserting ``physician enrolled under section 1866(j) or other 
professional, as determined by the Secretary''.
    (b) Home Health Services.--
            (1) Part a.--Section 1814(a)(2) of such Act (42 U.S.C. 
        1395(a)(2)) is amended in the matter preceding subparagraph (A) 
        by inserting ``in the case of services described in 
        subparagraph (C), a physician enrolled under section 1866(j) or 
        other professional, as determined by the Secretary,'' before 
        ``or, in the case of services''.
            (2) Part b.--Section 1835(a)(2) of such Act (42 U.S.C. 
        1395n(a)(2)) is amended in the matter preceding subparagraph 
        (A) by inserting ``, or in the case of services described in 
        subparagraph (A), a physician enrolled under section 1866(j) or 
        other professional, as determined by the Secretary,'' after ``a 
        physician''.
    (c) Discretion to Expand Application.--The Secretary may extend the 
requirement applied by the amendments made by subsections (a) and (b) 
to durable medical equipment and home health services (relating to 
requiring certifications and written orders to be made by enrolled 
physicians and health professions) to other categories of items or 
services under this title, including covered part D drugs as defined in 
section 1860D-2(e), if the Secretary determines that such application 
would help to reduce the risk of waste, fraud, and abuse with respect 
to such other categories under title XVIII of the Social Security Act.
    (d) Effective Date.--The amendments made by this section shall 
apply to written orders and certifications made on or after July 1, 
2010.

SEC. 1638. REQUIREMENT FOR PHYSICIANS TO PROVIDE DOCUMENTATION ON 
              REFERRALS TO PROGRAMS AT HIGH RISK OF WASTE AND ABUSE.

    (a) Physicians and Other Suppliers.--Section 1842(h) of the Social 
Security Act is further amended by adding at the end the following new 
paragraph
    ``(9) The Secretary may disenroll, for a period of not more than 
one year for each act, a physician or supplier under section 1866(j) if 
such physician or supplier fails to maintain and, upon request of the 
Secretary, provide access to documentation relating to written orders 
or requests for payment for durable medical equipment, certifications 
for home health services, or referrals for other items or services 
written or ordered by such physician or supplier under this title, as 
specified by the Secretary.''.
    (b) Providers of Services.--Section 1866(a)(1) of such Act (42 
U.S.C. 1395cc), is amended--
            (1) in subparagraph (U), by striking at the end ``and'';
            (2) in subparagraph (V), by striking the period at the end 
        and adding ``; and''; and
            (3) by adding at the end the following new subparagraph:
                    ``(W) maintain and, upon request of the Secretary, 
                provide access to documentation relating to written 
                orders or requests for payment for durable medical 
                equipment, certifications for home health services, or 
                referrals for other items or services written or 
                ordered by the provider under this title, as specified 
                by the Secretary.''.
    (c) OIG Permissive Exclusion Authority.--Section 1128(b)(11) of the 
Social Security Act (42 U.S.C. 1320a-7(b)(11)) is amended by inserting 
``, ordering, referring for furnishing, or certifying the need for'' 
after ``furnishing''.
    (d) Effective Date.--The amendments made by this section shall 
apply to orders, certifications, and referrals made on or after January 
1, 2010.

SEC. 1639. FACE-TO-FACE ENCOUNTER WITH PATIENT REQUIRED BEFORE 
              ELIGIBILITY CERTIFICATIONS FOR HOME HEALTH SERVICES OR 
              DURABLE MEDICAL EQUIPMENT.

    (a) Condition of Payment for Home Health Services.--
            (1) Part a.--Section 1814(a)(2)(C) of such Act is amended--
                    (A) by striking ``and such services'' and inserting 
                ``such services''; and
                    (B) by inserting after ``care of a physician'' the 
                following: ``, and, in the case of a certification or 
                recertification made by a physician after January 1, 
                2010, prior to making such certification the physician 
                must document that the physician has had a face-to-face 
                encounter (including through use of telehealth and 
                other than with respect to encounters that are incident 
                to services involved) with the individual during the 6-
                month period preceding such certification, or other 
                reasonable timeframe as determined by the Secretary''.
            (2) Part b.--Section 1835(a)(2)(A) of the Social Security 
        Act is amended--
                    (A) by striking ``and'' before ``(iii)''; and
                    (B) by inserting after ``care of a physician'' the 
                following: ``, and (iv) in the case of a certification 
                or recertification after January 1, 2010, prior to 
                making such certification the physician must document 
                that the physician has had a face-to-face encounter 
                (including through use of telehealth and other than 
                with respect to encounters that are incident to 
                services involved) with the individual during the 6-
                month period preceding such certification or 
                recertification, or other reasonable timeframe as 
                determined by the Secretary''.
    (b) Condition of Payment for Durable Medical Equipment.--Section 
1834(a)(11)(B) of the Social Security Act (42 U.S.C. 1395m(a)(11)(B)) 
is amended by adding before the period at the end the following: ``and 
shall require that any written order required for payment under this 
subsection be written only pursuant to the eligible health care 
professional authorized to make such written order documenting that 
such professional has had a face-to-face encounter (including through 
use of telehealth and other than with respect to encounters that are 
incident to services involved) with the individual involved during the 
6-month period preceding such written order, or other reasonable 
timeframe as determined by the Secretary''.
    (c) Application to Other Areas Under Medicare.--The Secretary may 
apply a face-to-face encounter requirement similar to the requirement 
described in the amendments made by subsections (a) and (b) to other 
items and services for which payment is provided under title XVIII of 
the Social Security Act based upon a finding that such a decision would 
reduce the risk of waste, fraud, or abuse.
    (d) Application to Medicaid and CHIP.--The face-to-face encounter 
requirements described in the amendments made by subsections (a) and 
(b) and any expanded application of similar requirements pursuant to 
subsection (c) shall apply with respect to a certification or 
recertification for home health services under title XIX or XXI of the 
Social Security Act, a written order for durable medical equipment 
under such title, and any other applicable item or service identified 
pursuant to subsection (c) for which payment is made under such title, 
respectively, in the same manner and to the same extent as such 
requirements apply in the case of such a certification or 
recertification, written order, or other applicable item or service so 
identified, respectively, under title XVIII of such Act.

SEC. 1640. EXTENSION OF TESTIMONIAL SUBPOENA AUTHORITY TO PROGRAM 
              EXCLUSION INVESTIGATIONS.

    (a) In General.--Section 1128(f) of the Social Security Act (42 
U.S.C. 1320a-7(f)) is amended by adding at the end the following new 
paragraph:
    ``(4) The provisions of subsections (d) and (e) of section 205 
shall apply with respect to this section to the same extent as they are 
applicable with respect to title II. The Secretary may delegate the 
authority granted by section 205(d) (as made applicable to this 
section) to the Inspector General of the Department of Health and Human 
Services or the Administrator of the Centers for Medicare & Medicaid 
Services for purposes of any investigation under this section.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to investigations beginning on or after January 1, 2010.

SEC. 1641. REQUIRED REPAYMENTS OF MEDICARE AND MEDICAID OVERPAYMENTS.

    Section 1128G of the Social Security Act, as inserted by section 
1631 and amended by section 1632, is further amended by adding at the 
end the following new subsection:
    ``(c) Reports on and Repayment of Overpayments Identified Through 
Internal Audits and Reviews.--
            ``(1) Reporting and returning overpayments.--If a person 
        knows of an overpayment, the person must--
                    ``(A) report and return the overpayment to the 
                Secretary, the State, an intermediary, a carrier, or a 
                contractor, as appropriate, at the correct address, and
                    ``(B) notify the Secretary, the State, 
                intermediary, carrier, or contractor to whom the 
                overpayment was returned in writing of the reason for 
                the overpayment.
            ``(2) Timing.--Subject to section 1620(d) of the Affordable 
        Health Care for America Act, an overpayment must be reported 
        and returned under paragraph (1)(A) by not later than the date 
        that is 60 days after the date the person knows of the 
        overpayment.
        Any known overpayment retained later than the applicable date 
        specified in this paragraph creates an obligation as defined in 
        section 3729(b)(3) of title 31 of the United States Code.
            ``(3) Clarification.--Repayment of any overpayments (or 
        refunding by withholding of future payments) by a provider of 
        services or supplier does not otherwise limit the provider or 
        supplier's potential liability for administrative obligations 
        such as applicable interests, fines, and penalties or civil or 
        criminal sanctions involving the same claim if it is determined 
        later that the reason for the overpayment was related to fraud 
        or other intentional conduct by the provider or supplier or the 
        employees or agents of such provider or supplier.
            ``(4) Definitions.--In this subsection:
                    ``(A) Knows.--The term `knows' has the meaning 
                given the terms `knowing' and `knowingly' in section 
                3729(b) of title 31 of the United States Code.
                    ``(B) Overpayment.--The term ``overpayment'' means 
                any funds that a person receives or retains under title 
                XVIII, XIX, or XXI to which the person, after 
                applicable reconciliation (pursuant to the applicable 
                existing process under the respective title), is not 
                entitled under such title.
                    ``(C) Person.--The term `person' means a provider 
                of services, supplier, Medicaid managed care 
                organization (as defined in section 1903(m)(1)(A)), 
                Medicare Advantage organization (as defined in section 
                1859(a)(1)), or PDP sponsor (as defined in section 
                1860D-41(a)(13)), but excluding a beneficiary.''.

SEC. 1642. EXPANDED APPLICATION OF HARDSHIP WAIVERS FOR OIG EXCLUSIONS 
              TO BENEFICIARIES OF ANY FEDERAL HEALTH CARE PROGRAM.

    Section 1128(c)(3)(B) of the Social Security Act (42 U.S.C. 1320a-
7(c)(3)(B)) is amended by striking ``individuals entitled to benefits 
under part A of title XVIII or enrolled under part B of such title, or 
both'' and inserting ``beneficiaries (as defined in section 
1128A(i)(5)) of that program''.

SEC. 1643. ACCESS TO CERTAIN INFORMATION ON RENAL DIALYSIS FACILITIES.

    Section 1881(b) of the Social Security Act (42 U.S.C. 1395rr(b)) is 
amended by adding at the end the following new paragraph:
    ``(15) For purposes of evaluating or auditing payments made to 
renal dialysis facilities for items and services under this section 
under paragraph (1), each such renal dialysis facility, upon the 
request of the Secretary, shall provide to the Secretary access to 
information relating to any ownership or compensation arrangement 
between such facility and the medical director of such facility or 
between such facility and any physician.''.

SEC. 1644. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES 
              REQUIRED TO REGISTER UNDER MEDICARE.

    (a) Medicare.--Section 1866(j)(1) of the Social Security Act (42 
U.S.C. 1395cc(j)(1)) is amended by adding at the end the following new 
subparagraph:
                    ``(D) Billing agents and clearinghouses required to 
                be registered under medicare.--Any agent, 
                clearinghouse, or other alternate payee that submits 
                claims on behalf of a health care provider must be 
                registered with the Secretary in a form and manner 
                specified by the Secretary.''.
    (b) Medicaid.--For a similar provision with respect to the Medicaid 
program under title XIX of the Social Security Act, see section 1759.
    (c) Effective Date.--The amendment made by subsection (a) shall 
apply to claims submitted on or after January 1, 2012.

SEC. 1645. CONFORMING CIVIL MONETARY PENALTIES TO FALSE CLAIMS ACT 
              AMENDMENTS.

    Section 1128A of the Social Security Act, as amended by sections 
1611, 1612, 1613, and 1615, is further amended--
            (1) in subsection (a)--
                    (A) in paragraph (1), by striking ``to an officer, 
                employee, or agent of the United States, or of any 
                department or agency thereof, or of any State agency 
                (as defined in subsection (i)(1))'';
                    (B) in paragraph (4)--
                            (i) in the matter preceding subparagraph 
                        (A), by striking ``participating in a program 
                        under title XVIII or a State health care 
                        program'' and inserting ``participating in a 
                        Federal health care program (as defined in 
                        section 1128B(f))''; and
                            (ii) in subparagraph (A), by striking 
                        ``title XVIII or a State health care program'' 
                        and inserting ``a Federal health care program 
                        (as defined in section 1128B(f))'';
                    (C) by striking ``or'' at the end of paragraph 
                (10);
                    (D) by inserting after paragraph (11) the following 
                new paragraphs:
            ``(12) conspires to commit a violation of this section; or
            ``(13) knowingly makes, uses, or causes to be made or used, 
        a false record or statement material to an obligation to pay or 
        transmit money or property to a Federal health care program, or 
        knowingly conceals or knowingly and improperly avoids or 
        decreases an obligation to pay or transmit money or property to 
        a Federal health care program;''; and
                    (E) in the matter following paragraph (13), as 
                inserted by subparagraph (D)--
                            (i) by striking ``or'' before ``in cases 
                        under paragraph (11)''; and
                            (ii) by inserting ``, in cases under 
                        paragraph (12), $50,000 for any violation 
                        described in this section committed in 
                        furtherance of the conspiracy involved; or in 
                        cases under paragraph (13), $50,000 for each 
                        false record or statement, or concealment, 
                        avoidance, or decrease'' after ``by an excluded 
                        individual''; and
                    (F) in the second sentence, by striking ``such 
                false statement, omission, or misrepresentation)'' and 
                inserting ``such false statement or misrepresentation, 
                in cases under paragraph (12), an assessment of not 
                more than 3 times the total amount that would otherwise 
                apply for any violation described in this section 
                committed in furtherance of the conspiracy involved, or 
                in cases under paragraph (13), an assessment of not 
                more than 3 times the total amount of the obligation to 
                which the false record or statement was material or 
                that was avoided or decreased)''.
            (2) in subsection (c)(1), by striking ``six years'' and 
        inserting ``10 years''; and
            (3) in subsection (i)--
                    (A) by amending paragraph (2) to read as follows:
            ``(2) The term `claim' means any application, request, or 
        demand, whether under contract, or otherwise, for money or 
        property for items and services under a Federal health care 
        program (as defined in section 1128B(f)), whether or not the 
        United States or a State agency has title to the money or 
        property, that--
                    ``(A) is presented or caused to be presented to an 
                officer, employee, or agent of the United States, or of 
                any department or agency thereof, or of any State 
                agency (as defined in subsection (i)(1)); or
                    ``(B) is made to a contractor, grantee, or other 
                recipient if the money or property is to be spent or 
                used on the Federal health care program's behalf or to 
                advance a Federal health care program interest, and if 
                the Federal health care program--
                            ``(i) provides or has provided any portion 
                        of the money or property requested or demanded; 
                        or
                            ``(ii) will reimburse such contractor, 
                        grantee, or other recipient for any portion of 
                        the money or property which is requested or 
                        demanded.'';
                    (B) by amending paragraph (3) to read as follows:
            ``(3) The term `item or service' means, without limitation, 
        any medical, social, management, administrative, or other item 
        or service used in connection with or directly or indirectly 
        related to a Federal health care program.'';
                    (C) in paragraph (6)--
                            (i) in subparagraph (C), by striking at the 
                        end ``or'';
                            (ii) in the first subparagraph (D), by 
                        striking at the end the period and inserting 
                        ``; or''; and
                            (iii) by redesignating the second 
                        subparagraph (D) as a subparagraph (E);
                    (D) by amending paragraph (7) to read as follows:
            ``(7) The terms `knowing', `knowingly', and `should know' 
        mean that a person, with respect to information--
                    ``(A) has actual knowledge of the information;
                    ``(B) acts in deliberate ignorance of the truth or 
                falsity of the information; or
                    ``(C) acts in reckless disregard of the truth or 
                falsity of the information;
        and require no proof of specific intent to defraud.''; and
                    (E) by adding at the end the following new 
                paragraphs:
            ``(8) The term `obligation' means an established duty, 
        whether or not fixed, arising from an express or implied 
        contractual, grantor-grantee, or licensor-licensee 
        relationship, from a fee-based or similar relationship, from 
        statute or regulation, or from the retention of any 
        overpayment.
            ``(9) The term `material' means having a natural tendency 
        to influence, or be capable of influencing, the payment or 
        receipt of money or property.''.

SEC. 1646. REQUIRING PROVIDER AND SUPPLIER PAYMENTS UNDER MEDICARE TO 
              BE MADE THROUGH DIRECT DEPOSIT OR ELECTRONIC FUNDS 
              TRANSFER (EFT) AT INSURED DEPOSITORY INSTITUTIONS.

    (a) Medicare.--Section 1874 of the Social Security Act (42 U.S.C. 
1395kk) is amended by adding at the end the following new subsection:
    ``(e) Limitation on Payment to Providers of Services and 
Suppliers.--No payment shall be made under this title for items and 
services furnished by a provider of services or supplier unless each 
payment to the provider of services or supplier is in the form of 
direct deposit or electronic funds transfer to the provider of 
services' or supplier's account, as applicable, at a depository 
institution (as defined in section 19(b)(1)(A) of the Federal Reserve 
Act.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to each payment made to a provider of services, provider, or 
supplier on or after such date (not later than July 1, 2012) as the 
Secretary of Health and Human Services shall specify, regardless of 
when the items and services for which such payment is made were 
furnished.

SEC. 1647. INSPECTOR GENERAL FOR THE HEALTH CHOICES ADMINISTRATION.

    (a) Establishment; Appointment.--There is hereby established an 
Office of Inspector General for the Health Choices Administration, to 
be headed by the Inspector General for the Health Choices 
Administration to be appointed by the President, by and with the advice 
and consent of the Senate.
    (b) Amendments to the Inspector General Act of 1978.--
            (1) Application to health choices administration.--Section 
        12 of the Inspector General Act of 1978 (5 U.S.C. App.) is 
        amended--
                    (A) in paragraph (1), by striking ``or the Federal 
                Cochairpersons of the Commissions established under 
                section 15301 of title 40, United States Code'' and 
                inserting ``the Federal Cochairpersons of the 
                Commissions established under section 15301 of title 
                40, United States Code; or the Commissioner of the 
                Health Choices Administration established under section 
                241 of the Affordable Health Care for America Act''; 
                and
                    (B) in paragraph (2), by striking ``or the 
                Commissions established under section 15301 of title 
                40, United States Code'' and inserting ``the 
                Commissions established under section 15301 of title 
                40, United States Code, or the Health Choices 
                Administration established under section 241 of the 
                Affordable Health Care for America Act''.
            (2) Special provisions relating to health choices 
        administration and hhs.--The Inspector General Act of 1978 (5 
        U.S.C. App.) is further amended by inserting after section 8L 
        the following new section:

``SEC. 8M SPECIAL PROVISIONS RELATING TO THE HEALTH CHOICES 
              ADMINISTRATION AND THE DEPARTMENT OF HEALTH AND HUMAN 
              SERVICES.

    ``(a) The Inspector General of the Health Choices Administration 
shall--
            ``(1) have the authority to conduct, supervise, and 
        coordinate audits, evaluations, and investigations of the 
        programs and operations of the Health Choices Administration 
        established under section 241 of the Affordable Health Care for 
        America Act, including matters relating to fraud, abuse, and 
        misconduct in connection with the admission and continued 
        participation of any health benefits plan participating in the 
        Health Insurance Exchange established under section 301 of such 
        Act;
            ``(2) have the authority to conduct audits, evaluations, 
        and investigations relating to any private Exchange-
        participating health benefits plan, as defined in section 
        201(c) of such Act;
            ``(3) have the authority, in consultation with the Office 
        of Inspector General for the Department of Health and Human 
        Services and subject to subsection (b), to conduct audits, 
        evaluations, and investigations relating to the public health 
        insurance option established under section 321 of such Act; and
            ``(4) have access to all relevant records necessary to 
        carry out this section, including records relating to claims 
        paid by Exchange-participating health benefits plans.
    ``(b) Authority granted to the Health Choices Administration and 
the Inspector General of the Health Choices Administration by the 
Affordable Health Care for America Act does not limit the duties, 
authorities, and responsibilities of the Office of Inspector General 
for the Department of Health and Human Services, as in existence as of 
the date of the enactment of the Affordable Health Care for America Act 
, to oversee programs and operations of such department. The Office of 
Inspector General for the Department of Health and Human Services 
retains primary jurisdiction over fraud and abuse in connection with 
payments made under the public health insurance option established 
under section 321 of such Act and administered by the Department of 
Health and Human Services.''.
            (3) Application of rule of construction.--Section 8J of the 
        Inspector General Act of 1978 (5 U.S.C. App.) is amended by 
        striking ``or 8H'' and inserting ``, 8H, or 8M''.
    (c) Effective Date.--The provisions of and amendments made by this 
section shall take effect on the date of the enactment of this Act.

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

SEC. 1651. ACCESS TO INFORMATION NECESSARY TO IDENTIFY FRAUD, WASTE, 
              AND ABUSE.

    (a) GAO Access.--Subchapter II of chapter 7 of title 31, United 
States Code, is amended by adding at the end the following:
``Sec. 721. Access to certain information
    ``No provision of the Social Security Act shall be construed to 
limit, amend, or supersede the authority of the Comptroller General to 
obtain any information, to inspect any record, or to interview any 
officer or employee under section 716 of this title, including with 
respect to any information disclosed to or obtained by the Secretary of 
Health and Human Services under part C or D of title XVIII of the 
Social Security Act.''.
    (b) Access to Medicare Part D Data Program Integrity Purposes.--
            (1) Provision of information as condition of payment.--
        Section 1860D-15(d)(2)(B) of the Social Security Act (42 U.S.C. 
        1395w-115(d)(2)(B)) is amended--
                    (A) by striking ``may be used by officers'' and all 
                that follows through the period and inserting ``may be 
                used by--''; and
                    (B) by adding at the end the following clauses:
                            ``(i) officers, employees, and contractors 
                        of the Department of Health and Human Services 
                        only for the purposes of, and to the extent 
                        necessary in, carrying out this section; and
                            ``(ii) the Inspector General of the 
                        Department of Health and Human Services, the 
                        Administrator of the Centers for Medicare & 
                        Medicaid Services, and the Attorney General 
                        only for the purposes of protecting the 
                        integrity of the programs under this title and 
                        title XIX; conducting the activities described 
                        in section 1893 and subparagraphs (A) through 
                        (E) of section 1128C(a)(1); and for 
                        investigation, audit, evaluation, oversight, 
                        and  law enforcement purposes to the extent 
                        consistent with applicable law.''.
            (2) General disclosure of information.--Section 1860D-
        15(f)(2) of the Social Security Act (42 U.S.C. 1395w-115(f)(2)) 
        is amended--
                    (A) by striking ``may be used by officers'' and all 
                that follows through the period and inserting ``may be 
                used by--''; and
                    (B) by adding at the end the following 
                subparagraphs:
                    ``(A) officers, employees, and contractors of the 
                Department of Health and Human Services only for the 
                purposes of, and to the extent necessary in, carrying 
                out this section; and
                    ``(B) the Inspector General of the Department of 
                Health and Human Services, the Administrator of the 
                Centers for Medicare & Medicaid Services, and the 
                Attorney General only for the purposes of protecting 
                the integrity of the programs under this title and 
                title XIX; conducting the activities described in 
                section 1893 and subparagraphs (A) through (E) of 
                section 1128C(a)(1); and for investigation, audit, 
                evaluation, oversight, and  law enforcement purposes to 
                the extent consistent with applicable law.''.

SEC. 1652. ELIMINATION OF DUPLICATION BETWEEN THE HEALTHCARE INTEGRITY 
              AND PROTECTION DATA BANK AND THE NATIONAL PRACTITIONER 
              DATA BANK.

    (a) In General.--To eliminate duplication between the Healthcare 
Integrity and Protection Data Bank (HIPDB) established under section 
1128E of the Social Security Act and the National Practitioner Data 
Bank (NPBD) established under the Health Care Quality Improvement Act 
of 1986, section 1128E of the Social Security Act (42 U.S.C. 1320a-7e) 
is amended--
            (1) in subsection (a), by striking ``Not later than'' and 
        inserting ``Subject to subsection (h), not later than'';
            (2) in the first sentence of subsection (d)(2), by striking 
        ``(other than with respect to requests by Federal agencies)''; 
        and
            (3) by adding at the end the following new subsection:
    ``(h) Sunset of the Healthcare Integrity and Protection Data Bank; 
Transition Process.--Effective upon the enactment of this subsection, 
the Secretary shall implement a process to eliminate duplication 
between the Healthcare Integrity and Protection Data Bank (in this 
subsection referred to as the `HIPDB' established pursuant to 
subsection (a) and the National Practitioner Data Bank (in this 
subsection referred to as the `NPDB') as implemented under the Health 
Care Quality Improvement Act of 1986 and section 1921 of this Act, 
including systems testing necessary to ensure that information formerly 
collected in the HIPDB will be accessible through the NPDB, and other 
activities necessary to eliminate duplication between the two data 
banks. Upon the completion of such process, notwithstanding any other 
provision of law, the Secretary shall cease the operation of the HIPDB 
and shall collect information required to be reported under the 
preceding provisions of this section in the NPDB. Except as otherwise 
provided in this subsection, the provisions of subsections (a) through 
(g) shall continue to apply with respect to the reporting of (or 
failure to report), access to, and other treatment of the information 
specified in this section.''.
    (b) Elimination of the Responsibility of the HHS Office of the 
Inspector General.--Section 1128C(a)(1) of the Social Security Act (42 
U.S.C. 1320a-7c(a)(1)) is amended--
            (1) in subparagraph (C), by adding at the end ``and'';
            (2) in subparagraph (D), by striking at the end ``, and'' 
        and inserting a period; and
            (3) by striking subparagraph (E).
    (c) Special Provision for Access to the National Practitioner Data 
Bank by the Department of Veterans Affairs.--
            (1) In general.--Notwithstanding any other provision of 
        law, during the one year period that begins on the effective 
        date specified in subsection (e)(1), the information described 
        in paragraph (2) shall be available from the National 
        Practitioner Data Bank (described in section 1921 of the Social 
        Security Act) to the Secretary of Veterans Affairs without 
        charge.
            (2) Information described.--For purposes of paragraph (1), 
        the information described in this paragraph is the information 
        that would, but for the amendments made by this section, have 
        been available to the Secretary of Veterans Affairs from the 
        Healthcare Integrity and Protection Data Bank.
    (d) Funding.--Notwithstanding any provisions of this Act, sections 
1128E(d)(2) and 1817(k)(3) of the Social Security Act, or any other 
provision of law, there shall be available for carrying out the 
transition process under section 1128E(h) of the Social Security Act 
over the period required to complete such process, and for operation of 
the National Practitioner Data Bank until such process is completed, 
without fiscal year limitation--
            (1) any fees collected pursuant to section 1128E(d)(2) of 
        such Act; and
            (2) such additional amounts as necessary, from 
        appropriations available to the Secretary and to the Office of 
        the Inspector General of the Department of Health and Human 
        Services under clauses (i) and (ii), respectively, of section 
        1817(k)(3)(A) of such Act, for costs of such activities during 
        the first 12 months following the date of the enactment of this 
        Act.
    (e) Effective Date.--The amendments made--
            (1) by subsection (a)(2) shall take effect on the first day 
        after the Secretary of Health and Human Services certifies that 
        the process implemented pursuant to section 1128E(h) of the 
        Social Security Act (as added by subsection (a)(3)) is 
        complete; and
            (2) by subsection (b) shall take effect on the earlier of 
        the date specified in paragraph (1) or the first day of the 
        second succeeding fiscal year after the fiscal year during 
        which this Act is enacted.

SEC. 1653. COMPLIANCE WITH HIPAA PRIVACY AND SECURITY STANDARDS.

    The provisions of sections 262(a) and 264 of the Health Insurance 
Portability and Accountability Act of 1996 (and standards promulgated 
pursuant to such sections) and the Privacy Act of 1974 shall apply with 
respect to the provisions of this subtitle and amendments made by this 
subtitle.

                      TITLE VII--MEDICAID AND CHIP

SEC. 1. TABLE OF CONTENTS [TEMPORARY].

Sec. 1. Table of contents [Temporary].
                 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

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).
                         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.
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.

                 Subtitle A--Medicaid and Health Reform

SEC. 1701. ELIGIBILITY FOR INDIVIDUALS WITH INCOME BELOW 150 PERCENT OF 
              THE FEDERAL POVERTY LEVEL.

    (a) Eligibility for Non-traditional Individuals With Income Below 
150 Percent of the Federal Poverty Level.--
            (1) Full medicaid benefits for non-medicare eligible 
        individuals.--Section 1902(a)(10)(A)(i) of the Social Security 
        Act (42 U.S.C. 1396b(a)(10)(A)(i)) is amended--
                    (A) by striking ``or'' at the end of subclause 
                (VI);
                    (B) by adding ``or'' at the end of subclause (VII); 
                and
                    (C) by adding at the end the following new 
                subclause:
                                    ``(VIII) who are under 65 years of 
                                age, who are not described in a 
                                previous subclause of this clause, who 
                                are not entitled to hospital insurance 
                                benefits under part A of title XVIII, 
                                and whose family income (determined 
                                using methodologies and procedures 
                                specified by the Secretary in 
                                consultation with the Health Choices 
                                Commissioner) does not exceed 150 
                                percent of the income official poverty 
                                line (as defined by the Office of 
                                Management and Budget, and revised 
                                annually in accordance with section 
                                673(2) of the Omnibus Budget 
                                Reconciliation Act of 1981) applicable 
                                to a family of the size involved;''.
            (2) Medicare cost sharing assistance for medicare-eligible 
        individuals.--Section 1902(a)(10)(E) of such Act (42 U.S.C. 
        1396b(a)(10)(E)) is amended--
                    (A) in clause (iii), by striking ``and'' at the 
                end;
                    (B) in clause (iv), by adding ``and'' at the end; 
                and
                    (C) by adding at the end the following new clause:
                    ``(v) for making medical assistance available for 
                medicare cost-sharing described in subparagraphs (B) 
                and (C) of section 1905(p)(3), for individuals under 65 
                years of age who would be qualified medicare 
                beneficiaries described in section 1905(p)(1) but for 
                the fact that their income exceeds the income level 
                established by the State under section 1905(p)(2) but 
                is less than 150 percent of the official poverty line 
                (referred to in such section) for a family of the size 
                involved; and''.
            (3) Increased fmap for non-traditional full medicaid 
        eligible individuals.--Section 1905 of such Act (42 U.S.C. 
        1396d) is amended--
                    (A) in the first sentence of subsection (b), by 
                striking ``and'' before ``(4)'' and by inserting before 
                the period at the end the following: ``, and (5) 100 
                percent (for periods before 2015 and 91 percent for 
                periods beginning with 2015) with respect to amounts 
                described in subsection (y)''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(y) Additional Expenditures Subject to Increased FMAP.--For 
purposes of section 1905(b)(5), the amounts described in this 
subsection are the following:
            ``(1) Amounts expended for medical assistance for 
        individuals described in subclause (VIII) of section 
        1902(a)(10)(A)(i).''.
            (4) Construction.--Nothing in this subsection shall be 
        construed as not providing for coverage under subparagraph 
        (A)(i)(VIII) or (E)(v) of section 1902(a)(10) of the Social 
        Security Act, as added by paragraphs (1) and (2), or an 
        increased FMAP under the amendments made by paragraph (3), for 
        an individual who has been provided medical assistance under 
        title XIX of the Act under a demonstration waiver approved 
        under section 1115 of such Act or with State funds.
            (5) Conforming amendments.--
                    (A) Section 1903(f)(4) of the Social Security Act 
                (42 U.S.C. 1396b(f)(4)) is amended--
                            (i) by inserting 
                        ``1902(a)(10)(A)(i)(VIII),'' after 
                        ``1902(a)(10)(A)(i)(VII),''; and
                            (ii) by inserting ``1902(a)(10)(E)(v),'' 
                        before ``1905(p)(1)''.
                    (B) Section 1905(a) of such Act (42 U.S.C. 
                1396d(a)), as amended by sections 1714(a)(4) and 
                1731(c), is further amended, in the matter preceding 
                paragraph (1)--
                            (i) by striking ``or'' at the end of clause 
                        (xiv);
                            (ii) by adding ``or'' at the end of clause 
                        (xv); and
                            (iii) by inserting after clause (xv) the 
                        following:
                            ``(xvi) individuals described in section 
                        1902(a)(10)(A)(i)(VIII),''.
    (b) Eligibility for Traditional Medicaid Eligible Individuals With 
Income Not Exceeding 150 Percent of the Federal Poverty Level .--
            (1) In general.--Section 1902(a)(10)(A)(i) of the Social 
        Security Act (42 U.S.C. 1396b(a)(10)(A)(i)), as amended by 
        subsection (a), is amended--
                    (A) by striking ``or'' at the end of subclause 
                (VII); and
                    (B) by adding at the end the following new 
                subclause:
                                    ``(IX) who are over 18, and under 
                                65 years of age, who would be eligible 
                                for medical assistance under the State 
                                plan under subclause (I) or section 
                                1931 (based on the income standards, 
                                methodologies, and procedures in effect 
                                as of June 16, 2009) but for income, 
                                who are in families whose income does 
                                not exceed 150 percent of the income 
                                official poverty line (as defined by 
                                the Office of Management and Budget, 
                                and revised annually in accordance with 
                                section 673(2) of the Omnibus Budget 
                                Reconciliation Act of 1981) applicable 
                                to a family of the size involved; or
                                    ``(X) beginning with 2014, who are 
                                over 5, and under 19, years of age, who 
                                would be eligible for medical 
                                assistance under the State plan under 
                                subclause (I) or (VII) (based on the 
                                income standards, methodologies, and 
                                procedures in effect as of June 16, 
                                2009) but for income, who are in 
                                families whose income does not exceed 
                                150 percent of the income official 
                                poverty line (as defined by the Office 
                                of Management and Budget, and revised 
                                annually in accordance with section 
                                673(2) of the Omnibus Budget 
                                Reconciliation Act of 1981) applicable 
                                to a family of the size involved; or
                                    ``(XI) beginning with 2014, who are 
                                under 19 years of age, who are not 
                                described in subclause (X), and who 
                                would be eligible for child health 
                                assistance under a State child health 
                                plan insofar as such plan provides 
                                benefits under this title (as described 
                                in section 2101(a)(2)) based on such 
                                plan as in effect as of June 16, 2009; 
                                or''.
            (2) Increased fmap for certain traditional medicaid 
        eligible individuals.--
                    (A) Increased fmap for adults.--Section 1905(y) of 
                such Act (42 U.S.C. 1396d(y)), as added by subsection 
                (a)(2)(B), is amended by inserting ``or (IX)'' after 
                ``(VIII)''.
                    (B) Enhanced fmap for children.--Section 1905(b)(4) 
                of such Act is amended by inserting 
                ``1902(a)(10)(A)(i)(X), 1902(a)(10)(A)(i)(XI), or'' 
                after ``on the basis of section''.
            (3) Construction.--Nothing in this subsection shall be 
        construed as not providing for coverage under subclause (IX), 
        (X), or (XI) of section 1902(a)(10)(A)(i) of the Social 
        Security Act, as added by paragraph (1), or an increased or 
        enhanced FMAP under the amendments made by paragraph (2), for 
        an individual who has been provided medical assistance under 
        title XIX of the Act under a demonstration waiver approved 
        under section 1115 of such Act or with State funds.
            (4) Conforming amendment.--Section 1903(f)(4) of the Social 
        Security Act (42 U.S.C. 1396b(f)(4)), as amended by subsection 
        (a)(4), is amended by inserting ``1902(a)(10)(A)(i)(IX), 
        1902(a)(10)(A)(i)(X), 1902(a)(10)(A)(i)(XI),'' after 
        ``1902(a)(10)(A)(i)(VIII),''.
    (c) Increased Matching Rate for Temporary Coverage of Certain 
Newborns.--Section 1905(y) of such Act, as added by subsection 
(a)(3)(B), is amended by adding at the end the following:
            ``(2) Amounts expended for medical assistance for children 
        described in section 305(d)(1) of the Affordable Health Care 
        for America Act during the time period specified in such 
        section.''.
    (d) Network Adequacy.--Section 1932(a)(2) of the Social Security 
Act (42 U.S.C. 1396u-2(a)(2)) is amended by adding at the end the 
following new subparagraph:
                    ``(D) Enrollment of non-traditional medicaid 
                eligibles.--A State may not require under paragraph (1) 
                the enrollment in a managed care entity of an 
                individual described in section 1902(a)(10)(A)(i)(VIII) 
                unless the State demonstrates, to the satisfaction of 
                the Secretary, that the entity, through its provider 
                network and other arrangements, has the capacity to 
                meet the health, mental health, and substance abuse 
                needs of such individuals.''.
    (e) Effective Date.--The amendments made by this section shall take 
effect on the first day of Y1, and shall apply with respect to items 
and services furnished on or after such date.

SEC. 1702. REQUIREMENTS AND SPECIAL RULES FOR CERTAIN MEDICAID ELIGIBLE 
              INDIVIDUALS.

    (a) In General.--Title XIX of the Social Security Act is amended by 
adding at the end the following new section:

    `` requirements and special rules for certain medicaid eligible 
                              individuals

    ``Sec. 1943.  (a) Coordination With NHI Exchange Through Memorandum 
of Understanding.--
            ``(1) In general.--The State shall enter into a Medicaid 
        memorandum of understanding described in section 305(e)(2) of 
        the Affordable Health Care for America Act with the Health 
        Choices Commissioner, acting in consultation with the 
        Secretary, with respect to coordinating the implementation of 
        the provisions of division A of such Act with the State plan 
        under this title in order to ensure the enrollment of Medicaid 
        eligible individuals in acceptable coverage. Nothing in this 
        section shall be construed as permitting such memorandum to 
        modify or vitiate any requirement of a State plan under this 
        title.
            ``(2) Enrollment of exchange-referred individuals.--
                    ``(A) Non-traditional individuals.--Pursuant to 
                such memorandum the State shall accept without further 
                determination the enrollment under this title of an 
                individual determined by the Commissioner to be a non-
                traditional Medicaid eligible individual. The State 
                shall not do any redeterminations of eligibility for 
                such individuals unless the periodicity of such 
                redeterminations is consistent with the periodicity for 
                redeterminations by the Commissioner of eligibility for 
                affordability credits under subtitle C of title II of 
                division A of the Affordable Health Care for America 
                Act, as specified under such memorandum.
                    ``(B) Traditional individuals.--Pursuant to such 
                memorandum, the State shall accept without further 
                determination the enrollment under this title of an 
                individual determined by the Commissioner to be a 
                traditional Medicaid eligible individual. The State may 
                do redeterminations of eligibility of such individual 
                consistent with such section and the memorandum.
            ``(3) Determinations of eligibility for affordability 
        credits.--If the Commissioner determines that a State Medicaid 
        agency has the capacity to make determinations of eligibility 
        for affordability credits under subtitle C of title II of 
        division A of the Affordable Health Care for America Act, under 
        such memorandum--
                    ``(A) the State Medicaid agency shall conduct such 
                determinations for any Exchange-eligible individual who 
                requests such a determination;
                    ``(B) in the case that a State Medicaid agency 
                determines that an Exchange-eligible individual is not 
                eligible for affordability credits, the agency shall 
                forward the information on the basis of which such 
                determination was made to the Commissioner; and
                    ``(C) the Commissioner shall reimburse the State 
                Medicaid agency for the costs of conducting such 
                determinations.
            ``(4) Referrals under memorandum.--Pursuant to such 
        memorandum, if an individual applies to the State for 
        assistance in obtaining health coverage and the State 
        determines that the individual is not eligible for medical 
        assistance under this title and is not authorized under such 
        memorandum to make an determination with respect to eligibility 
        for coverage and affordability credits through the Health 
        Insurance Exchange, the State shall refer the individual to the 
        Commissioner for a determination of such eligibility and, with 
        the individual's authorization, provide to the Commissioner 
        information obtained by the State as part of the application 
        process.
            ``(5) Additional terms.--Such memorandum shall include such 
        additional provisions as are necessary to implement efficiently 
        the provisions of this section and title II of division A of 
        the Affordable Health Care for America Act.
    ``(b) Treatment of Certain Newborns.--
            ``(1) In general.--In the case of a child who is deemed 
        under section 305(d) of the Affordable Health Care for America 
        Act to be a Medicaid eligible individual and enrolled under 
        this title pursuant to such section, the State shall provide 
        for a determination, by not later than the end of the period 
        referred to in paragraph (2) of such section, of the child's 
        eligibility for medical assistance under this title.
            ``(2) Extended treatment as traditional medicaid eligible 
        individual.--In accordance with paragraph (2) of section 305(d) 
        of the Affordable Health Care for America Act, in the case of a 
        child described in paragraph (1) of such section who at the end 
        of the period referred to in such paragraph is not otherwise 
        covered under acceptable coverage, the child shall be deemed 
        (until such time as the child obtains such coverage or the 
        State otherwise makes a determination of the child's 
        eligibility for medical assistance under its plan under this 
        title pursuant to paragraph (1)) to be a Medicaid eligible 
        individual described in section 1902(l)(1)(B).
    ``(c) Definitions.--In this section:
            ``(1) Medicaid eligible individual.--The term `Medicaid 
        eligible individual' means an individual who is eligible for 
        medical assistance under Medicaid.
            ``(2) Traditional medicaid eligible individual.--The term 
        `traditional Medicaid eligible individual' means a Medicaid 
        eligible individual other than an individual who is--
                    ``(A) a Medicaid eligible individual by reason of 
                the application of subclause (VIII) of section 
                1902(a)(10)(A)(i) of the Social Security Act; or
                    ``(B) a childless adult not described in section 
                1902(a)(10)(A) or (C) of such Act (as in effect as of 
                the day before the date of the enactment of this Act).
            ``(3) Non-traditional medicaid eligible individual.--The 
        term `non-traditional Medicaid eligible individual' means a 
        Medicaid eligible individual who is not a traditional Medicaid 
        eligible individual.
            ``(4) Memorandum.--The term `memorandum' means a Medicaid 
        memorandum of understanding under section 305(e)(2) of the 
        Affordable Health Care for America Act.
            ``(5) Y1.--The term `Y1' has the meaning given such term in 
        section 100(c) of the Affordable Health Care for America 
        Act.''.
    (b) Conforming Amendments to Error Rate.--
            (1) Section 1903(u)(1)(D) of the Social Security Act (42 
        U.S.C. 1396b(u)(1)(D)) is amended by adding at the end the 
        following new clause:
    ``(vi) In determining the amount of erroneous excess payments, 
there shall not be included any erroneous payments made that are 
attributable to an error in an eligibility determination under subtitle 
C of title II of division A of the Affordable Health Care for America 
Act.''.
            (2) Section 2105(c)(11) of such Act (42 U.S.C. 
        1397ee(c)(11)) is amended by adding at the end the following 
        new sentence: ``Clause (vi) of section 1903(u)(1)(D) shall 
        apply with respect to the application of such requirements 
        under this title and title XIX.''.

SEC. 1703. CHIP AND MEDICAID MAINTENANCE OF ELIGIBILITY.

    (a) CHIP Maintenance of Eligibility.--Section 1902 of the Social 
Security Act (42 U.S.C. 1396a) is amended--
            (1) in subsection (a), as amended by section 
        1631(b)(1)(D)--
                    (A) by striking ``and'' at the end of paragraph 
                (73);
                    (B) by striking the period at the end of paragraph 
                (74) and inserting ``; and''; and
                    (C) by inserting after paragraph (74) the following 
                new paragraph:
            ``(75) provide for maintenance of effort under the State 
        child health plan under title XXI in accordance with subsection 
        (gg).''; and
            (2) by adding at the end the following new subsection:
    ``(gg) CHIP Maintenance of Eligibility Requirement.--
            ``(1) In general.--Subject to paragraph (2), as a condition 
        of its State plan under this title under subsection (a)(75) and 
        receipt of any Federal financial assistance under section 
        1903(a) for calendar quarters beginning after the date of the 
        enactment of this subsection and before CHIP MOE termination 
        date specified in paragraph (3), a State shall not have in 
        effect eligibility standards, methodologies, or procedures 
        under its State child health plan under title XXI (including 
        any waiver under such title or demonstration project under 
        section 1115) that are more restrictive than the eligibility 
        standards, methodologies, or procedures, respectively, under 
        such plan (or waiver) as in effect on June 16, 2009.
            ``(2) Limitation.--Paragraph (1) shall not be construed as 
        preventing a State from imposing a limitation described in 
        section 2110(b)(5)(C)(i)(II) for a fiscal year in order to 
        limit expenditures under its State child health plan under 
        title XXI to those for which Federal financial participation is 
        available under section 2105 for the fiscal year.
            ``(3) CHIP moe termination date.--In paragraph (1), the 
        `CHIP MOE termination date' for a State is the date that is the 
        last day of Y1 (as defined in section 100(c) of the Affordable 
        Health Care for America Act).
            ``(4) CHIP transition report.--Not later than December 31, 
        2011, the Secretary shall submit to Congress a report--
                    ``(A) that compares the benefits packages offered 
                under an average State child health plan under title 
                XXI in 2011 and to the benefit standards initially 
                adopted under section 224(b) of the Affordable Health 
                Care for America Act and for affordability credits 
                under subtitle C of title II of division C of such Act; 
                and
                    ``(B) that includes such recommendations as may be 
                necessary to ensure that--
                            ``(i) such coverage is at least comparable 
                        to the coverage provided to children under such 
                        an average State child health plan; and
                            ``(ii) there are procedures in effect for 
                        the enrollment of CHIP enrollees (including 
                        CHIP-eligible pregnant women) at the end of Y1 
                        under this title, into a qualified health 
                        benefits plan offered through the Health 
                        Insurance Exchange, or into other acceptable 
                        coverage (as defined for purposes of such Act) 
                        without interruption of coverage or a written 
                        plan of treatment.''.
    (b) Medicaid Maintenance of Effort; Simplifying and Coordinating 
Eligibility Rules Between Exchange and Medicaid.--
            (1) In general.--Section 1903 of such Act (42 U.S.C. 1396b) 
        is amended by adding at the end the following new subsection:
    ``(aa) Maintenance of Medicaid Effort; Simplifying and Coordinating 
Eligibility Rules Between Health Insurance Exchange and Medicaid.--
            ``(1) Maintenance of effort.--
                    ``(A) In general.--Subject to subparagraph (B), a 
                State is not eligible for payment under subsection (a) 
                for a calendar quarter beginning after the date of the 
                enactment of this subsection if eligibility standards, 
                methodologies, or procedures under its plan under this 
                title (including any waiver under this title or 
                demonstration project under section 1115) that are more 
                restrictive than the eligibility standards, 
                methodologies, or procedures, respectively, under such 
                plan (or waiver) as in effect on June 16, 2009. The 
                Secretary shall extend such a waiver (including the 
                availability of Federal financial participation under 
                such waiver) for such period as may be required for a 
                State to meet the requirement of the previous sentence.
                    ``(B) Exception for certain demonstration 
                projects.--In the case of a State demonstration project 
                under section 1115 in effect on June 16, 2009, that 
                permits individuals to be eligible solely to receive a 
                premium or cost-sharing subsidy for individual or group 
                health insurance coverage, effective for coverage 
                provided in Y1--
                            ``(i) the Secretary shall permit the State 
                        to amend such waiver to apply more restrictive 
                        eligibility standards, methodologies, or 
                        procedures with respect to such individuals 
                        under such waiver; and
                            ``(ii) the application of such more 
                        restrictive, standards, methodologies, or 
                        procedures under such an amendment shall not be 
                        considered in violation of the requirement of 
                        subparagraph (A).
            ``(2) Removal of asset test for certain eligibility 
        categories.--
                    ``(A) In general.--A State is not eligible for 
                payment under subsection (a) for a calendar quarter 
                beginning on or after the first day of Y1 (as defined 
                in section 100(c) of the Affordable Health Care for 
                America Act), if the State applies any asset or 
                resource test in determining (or redetermining) 
                eligibility of any individual on or after such first 
                day under any of the following:
                            ``(i) Subclause (I), (III), (IV), (VI), 
                        (VIII), (IX), (X), or (XI) of section 
                        1902(a)(10)(A)(i).
                            ``(ii) Subclause (II), (IX), (XIV) or 
                        (XVII) of section 1902(a)(10)(A)(ii).
                            ``(iii) Section 1931(b).
                    ``(B) Overriding contrary provisions; references.--
                The provisions of this title that prevent the waiver of 
                an asset or resource test described in subparagraph (A) 
                are hereby waived.
                    ``(C) References.--Any reference to a provision 
                described in a provision in subparagraph (A) shall be 
                deemed to be a reference to such provision as modified 
                through the application of subparagraphs (A) and 
                (B).''.
            (2) Conforming amendments.--(A) Section 1902(a)(10)(A) of 
        such Act (42 U.S.C. 1396a(a)(10)(A)) is amended, in the matter 
        before clause (i), by inserting ``subject to section 
        1903(aa)(2),'' after ``(A)''.
            (B) Section 1931(b)(1) of such Act (42 U.S.C. 1396u-
        1(b)(1)) is amended by inserting ``and section 1903(aa)(2)'' 
        after ``and (3)''.
    (c) Standards for Benchmark Packages.--Section 1937(b) of such Act 
(42 U.S.C. 1396u-7(b)) is amended--
            (1) in each of paragraphs (1) and (2), by inserting 
        ``subject to paragraph (5),'' after ``subsection (a)(1),''; and
            (2) by adding at the end the following new paragraph:
            ``(5) Minimum standards.--Effective January 1, 2013, any 
        benchmark benefit package (or benchmark equivalent coverage 
        under paragraph (2)) must meet the minimum benefits and cost-
        sharing standards of a basic plan offered through the Health 
        Insurance Exchange.''.
    (d) Repeal of CHIP.--Section 2104(a) of the Social Security Act is 
amended by inserting at the end the following:
        ``No funds shall be appropriated or authorized to be 
        appropriated under this section for fiscal year 2014 and 
        subsequent years.''.

SEC. 1704. REDUCTION IN MEDICAID DSH.

    (a) Report.--
            (1) In general.--Not later than January 1, 2016, the 
        Secretary of Health and Human Services (in this title referred 
        to as the ``Secretary'') shall submit to Congress a report 
        concerning the extent to which, based upon the impact of the 
        health care reforms carried out under division A in reducing 
        the number of uninsured individuals, there is a continued role 
        for Medicaid DSH. In preparing the report, the Secretary shall 
        consult with community-based health care networks serving low-
        income beneficiaries.
            (2) Matters to be included.--The report shall include the 
        following:
                    (A) Recommendations.--Recommendations regarding--
                            (i) the appropriate targeting of Medicaid 
                        DSH within States; and
                            (ii) the distribution of Medicaid DSH among 
                        the States, taking into account the ratio of 
                        the amount of DSH funds allocated to a State to 
                        the number of uninsured individuals in such 
                        State.
                    (B) Specification of dsh health reform 
                methodology.--The DSH Health Reform methodology 
                described in paragraph (2) of subsection (b) for 
                purposes of implementing the requirements of such 
                subsection.
            (3) Coordination with medicare dsh report.--The Secretary 
        shall coordinate the report under this subsection with the 
        report on Medicare DSH under section 1112.
            (4) Medicaid dsh.--In this section, the term ``Medicaid 
        DSH'' means adjustments in payments under section 1923 of the 
        Social Security Act for inpatient hospital services furnished 
        by disproportionate share hospitals.
    (b) Medicaid DSH Reductions.--
            (1) Reductions.--
                    (A) In general.--For each of fiscal years 2017 
                through 2019 the Secretary shall effect the following 
                reductions:
                            (i) Reduction dsh allotments.--The 
                        Secretary shall reduce DSH allotments to States 
                        in the amount specified under the DSH health 
                        reform methodology under paragraph (2) for the 
                        State for the fiscal year.
                            (ii) Reductions in payments.--The Secretary 
                        shall reduce payments to States under section 
                        1903(a) of the Social Security Act (42 U.S.C. 
                        1396b(a)) for each calendar quarter in the 
                        fiscal year, in the manner specified in 
                        subparagraph (C), in an amount equal to \1/4\ 
                        of the DSH allotment reduction under clause (i) 
                        for the State for the fiscal year.
                    (B) Aggregate reductions.--The aggregate reductions 
                in DSH allotments for all States under subparagraph 
                (A)(i) shall be equal to--
                            (i) $1,500,000,000 for fiscal year 2017;
                            (ii) $2,500,000,000 for fiscal year 2018; 
                        and
                            (iii) $6,000,000,000 for fiscal year 2019.
                The Secretary shall distribute such aggregate reduction 
                among States in accordance with paragraph (2).
                    (C) Manner of payment reduction.--The amount of the 
                payment reduction under subparagraph (A)(ii) for a 
                State for a quarter shall be deemed an overpayment to 
                the State under title XIX of the Social Security Act to 
                be disallowed against the State's regular quarterly 
                draw for all Medicaid spending under section 1903(d)(2) 
                of such Act (42 U.S.C. 1396b(d)(2)). Such a 
                disallowance is not subject to a reconsideration under 
                1116(d) of such Act (42 U.S.C. 1316(d)).
                    (D) Definitions.--In this section:
                            (i) State.--The term ``State'' means the 50 
                        States and the District of Columbia.
                            (ii) DSH allotment.--The term ``DSH 
                        allotment'' means, with respect to a State for 
                        a fiscal year, the allotment made under section 
                        1923(f) of the Social Security Act (42 U.S.C. 
                        1396r-4(f)) to the State for the fiscal year.
            (2) DSH health reform methodology.--The Secretary shall 
        carry out paragraph (1) through use of a DSH Health Reform 
        methodology issued by the Secretary that imposes the largest 
        percentage reductions on the States that--
                    (A) have the lowest percentages of uninsured 
                individuals (determined on the basis of audited 
                hospital cost reports) during the most recent year for 
                which such data are available; or
                    (B) do not target their DSH payments on--
                            (i) hospitals with high volumes of Medicaid 
                        inpatients (as defined in section 1923(b)(1)(A) 
                        of the Social Security Act (42 U.S.C. 1396r-
                        4(b)(1)(A)); and
                            (ii) hospitals that have high levels of 
                        uncompensated care (excluding bad debt).
            (3) DSH allotment publications.--
                    (A) In general.--Not later than the publication 
                deadline specified in subparagraph (B), the Secretary 
                shall publish in the Federal Register a notice 
                specifying the DSH allotment to each State under 
                1923(f) of the Social Security Act for the respective 
                fiscal year specified in such subparagraph, consistent 
                with the application of the DSH Health Reform 
                methodology described in paragraph (2).
                    (B) Publication deadline.--The publication deadline 
                specified in this subparagraph is--
                            (i) January 1, 2016, with respect to DSH 
                        allotments described in subparagraph (A) for 
                        fiscal year 2017;
                            (ii) January 1, 2017, with respect to DSH 
                        allotments described in subparagraph (A) for 
                        fiscal year 2018; and
                            (iii) January 1, 2018, with respect to DSH 
                        allotments described in subparagraph (A) for 
                        fiscal year 2019.
    (c) Conforming Amendments.--
            (1) Section 1923(f) of the Social Security Act (42 U.S.C. 
        1396r-4(f)) is amended--
                    (A) by redesignating paragraph (7) as paragraph 
                (8); and
                    (B) by inserting after paragraph (6) the following 
                new paragraph:
            ``(7) Special rule for fiscal years 2017, 2018, and 2019.--
        For each of fiscal years 2017, 2018, and 2018, the DSH 
        allotments under this subsection are subject to reduction under 
        section 1704(b) of the Affordable Health Care for America 
        Act.''.
            (2) The second sentence of section 1923(b)(4) of such Act 
        (42 U.S.C. 1396r-4(b)(4)) is amended by inserting before the 
        period the following: ``or to affect the authority of the 
        Secretary to issue and implement the DSH Health Reform 
        methodology under section 1704(b)(2) of the Affordable Health 
        Care for America Act''.
    (d) Disproportionate Share Hospitals (DSH) and Essential Access 
Hospital (EAH) Non-discrimination.--
            (1) In general.--Section 1923(d) of the Social Security Act 
        (42 U.S.C. 1396r-4) is amended by adding at the end the 
        following new paragraph:
            ``(4) No hospital may be defined or deemed as a 
        disproportionate share hospital, or as an essential access 
        hospital (for purposes of subsection (f)(6)(A)(iv)), under a 
        State plan under this title or subsection (b) of this section 
        (including any demonstration project under section 1115) unless 
        the hospital--
                    ``(A) provides services to beneficiaries under this 
                title without discrimination on the ground of race, 
                color, national origin, creed, source of payment, 
                status as a beneficiary under this title, or any other 
                ground unrelated to such beneficiary's need for the 
                services or the availability of the needed services in 
                the hospital; and
                    ``(B) makes arrangements for, and accepts, 
                reimbursement under this title for services provided to 
                eligible beneficiaries under this title.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to expenditures made on or after July 1, 2010.

SEC. 1705. EXPANDED OUTSTATIONING.

    (a) In General.--Section 1902(a)(55) of the Social Security Act (42 
U.S.C. 1396a(a)(55)) is amended by striking ``under subsection 
(a)(10)(A)(i)(IV), (a)(10)(A)(i)(VI), (a)(10)(A)(i)(VII), or 
(a)(10)(A)(ii)(IX)'' and inserting ``(including receipt and processing 
of applications of individuals for affordability credits under subtitle 
C of title II of division A of the Affordable Health Care for America 
Act pursuant to a Medicaid memorandum of understanding under section 
1943(a)(1))''.
    (b) Effective Date.--Except as provided in section 1790, the 
amendment made by subsection (a) shall apply to services furnished on 
or after July 1, 2010, without regard to whether or not final 
regulations to carry out such amendment have been promulgated by such 
date.

                         Subtitle B--Prevention

SEC. 1711. REQUIRED COVERAGE OF PREVENTIVE SERVICES.

    (a) Coverage.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by section 1701(a)(3)(B), is amended--
            (1) in subsection (a)(4)--
                    (A) by striking ``and'' before ``(C)''; and
                    (B) by inserting before the semicolon at the end 
                the following: ``; and (D) preventive services 
                described in subsection (z)''; and
            (2) by adding at the end the following new subsection:
    ``(z) Preventive Services.--The preventive services described in 
this subsection are services not otherwise described in subsection (a) 
or (r) that the Secretary determines are--
            ``(1)(A) recommended with a grade of A or B by the Task 
        Force for Clinical Preventive Services; or
            ``(B) vaccines recommended for use as appropriate by the 
        Director of the Centers for Disease Control and Prevention; and
            ``(2) appropriate for individuals entitled to medical 
        assistance under this title.''.
    (b) Elimination of Cost-sharing.--
            (1) Subsections (a)(2)(D) and (b)(2)(D) of section 1916 of 
        such Act (42 U.S.C. 1396o) are each amended by inserting 
        ``preventive services described in section 1905(z),'' after 
        ``emergency services (as defined by the Secretary),''.
            (2) Section 1916A(a)(1) of such Act (42 U.S.C. 1396o-1 
        (a)(1)) is amended by inserting ``, preventive services 
        described in section 1905(z),'' after ``subsection (c)''.
    (c) Conforming Amendment.--Section 1928 of such Act (42 U.S.C. 
1396s) is amended--
            (1) in subsection (c)(2)(B)(i), by striking ``the advisory 
        committee referred to in subsection (e)'' and inserting ``the 
        Director of the Centers for Disease Control and Prevention'';
            (2) in subsection (e), by striking ``Advisory Committee'' 
        and all that follows and inserting ``Director of the Centers 
        for Disease Control and Prevention.''; and
            (3) by striking subsection (g).
    (d) Effective Date.--Except as provided in section 1790, the 
amendments made by this section shall apply to services furnished on or 
after July 1, 2010, without regard to whether or not final regulations 
to carry out such amendments have been promulgated by such date.

SEC. 1712. TOBACCO CESSATION.

    (a) Dropping Tobacco Cessation Exclusion From Covered Outpatient 
Drugs.--Section 1927(d)(2) of the Social Security Act (42 U.S.C. 1396r-
8(d)(2)) is amended--
            (1) by striking subparagraph (E);
            (2) in subparagraph (G), by inserting before the period at 
        the end the following: ``, except agents approved by the Food 
        and Drug Administration for purposes of promoting, and when 
        used to promote, tobacco cessation''; and
            (3) by redesignating subparagraphs (F) through (K) as 
        subparagraphs (E) through (J), respectively.
    (b) Effective Date.--The amendments made by this section shall 
apply to drugs and services furnished on or after January 1, 2010.

SEC. 1713. OPTIONAL COVERAGE OF NURSE HOME VISITATION SERVICES.

    (a) In General.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by sections 1701(a)(3)(B) and 1711(a), is amended--
            (1) in subsection (a)--
                    (A) in paragraph (27), by striking ``and'' at the 
                end;
                    (B) by redesignating paragraph (28) as paragraph 
                (29); and
                    (C) by inserting after paragraph (27) the following 
                new paragraph:
            ``(28) nurse home visitation services (as defined in 
        subsection (aa)); and''; and
            (2) by adding at the end the following new subsection:
    ``(aa) The term `nurse home visitation services' means home visits 
by trained nurses to families with a first-time pregnant woman, or a 
child (under 2 years of age), who is eligible for medical assistance 
under this title, but only, to the extent determined by the Secretary 
based upon evidence, that such services are effective in one or more of 
the following:
            ``(1) Improving maternal or child health and pregnancy 
        outcomes or increasing birth intervals between pregnancies.
            ``(2) Reducing the incidence of child abuse, neglect, and 
        injury, improving family stability (including reduction in the 
        incidence of intimate partner violence), or reducing maternal 
        and child involvement in the criminal justice system.
            ``(3) Increasing economic self-sufficiency, employment 
        advancement, school-readiness, and educational achievement, or 
        reducing dependence on public assistance.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2010.
    (c) Construction.--Nothing in the amendments made by this section 
shall be construed as affecting the ability of a State under title XIX 
or XXI of the Social Security Act to provide nurse home visitation 
services as part of another class of items and services falling within 
the definition of medical assistance or child health assistance under 
the respective title, or as an administrative expenditure for which 
payment is made under section 1903(a) or 2105(a) of such Act, 
respectively, on or after the date of the enactment of this Act.

SEC. 1714. STATE ELIGIBILITY OPTION FOR FAMILY PLANNING SERVICES.

    (a) Coverage as Optional Categorically Needy Group.--
            (1) In general.--Section 1902(a)(10)(A)(ii) of the Social 
        Security Act (42 U.S.C. 1396a(a)(10)(A)(ii)) is amended--
                    (A) in subclause (XVIII), by striking ``or'' at the 
                end;
                    (B) in subclause (XIX), by adding ``or'' at the 
                end; and
                    (C) by adding at the end the following new 
                subclause:
                                    ``(XX) who are described in 
                                subsection (hh) (relating to 
                                individuals who meet certain income 
                                standards);''.
            (2) Group described.--Section 1902 of such Act (42 U.S.C. 
        1396a), as amended by section 1703, is amended by adding at the 
        end the following new subsection:
    ``(hh)(1) Individuals described in this subsection are 
individuals--
                    ``(A) whose income does not exceed an income 
                eligibility level established by the State that does 
                not exceed the highest income eligibility level 
                established under the State plan under this title (or 
                under its State child health plan under title XXI) for 
                pregnant women; and
                    ``(B) who are not pregnant.
    ``(2) At the option of a State, individuals described in this 
subsection may include individuals who, had individuals applied on or 
before January 1, 2007, would have been made eligible pursuant to the 
standards and processes imposed by that State for benefits described in 
clause (XV) of the matter following subparagraph (G) of section 
subsection (a)(10) pursuant to a demonstration project waiver granted 
under section 1115.
    ``(3) At the option of a State, for purposes of subsection 
(a)(17)(B), in determining eligibility for services under this 
subsection, the State may consider only the income of the applicant or 
recipient.''.
            (3) Limitation on benefits.--Section 1902(a)(10) of such 
        Act (42 U.S.C. 1396a(a)(10)) is amended in the matter following 
        subparagraph (G)--
                    (A) by striking ``and (XIV)'' and inserting 
                ``(XIV)''; and
                    (B) by inserting ``, and (XV) the medical 
                assistance made available to an individual described in 
                subsection (hh) shall be limited to family planning 
                services and supplies described in section 
                1905(a)(4)(C) including medical diagnosis and treatment 
                services that are provided pursuant to a family 
                planning service in a family planning setting'' after 
                ``cervical cancer''.
            (4) Conforming amendments.--Section 1905(a) of such Act (42 
        U.S.C. 1396d(a)), as amended by section 1731(c), is amended in 
        the matter preceding paragraph (1)--
                    (A) in clause (xiii), by striking ``or'' at the 
                end;
                    (B) in clause (xiv), by adding ``or'' at the end; 
                and
                    (C) by inserting after clause (xiv) the following:
            ``(xv) individuals described in section 1902(hh),''.
    (b) Presumptive Eligibility.--
            (1) In general.--Title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.) is amended by inserting after section 
        1920B the following:

         ``presumptive eligibility for family planning services

    ``Sec. 1920C.  (a) State Option.--State plan approved under section 
1902 may provide for making medical assistance available to an 
individual described in section 1902(hh) (relating to individuals who 
meet certain income eligibility standard) during a presumptive 
eligibility period. In the case of an individual described in section 
1902(hh), such medical assistance shall be limited to family planning 
services and supplies described in 1905(a)(4)(C) and, at the State's 
option, medical diagnosis and treatment services that are provided in 
conjunction with a family planning service in a family planning 
setting.
    ``(b) Definitions.--For purposes of this section:
            ``(1) Presumptive eligibility period.--The term 
        `presumptive eligibility period' means, with respect to an 
        individual described in subsection (a), the period that--
                    ``(A) begins with the date on which a qualified 
                entity determines, on the basis of preliminary 
                information, that the individual is described in 
                section 1902(hh); and
                    ``(B) ends with (and includes) the earlier of--
                            ``(i) the day on which a determination is 
                        made with respect to the eligibility of such 
                        individual for services under the State plan; 
                        or
                            ``(ii) in the case of such an individual 
                        who does not file an application by the last 
                        day of the month following the month during 
                        which the entity makes the determination 
                        referred to in subparagraph (A), such last day.
            ``(2) Qualified entity.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                term `qualified entity' means any entity that--
                            ``(i) is eligible for payments under a 
                        State plan approved under this title; and
                            ``(ii) is determined by the State agency to 
                        be capable of making determinations of the type 
                        described in paragraph (1)(A).
                    ``(B) Rule of construction.--Nothing in this 
                paragraph shall be construed as preventing a State from 
                limiting the classes of entities that may become 
                qualified entities in order to prevent fraud and abuse.
    ``(c) Administration.--
            ``(1) In general.--The State agency shall provide qualified 
        entities with--
                    ``(A) such forms as are necessary for an 
                application to be made by an individual described in 
                subsection (a) for medical assistance under the State 
                plan; and
                    ``(B) information on how to assist such individuals 
                in completing and filing such forms.
            ``(2) Notification requirements.--A qualified entity that 
        determines under subsection (b)(1)(A) that an individual 
        described in subsection (a) is presumptively eligible for 
        medical assistance under a State plan shall--
                    ``(A) notify the State agency of the determination 
                within 5 working days after the date on which 
                determination is made; and
                    ``(B) inform such individual at the time the 
                determination is made that an application for medical 
                assistance is required to be made by not later than the 
                last day of the month following the month during which 
                the determination is made.
            ``(3) Application for medical assistance.--In the case of 
        an individual described in subsection (a) who is determined by 
        a qualified entity to be presumptively eligible for medical 
        assistance under a State plan, the individual shall apply for 
        medical assistance by not later than the last day of the month 
        following the month during which the determination is made.
    ``(d) Payment.--Notwithstanding any other provision of law, medical 
assistance that--
            ``(1) is furnished to an individual described in subsection 
        (a)--
                    ``(A) during a presumptive eligibility period;
                    ``(B) by a entity that is eligible for payments 
                under the State plan; and
            ``(2) is included in the care and services covered by the 
        State plan,
shall be treated as medical assistance provided by such plan for 
purposes of clause (4) of the first sentence of section 1905(b).''.
            (2) Conforming amendments.--
                    (A) Section 1902(a)(47) of the Social Security Act 
                (42 U.S.C. 1396a(a)(47)) is amended by inserting before 
                the semicolon at the end the following: ``and provide 
                for making medical assistance available to individuals 
                described in subsection (a) of section 1920C during a 
                presumptive eligibility period in accordance with such 
                section''.
                    (B) Section 1903(u)(1)(D)(v) of such Act (42 U.S.C. 
                1396b(u)(1)(D)(v)) is amended--
                            (i) by striking ``or for'' and inserting 
                        ``for''; and
                            (ii) by inserting before the period the 
                        following: ``, or for medical assistance 
                        provided to an individual described in 
                        subsection (a) of section 1920C during a 
                        presumptive eligibility period under such 
                        section''.
    (c) Clarification of Coverage of Family Planning Services and 
Supplies.--Section 1937(b) of the Social Security Act (42 U.S.C. 1396u-
7(b)), as amended by section 1703(c)(2), is amended by adding at the 
end the following:
            ``(6) Coverage of family planning services and supplies.--
        Notwithstanding the previous provisions of this section, a 
        State may not provide for medical assistance through enrollment 
        of an individual with benchmark coverage or benchmark-
        equivalent coverage under this section unless such coverage 
        includes for any individual described in section 1905(a)(4)(C), 
        medical assistance for family planning services and supplies in 
        accordance with such section.''.
    (d) Effective Date.--The amendments made by this section take 
effect on the date of the enactment of this Act and shall apply to 
items and services furnished on or after such date.

                           Subtitle C--Access

SEC. 1721. PAYMENTS TO PRIMARY CARE PRACTITIONERS.

    (a) In General.--
            (1) Fee-for-service payments.--Section 1902 of the Social 
        Security Act (42 U.S.C. 1396b)as amended by sections 1703(a), 
        1714(a), 1731(a), and 1746, is amended--
                    (A) in subsection (a)(13)--
                            (i) by striking ``and'' at the end of 
                        subparagraph (A);
                            (ii) by adding ``and'' at the end of 
                        subparagraph (B); and
                            (iii) by adding at the end the following 
                        new subparagraph:
                    ``(C) payment for primary care services (as defined 
                in subsection (kk)(1)) furnished by physicians (or for 
                services furnished by other health care professionals 
                that would be primary care services under such section 
                if furnished by a physician) at a rate not less than 80 
                percent of the payment rate that would be applicable if 
                the adjustment described in subsection (kk)(2) were to 
                apply to such services and physicians or professionals 
                (as the case may be) under part B of title XVIII for 
                services furnished in 2010, 90 percent of such adjusted 
                payment rate for services and physicians (or 
                professionals) furnished in 2011, or 100 percent of 
                such adjusted payment rate for services and physicians 
                (or professionals) furnished in 2012 and each 
                subsequent year;''; and
                    (B) by adding at the end the following new 
                subsection:
    ``(kk) Increased Payment for Primary Care Services.--For purposes 
of subsection (a)(13)(C):
            ``(1) Primary care services defined.--The term `primary 
        care services' means evaluation and management services, 
        without regard to the specialty of the physician furnishing the 
        services, that are procedure codes (for services covered under 
        title XVIII) for services in the category designated Evaluation 
        and Management in the Health Care Common Procedure Coding 
        System (established by the Secretary under section 1848(c)(5) 
        as of December 31, 2009, and as subsequently modified by the 
        Secretary).
            ``(2) Adjustment.--The adjustment described in this 
        paragraph is the substitution of 1.25 percent for the update 
        otherwise provided under section 1848(d)(4) for each year 
        beginning with 2010.''.
            (2) Under medicaid managed care plans.--Section 1932(f) of 
        such Act (42 U.S.C. 1396u-2(f)) is amended--
                    (A) in the heading, by adding at the end the 
                following: ``; Adequacy of Payment for Primary Care 
                Services''; and
                    (B) by inserting before the period at the end the 
                following: ``and, in the case of primary care services 
                described in section 1902(a)(13)(C), consistent with 
                the minimum payment rates specified in such section 
                (regardless of the manner in which such payments are 
                made, including in the form of capitation or partial 
                capitation)''.
    (b) Increase in Payment Using Increased FMAP.--Section 1905(y) of 
the Social Security Act, as added by section 1701(a)(3)(B) and as 
amended by section 1701(c)(2), is amended by adding at the end the 
following:
            ``(3)(A) The portion of the amounts expended for medical 
        assistance for services described in section 1902(a)(13)(C) 
        furnished on or after January 1, 2010, that is attributable to 
        the amount by which the minimum payment rate required under 
        such section (or, by application, section 1932(f)) exceeds the 
        payment rate applicable to such services under the State plan 
        as of June 16, 2009.
            ``(B) Subparagraph (A) shall not be construed as preventing 
        the payment of Federal financial participation based on the 
        Federal medical assistance percentage for amounts in excess of 
        those specified under such subparagraph.''.
    (c) Effective Date.--The amendments made by this section shall 
apply to services furnished on or after January 1, 2010.

SEC. 1722. MEDICAL HOME PILOT PROGRAM.

    (a) In General.--The Secretary of Health and Human Services shall 
establish under this section a medical home pilot program under which a 
State may apply to the Secretary for approval of a medical home pilot 
project described in subsection (b) (in this section referred to as a 
``pilot project'') for the application of the medical home concept 
under title XIX of the Social Security Act. The pilot program shall 
operate for a period of up to 5 years.
    (b) Pilot Project Described.--
            (1) In general.--A pilot project is a project that applies 
        one or more of the medical home models described in section 
        1866F(a)(3) of the Social Security Act (as inserted by section 
        1302(a)) or such other model as the Secretary may approve, to 
        individuals (including medically fragile children and high-risk 
        pregnant women) who are eligible for medical assistance under 
        title XIX of the Social Security Act. The Secretary shall 
        provide for appropriate coordination of the pilot program under 
        this section with the medical home pilot program under section 
        1866F of such Act.
            (2) Limitation.--A pilot project shall be for a duration of 
        not more than 5 years.
            (3) Consideration for certain technologies.--In considering 
        applications for pilots projects under this section, the 
        Secretary may approve a project which tests the effectiveness 
        of applications and devices, such as wireless patient 
        management technologies, that are approved by the Food and Drug 
        Administration and enable providers and practitioners to 
        communicate directly with their patients in managing chronic 
        illness.
    (c) Additional Incentives.--In the case of a pilot project, the 
Secretary may--
            (1) waive the requirements of section 1902(a)(1) of the 
        Social Security Act (relating to statewideness) and section 
        1902(a)(10)(B) of such Act (relating to comparability); and
            (2) increase to up to 90 percent (for the first 2 years of 
        the pilot program) or 75 percent (for the next 3 years) the 
        matching percentage for administrative expenditures (such as 
        those for community care workers).
    (d) Medically Fragile Children.--In the case of a model involving 
medically fragile children, the model shall ensure that the patient-
centered medical home services received by each child, in addition to 
fulfilling the requirements under 1866F(b)(1) of the Social Security 
Act, provide for continuous involvement and education of the parent or 
caregiver and for assistance to the child in obtaining necessary 
transitional care if a child's enrollment ceases for any reason.
    (e) Evaluation; Report.--
            (1) Evaluation.--The Secretary, using the criteria 
        described in section 1866F(e)(1) of the Social Security Act (as 
        inserted by section 1123), shall conduct an evaluation of the 
        pilot program under this section.
            (2) Report.--Not later than 60 days after the date of 
        completion of the evaluation under paragraph (1), the Secretary 
        shall submit to Congress and make available to the public a 
        report on the findings of the evaluation under such paragraph.
    (f) Funding.--The additional Federal financial participation 
resulting from the implementation of the pilot program under this 
section may not exceed in the aggregate $1,235,000,000 over the 5-year 
period of the program.

SEC. 1723. TRANSLATION OR INTERPRETATION SERVICES.

    (a) In General.--Section 1903(a)(2)(E) of the Social Security Act 
(42 U.S.C. 1396b(a)(2)), as added by section 201(b)(2)(A) of the 
Children's Health Insurance Program Reauthorization Act of 2009 (Public 
Law 111-3), is amended by inserting ``and other individuals'' after 
``children of families''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to payment for translation or interpretation services furnished 
on or after January 1, 2010.

SEC. 1724. OPTIONAL COVERAGE FOR FREESTANDING BIRTH CENTER SERVICES.

    (a) In General.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by section 1713(a), is amended--
            (1) in subsection (a)--
                    (A) by redesignating paragraph (29) as paragraph 
                (30);
                    (B) in paragraph (28), by striking at the end 
                ``and''; and
                    (C) by inserting after paragraph (28) the following 
                new paragraph:
            ``(29) freestanding birth center services (as defined in 
        subsection (l)(3)(A)) and other ambulatory services that are 
        offered by a freestanding birth center (as defined in 
        subsection (l)(3)(B)) and that are otherwise included in the 
        plan; and''; and
            (2) in subsection (l), by adding at the end the following 
        new paragraph:
    ``(3)(A) The term `freestanding birth center services' means 
services furnished to an individual at a freestanding birth center (as 
defined in subparagraph (B)), including by a licensed birth attendant 
(as defined in subparagraph (C)) at such center.
    ``(B) The term `freestanding birth center' means a health 
facility--
            ``(i) that is not a hospital; and
            ``(ii) where childbirth is planned to occur away from the 
        pregnant woman's residence.
    ``(C) The term `licensed birth attendant' means an individual who 
is licensed or registered by the State involved to provide health care 
at childbirth and who provides such care within the scope of practice 
under which the individual is legally authorized to perform such care 
under State law (or the State regulatory mechanism provided by State 
law), regardless of whether the individual is under the supervision of, 
or associated with, a physician or other health care provider. Nothing 
in this subparagraph shall be construed as changing State law 
requirements applicable to a licensed birth attendant.''.
    (b) Effective Date.--The amendments made by this section shall 
apply to items and services furnished on or after the date of the 
enactment of this Act.

SEC. 1725. INCLUSION OF PUBLIC HEALTH CLINICS UNDER THE VACCINES FOR 
              CHILDREN PROGRAM.

    Section 1928(b)(2)(A)(iii)(I) of the Social Security Act (42 U.S.C. 
1396s(b)(2)(A)(iii)(I)) is amended--
            (1) by striking ``or a rural health clinic'' and inserting 
        ``, a rural health clinic''; and
            (2) by inserting ``or a public health clinic,'' after 
        ```1905(l)(1)),''.

SEC. 1726. REQUIRING COVERAGE OF SERVICES OF PODIATRISTS.

    (a) In General.--Section 1905(a)(5)(A) of the Social Security Act 
(42 U.S.C. 1396d(a)(5)(A)) is amended by striking ``section 
1861(r)(1)'' and inserting ``paragraphs (1) and (3) of section 
1861(r)''.
    (b) Effective Date.--Except as provided in section 1790, the 
amendment made by subsection (a) shall apply to services furnished on 
or after January 1, 2010.

SEC. 1726A. REQUIRING COVERAGE OF SERVICES OF OPTOMETRISTS.

    (a) In General.--Section 1905(a)(5) of the Social Security Act (42 
U.S.C. 1396d(a)(5)) is amended--
            (1) by striking ``and'' before ``(B)''; and
            (2) by inserting before the semicolon at the end the 
        following: ``, and (C) medical and other health services (as 
        defined in section 1861(s)) as authorized by State law, 
        furnished by an optometrist (described in section 1861(r)(4)) 
        to the extent such services may be performed under State law''.
    (b) Effective Date.--Except as provided in section 1790, the 
amendments made by subsection (a) shall take effect 90 days after the 
date of the enactment of this Act and shall apply to services furnished 
or other actions required on or after such date.

SEC. 1727. THERAPEUTIC FOSTER CARE.

    (a) Rule of Construction.--Nothing in this title shall prevent or 
limit a State from covering therapeutic foster care for eligible 
children in out-of-home placements under section 1905(a) of the Social 
Security Act (42 U.S.C. 1396d(a)).
    (b) Therapeutic Foster Care Defined.--For purposes of this section, 
the term ``therapeutic foster care'' means a foster care program that 
provides--
            (1) to the child--
                    (A) structured daily activities that develop, 
                improve, monitor, and reinforce age-appropriate social, 
                communications, and behavioral skills;
                    (B) crisis intervention and crisis support 
                services;
                    (C) medication monitoring;
                    (D) counseling; and
                    (E) case management services; and
            (2) specialized training for the foster parent and 
        consultation with the foster parent on the management of 
        children with mental illnesses and related health and 
        developmental conditions.

SEC. 1728. ASSURING ADEQUATE PAYMENT LEVELS FOR SERVICES.

    (a) In General.--Title XIX of the Social Security Act is amended by 
inserting after section 1925 the following new section:

            ``assuring adequate payment levels for services

    ``Sec. 1926.  (a) In General.--A State plan under this title shall 
not be considered to meet the requirement of section 1902(a)(30)(A) for 
a year (beginning with 2011) unless, by not later than April 1 before 
the beginning of such year, the State submits to the Secretary an 
amendment to the plan that specifies the payment rates to be used for 
such services under the plan in such year and includes in such 
submission such additional data as will assist the Secretary in 
evaluating the State's compliance with such requirement, including data 
relating to how rates established for payments to medicaid managed care 
organizations under sections 1903(m) and 1932 take into account such 
payment rates.
    ``(b) Secretarial Review.--The Secretary, by not later than 90 days 
after the date of submission of a plan amendment under subsection (a), 
shall--
            ``(1) review each such amendment for compliance with the 
        requirement of section 1902(a)(30)(A); and
            ``(2) approve or disapprove each such amendment.
If the Secretary disapproves such an amendment, the State shall 
immediately submit a revised amendment that meets such requirement.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
take effect on the date of the enactment of this Act.

SEC. 1729. PRESERVING MEDICAID COVERAGE FOR YOUTHS UPON RELEASE FROM 
              PUBLIC INSTITUTIONS.

    Section 1902(a) of the Social Security Act (42 U.S.C. 1396a), as 
amended by section 1631(b) and 1703(a), is amended--
            (1) by striking ``and'' at the end of paragraph (74);
            (2) by striking the period at the end of paragraph (75) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (75) the following new 
        paragraph:
            ``(76) provide that in the case of any youth who is 18 
        years of age or younger, was enrolled for medical assistance 
        under the State plan immediately before becoming an inmate of a 
        public institution, is 18 years of age or younger upon release 
        from such institution, and is eligible for such medical 
        assistance under the State plan at the time of release from 
        such institution--
                    ``(A) during the period such youth is incarcerated 
                in a public institution, the State shall not terminate 
                eligibility for medical assistance under the State plan 
                for such youth;
                    ``(B) during the period such youth is incarcerated 
                in a public institution, the State shall establish a 
                process that ensures--
                            ``(i) that the State does not claim federal 
                        financial participation for services that are 
                        provided to such youth and that are excluded 
                        under subsection 1905(a)(28)(A); and
                            ``(ii) that the youth receives medical 
                        assistance for which federal participation is 
                        available under this title;
                    ``(C) on or before the date such youth is released 
                from such institution, the State shall ensure that such 
                youth is enrolled for medical assistance under this 
                title, unless and until there is a determination that 
                the individual is no longer eligible to be so enrolled; 
                and
                    ``(D) the State shall ensure that enrollment under 
                subparagraph (C) will be completed before such date so 
                that the youth can access medical assistance under this 
                title immediately upon leaving the institution.''

SEC. 1730. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH SERVICES 
              UNDER MEDICAID AND CHIP.

    Title XI of the Social Security Act (42 U.S.C. 1301 et seq.) is 
amended by inserting after section 1139A the following new section:

``SEC. 1139B. QUALITY MEASURES FOR MATERNITY AND ADULT HEALTH SERVICES 
              UNDER MEDICAID AND CHIP.

    ``(a) Maternity Care Quality Measures Under Medicaid and CHIP.--
            ``(1) Development of measures.--No later than January 1, 
        2011, the Secretary shall develop and publish for comment a 
        proposed set of measures that accurately describe the quality 
        of maternity care provided under State plans under titles XIX 
        and XXI. The Secretary shall publish a final recommended set of 
        such measures no later than July 1, 2011.
            ``(2) Standardized reporting format.--No later than January 
        1, 2012, the Secretary shall develop and publish a standardized 
        reporting format for maternity care quality measures for use by 
        State programs under titles XIX and XXI to collect data from 
        managed care entities and providers and practitioners that 
        participate in such programs and to report maternity care 
        quality measures to the Secretary.
    ``(b) Other Adult Health Quality Measures Under Medicaid.--
            ``(1) Development of measures.--The Secretary shall develop 
        quality measures that are not otherwise developed under section 
        1192 for services received under State plans under title XIX by 
        individuals who are 21 years of age or older but have not 
        attained age 65. The Secretary shall publish such quality 
        measures through notice and comment rulemaking.
            ``(2) Standardized reporting format.--The Secretary shall 
        develop and publish a standardized reporting format for quality 
        measures developed under paragraph (1) and section 1192 for 
        services furnished under State plans under title XIX to 
        individuals who are 21 years of age or older but have not 
        attained age 65 for use under such plans and State plans under 
        title XXI. The format shall enable State agencies administering 
        such plans to collect data from managed care entities and 
        providers and practitioners that participate in such plans and 
        to report quality measures to the Secretary.
    ``(c) Development Process.--With respect to the development of 
quality measures under subsections (a) and (b)--
            ``(1) Use of qualified entities.--The Secretary may enter 
        into agreements with public, nonprofit, or academic 
        institutions with technical expertise in the area of health 
        quality measurement to assist in such development. The 
        Secretary may carry out these agreements by contract, grant, or 
        otherwise.
            ``(2) Multi-stakeholder pre-rulemaking input.--The 
        Secretary shall obtain the input of stakeholders with respect 
        to such quality measures using a process similar to that 
        described in section 1808(d).
            ``(3) Coordination.--The Secretary shall coordinate the 
        development of such measures under such subsections and with 
        the development of child health quality measures under section 
        1139A.
    ``(d) Annual Report to Congress.--No later than January 1, 2013, 
and annually thereafter, the Secretary shall report to the Committee on 
Energy and Commerce of the House of Representatives the Committee on 
Finance of the Senate regarding--
            ``(1) the availability of reliable data relating to the 
        quality of maternity care furnished under State plans under 
        titles XIX and XXI;
            ``(2) the availability of reliable data relating to the 
        quality of services furnished under State plans under title XIX 
        to adults who are 21 years of age or older but have not 
        attained age 65; and
            ``(3) recommendations for improving the quality of such 
        care and services furnished under such State plans.
    ``(e) Rule of Construction.--Notwithstanding any other provision in 
this section, no quality measure developed, published, or used as a 
basis of measurement or reporting under this section may be used to 
establish an irrebuttable presumption regarding either the medical 
necessity of care or the maximum permissible coverage for any 
individual who receives medical assistance under title XIX or child 
health assistance under title XXI.
    ``(f) Appropriation.--For purposes of carrying out this section, in 
addition to funds otherwise available, out of any funds in the Treasury 
not otherwise appropriated, there are appropriated $40,000,000 for the 
5-fiscal-year period beginning with fiscal year 2010. Funds 
appropriated under this subsection shall remain available until 
expended.''.

SEC. 1730A. ACCOUNTABLE CARE ORGANIZATION PILOT PROGRAM.

    (a) In General.--The Secretary of Health and Human Services shall 
establish under this section an accountable care program under which a 
State may apply to the Secretary for approval of an accountable care 
organization pilot program described in subsection (b) (in this section 
referred to as a ``pilot program'') for the application of the 
accountable care organization concept under title XIX of the Social 
Security Act.
    (b) Pilot Program Described.--
            (1) In general.--The pilot program described in this 
        subsection is a program that applies one or more of the 
        accountable care organization models described in section 1866E 
        of the Social Security Act, as added by section 1301 of this 
        Act.
            (2) Limitation.--The pilot program shall operate for a 
        period of not more than 5 years.
    (c) Additional Incentives.--In the case of the pilot program under 
this section, the Secretary may--
            (1) waive the requirements of--
                    (A) section 1902(a)(1) of the Social Security Act 
                (relating to statewideness);
                    (B) section 1902(a)(10)(B) of such Act (relating to 
                comparability); and
            (2) increase the matching percentage for administrative 
        expenditures up to--
                    (A) 90 percent (for the first 2 years of the pilot 
                program); and
                    (B) 75 percent (for the next 3 years).
    (d) Evaluation; Report.--
            (1) Evaluation.--The Secretary shall conduct an evaluation 
        of the pilot program under this section. In conducting such 
        evaluation, the Secretary shall use the criteria used under 
        subsection (g)(1) of section 1866E of the Social Security Act 
        (as inserted by section 1301 of this Act) to evaluate pilot 
        programs under such section.
            (2) Report.--Not later than 60 days after the date of 
        completion of the evaluation under paragraph (1), the Secretary 
        shall submit to Congress and make available to the public a 
        report on the findings of the evaluation under such paragraph.

SEC. 1730B. FQHC COVERAGE.

    Section 1905(l)(2)(B) of the Social Security Act (42 U.S.C. 
1396d(l)(2)(B)) is amended--
            (1) by striking ``or'' at the end of clause (iii);
            (2) by striking the semicolon at the end of clause (iv) and 
        inserting ``, and''; and
            (3) by inserting after clause (iv) the following new 
        clause:
            ``(v) is receiving a grant under section 399Z-1 of the 
        Public Health Service Act;''.

                          Subtitle D--Coverage

SEC. 1731. OPTIONAL MEDICAID COVERAGE OF LOW-INCOME HIV-INFECTED 
              INDIVIDUALS.

    (a) In General.-- Section 1902 of the Social Security Act (42 
U.S.C. 1396a), as amended by section 1714(a)(1), is amended--
            (1) in subsection (a)(10)(A)(ii)--
                    (A) by striking ``or'' at the end of subclause 
                (XIX);
                    (B) by adding ``or'' at the end of subclause (XX); 
                and
                    (C) by adding at the end the following:
                                    ``(XXI) who are described in 
                                subsection (ii) (relating to HIV-
                                infected individuals);''; and
            (2) by adding at the end, as amended by sections 1703 and 
        1714(a), the following:
    ``(ii) Individuals described in this subsection are individuals not 
described in subsection (a)(10)(A)(i)--
            ``(1) who have HIV infection;
            ``(2) whose income (as determined under the State plan 
        under this title with respect to disabled individuals) does not 
        exceed the maximum amount of income a disabled individual 
        described in subsection (a)(10)(A)(i) may have and obtain 
        medical assistance under the plan; and
            ``(3) whose resources (as determined under the State plan 
        under this title with respect to disabled individuals) do not 
        exceed the maximum amount of resources a disabled individual 
        described in subsection (a)(10)(A)(i) may have and obtain 
        medical assistance under the plan.''.
    (b) Enhanced Match.--The first sentence of section 1905(b) of such 
Act (42 U.S.C. 1396d(b)) is amended by striking ``section 
1902(a)(10)(A)(ii)(XVIII)'' and inserting ``subclause (XVIII) or (XXI) 
of section 1902(a)(10)(A)(ii)''.
    (c) Conforming Amendments.--Section 1905(a) of such Act (42 U.S.C. 
1396d(a)) is amended, in the matter preceding paragraph (1)--
            (1) by striking ``or'' at the end of clause (xii);
            (2) by adding ``or'' at the end of clause (xiii); and
            (3) by inserting after clause (xiii) the following:
            ``(xiv) individuals described in section 1902(ii),''.
    (d) Exemption From Funding Limitation for Territories.--Section 
1108(g) of the Social Security Act (42 U.S.C. 1308(g)) is amended by 
adding at the end the following:
            ``(5) Disregarding medical assistance for optional low-
        income hiv-infected individuals.--The limitations under 
        subsection (f) and the previous provisions of this subsection 
        shall not apply to amounts expended for medical assistance for 
        individuals described in section 1902(ii) who are only eligible 
        for such assistance on the basis of section 
        1902(a)(10)(A)(ii)(XXI).''.
    (e) Effective Date; Sunset.--The amendments made by this section 
shall apply to expenditures for calendar quarters beginning on or after 
the date of the enactment of this Act, and before January 1, 2013, 
without regard to whether or not final regulations to carry out such 
amendments have been promulgated by such date.

SEC. 1732. EXTENDING TRANSITIONAL MEDICAID ASSISTANCE (TMA).

    Sections 1902(e)(1)(B) and 1925(f) of the Social Security Act (42 
U.S.C. 1396a(e)(1)(B), 1396r-6(f)), as amended by section 5004(a)(1) of 
the American Recovery and Reinvestment Act of 2009 (Public Law 111-5), 
are each amended by striking ``December 31, 2010'' and inserting 
``December 31, 2012''.

SEC. 1733. REQUIREMENT OF 12-MONTH CONTINUOUS COVERAGE UNDER CERTAIN 
              CHIP PROGRAMS.

    (a) In General.--Section 2102(b) of the Social Security Act (42 
U.S.C. 1397bb(b)) is amended by adding at the end the following new 
paragraph:
            ``(6) Requirement for 12-month continuous eligibility.--In 
        the case of a State child health plan that provides child 
        health assistance under this title through a means other than 
        described in section 2101(a)(2), the plan shall provide for 
        implementation under this title of the 12-month continuous 
        eligibility option described in section 1902(e)(12) for 
        targeted low-income children whose family income is below 200 
        percent of the poverty line.''.
    (b) Effective Date.--The amendment made by subsection (a) shall 
apply to determinations (and redeterminations) of eligibility made on 
or after January 1, 2010.

SEC. 1734. PREVENTING THE APPLICATION UNDER CHIP OF COVERAGE WAITING 
              PERIODS FOR CERTAIN CHILDREN.

    (a) In General.--Section 2102(b)(1) of the Social Security Act (42 
U.S.C. 1397bb(b)(1)) is amended--
            (1) in subparagraph (B)--
                    (A) in clause (iii), by striking ``and'' at the 
                end;
                    (B) in clause (iv), by striking the period at the 
                end and inserting ``; and''; and
                    (C) by adding at the end the following new clause:
                            ``(v) may not apply a waiting period 
                        (including a waiting period to carry out 
                        paragraph (3)(C)) in the case of a child 
                        described in subparagraph (C).''; and
            (2) by adding at the end the following new subparagraph:
                    ``(C) Description of children not subject to 
                waiting period.--For purposes of this paragraph, a 
                child described in this subparagraph is a child who, on 
                the date an application is submitted for such child for 
                child health assistance under this title, meets any of 
                the following requirements:
                            ``(i) Infants and toddlers.--The child is 
                        under two years of age.
                            ``(ii) Loss of group health plan 
                        coverage.--The child previously had private 
                        health insurance coverage through a group 
                        health plan or health insurance coverage 
                        offered through an employer and lost such 
                        coverage due to--
                                    ``(I) termination of an 
                                individual's employment;
                                    ``(II) a reduction in hours that an 
                                individual works for an employer;
                                    ``(III) elimination of an 
                                individual's retiree health benefits; 
                                or
                                    ``(IV) termination of an 
                                individual's group health plan or 
                                health insurance coverage offered 
                                through an employer.
                            ``(iii) Unaffordable private coverage.--
                                    ``(I) In general.--The family of 
                                the child demonstrates that the cost of 
                                health insurance coverage (including 
                                the cost of premiums, co-payments, 
                                deductibles, and other cost sharing) 
                                for such family exceeds 10 percent of 
                                the income of such family.
                                    ``(II) Determination of family 
                                income.--For purposes of subclause (I), 
                                family income shall be determined in 
                                the same manner specified by the State 
                                for purposes of determining a child's 
                                eligibility for child health assistance 
                                under this title.''.
    (b) Effective Date.--The amendments made by this section shall take 
effect as of the date that is 90 days after the date of the enactment 
of this Act.

SEC. 1735. ADULT DAY HEALTH CARE SERVICES.

    (a) In General.--The Secretary of Health and Human Services shall 
not--
            (1) withhold, suspend, disallow, or otherwise deny Federal 
        financial participation under section 1903(a) of the Social 
        Security Act (42 U.S.C. 1396b(a)) for the provision of adult 
        day health care services, day activity and health services, or 
        adult medical day care services, as defined under a State 
        Medicaid plan approved during or before 1994, during such 
        period if such services are provided consistent with such 
        definition and the requirements of such plan; or
            (2) withdraw Federal approval of any such State plan or 
        part thereof regarding the provision of such services (by 
        regulation or otherwise).
    (b) Effective Date.--Subsection (a) shall apply with respect to 
services provided on or after October 1, 2008.

SEC. 1736. MEDICAID COVERAGE FOR CITIZENS OF FREELY ASSOCIATED STATES.

    (a) In General.--Section 402(b)(2) of the Personal Responsibility 
and Work Opportunity Reconciliation Act of 1996 (8 U.S.C. 1612(b)(2)) 
is amended by adding at the end the following:
                    ``(G) Medicaid exception for citizens of freely 
                associated states.--With respect to eligibility for 
                benefits for the designated Federal program defined in 
                paragraph (3)(C) (relating to the Medicaid program), 
                section 401(a) and paragraph (1) shall not apply to any 
                individual who lawfully resides in 1 of the 50 States 
                or the District of Columbia in accordance with the 
                Compacts of Free Association between the Government of 
                the United States and the Governments of the Federated 
                States of Micronesia, the Republic of the Marshall 
                Islands, and the Republic of Palau.''.
    (b) Exception to 5-year Limited Eligibility.--Section 403(d) of 
such Act (8 U.S.C. 1613(d)) is amended--
            (1) in paragraph (1), by striking ``or'' at the end;
            (2) in paragraph (2), by striking the period at the end and 
        inserting ``; or''; and
            (3) by adding at the end the following:
            ``(3) an individual described in section 402(b)(2)(G), but 
        only with respect to the designated Federal program defined in 
        section 402(b)(3)(C).''.
    (c) Definition of Qualified Alien.--Section 431(b) of such Act (8 
U.S.C. 1641(b)) is amended--
            (1) in paragraph (6), by striking ``; or'' at the end and 
        inserting a comma;
            (2) in paragraph (7), by striking the period at the end and 
        inserting ``, or''; and
            (3) by adding at the end the following:
            ``(8) an individual who lawfully resides in the United 
        States in accordance with a Compact of Free Association 
        referred to in section 402(b)(2)(G), but only with respect to 
        the designated Federal program defined in section 402(b)(3)(C) 
        (relating to the Medicaid program).''.

SEC. 1737. CONTINUING REQUIREMENT OF MEDICAID COVERAGE OF NONEMERGENCY 
              TRANSPORTATION TO MEDICALLY NECESSARY SERVICES.

    (a) Requirement.--Section 1902(a)(10) of the Social Security Act 
(42 U.S.C. 1396a(a)(10)) is amended--
            (1) in subparagraph (A), in the matter preceding clause 
        (i), by striking ``and (21)'' and inserting ``, (21), and 
        (30)''; and
            (2) in subparagraph (C)(iv), by striking ``and (17)'' and 
        inserting ``, (17), and (30)''.
    (b) Description of Services.--Section 1905(a) of such Act (42 
U.S.C. 1395d(a)), as amended by sections 1713(a)(1) and 1724(a)(1), is 
amended--
            (1) in paragraph (29), by striking ``and'' at the end;
            (2) by redesignating paragraph (30) as paragraph (31) and 
        by striking the comma at the end and inserting a semicolon; and
            (3) by inserting after paragraph (29) the following new 
        paragraph:
            ``(30) nonemergency transportation to medically necessary 
        services, consistent with the requirement of section 431.53 of 
        title 42, Code of Federal Regulations, as in effect as of June 
        1, 2008; and''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act and shall apply to 
transportation on or after such date.

SEC. 1738. STATE OPTION TO DISREGARD CERTAIN INCOME IN PROVIDING 
              CONTINUED MEDICAID COVERAGE FOR CERTAIN INDIVIDUALS WITH 
              EXTREMELY HIGH PRESCRIPTION COSTS.

    Section 1902(e) of the Social Security Act (42 U.S.C. 1396b(e)), as 
amended by section 203(a) of the Children's Health Insurance Program 
Reauthorization Act of 2009 (Public Law 111-3), is amended by adding at 
the end the following new paragraph:
    ``(14)(A) At the option of the State, in the case of an individual 
with extremely high prescription drug costs described in subparagraph 
(B) who has been determined (without the application of this paragraph) 
to be eligible for medical assistance under this title, the State may, 
in redetermining the individual's eligibility for medical assistance 
under this title, disregard any family income of the individual to the 
extent such income is less than an amount that is specified by the 
State and does not exceed the amount specified in subparagraph (C), or, 
if greater, income equal to the cost of the orphan drugs described in 
subparagraph (B)(iii).
    ``(B) An individual with extremely high prescription drug costs 
described in this subparagraph for a 12-month period is an individual--
            ``(i) who is covered under health insurance or a health 
        benefits plan that has a maximum lifetime limit of not less 
        than $1,000,000 which includes all prescription drug coverage;
            ``(ii) who has exhausted all available prescription drug 
        coverage under the plan as of the beginning of such period;
            ``(iii) who incurs (or is reasonably expected to incur) on 
        an annual basis during the period costs for orphan drugs in 
        excess of the amount specified in subparagraph (C) for the 
        period; and
            ``(iv) whose annual family income (determined without 
        regard to this paragraph) as of the beginning of the period 
        does not exceed 75 percent of the amount incurred for such 
        drugs (as described in clause (iii)).
    ``(C) The amount specified in this subparagraph for a 12-month 
period beginning in--
            ``(i) 2009 or 2010, is $200,000; or
            ``(ii) a subsequent year, is the amount specified in clause 
        (i) (or this subparagraph) for the previous year increased by 
        the annual rate of increase in the medical care component of 
        the consumer price index (U.S. city average) for the 12-month 
        period ending in August of the previous year.
Any amount computed under clause (ii) that is not a multiple of $1,000 
shall be rounded to the nearest multiple of $1,000.
    ``(D) In applying this paragraph, amounts incurred for prescription 
drugs for cosmetic purposes shall not be taken into account.
    ``(E) With respect to an individual described in subparagraph (A), 
notwithstanding section 1916, the State plan--
            ``(i) shall provide for the application of cost-sharing 
        that is at least nominal as determined under section 1916; and
            ``(ii) may provide, consistent with section 1916A, for such 
        additional cost-sharing as does not exceed a maximum level of 
        cost-sharing that is specified by the Secretary and is adjusted 
        by the Secretary on an annual basis.
    ``(F) A State electing the option under this paragraph shall 
provide for a determination on an individual's application for 
continued medical assistance under this title within 30 days of the 
date the application if filed with the State.
    ``(G) In this paragraph:
            ``(i) The term `orphan drugs' means prescription drugs 
        designated under section 526 of the Federal Food, Drug, and 
        Cosmetic Act (21 U.S.C. 360bb) as a drug for a rare disease or 
        condition.
            ``(ii) The term `health benefits plan' includes coverage 
        under a plan offered under a State high risk pool.''.

SEC. 1739. PROVISIONS RELATING TO COMMUNITY LIVING ASSISTANCE SERVICES 
              AND SUPPORTS (CLASS).

    (a) Coordination With CLASS Provisions.--Section 1902(a) of the 
Social Security Act (42 U.S.C. 1396a(a)), as amended by sections 
1631(b), 1703(a), 1729, 1753, 1757(a), 1759(a), 1783(a), and 1907(b), 
is amended--
            (1) in paragraph (80), by striking ``and'' at the end;
            (2) in paragraph (81), by striking the period and inserting 
        ``; and''; and
            (3) by inserting after paragraph (81) the following:
            ``(82) provide that the State will comply with such 
        regulations regarding the application of primary and secondary 
        payor rules with respect to individuals who are eligible for 
        medical assistance under this title and are eligible 
        beneficiaries under the CLASS program established under title 
        XXXII of the Public Health Service Act as the Secretary shall 
        establish.''.
    (b) Assurance of Adequate Infrastructure for the Provision of 
Personal Care Attendant Workers.--Section 1902(a) of such Act (42 
U.S.C. 1396a(a)), as amended by subsection (a), is amended--
            (1) in paragraph (81), by striking ``and'' at the end;
            (2) in paragraph (82), by striking the period at the end 
        and inserting ``; and''; and
            (3) by inserting after paragraph (82), the following:
            ``(83) provide that, not later than 2 years after the date 
        of enactment of this paragraph, each State shall--
                    ``(A) assess the extent to which entities such as 
                providers of home care, home health services, home and 
                community service providers, public authorities created 
                to provide personal care services to individuals 
                eligible for medical assistance under the State plan, 
                and nonprofit organizations, are serving or have the 
                capacity to serve as fiscal agents for, employers of, 
                and providers of employment-related benefits for, 
                personal care attendant workers who provide personal 
                care services to individuals receiving benefits under 
                the CLASS program established under title XXXII of the 
                Public Health Service Act, including in rural and 
                underserved areas;
                    ``(B) designate or create such entities to serve as 
                fiscal agents for, employers of, and providers of 
                employment-related benefits for, such workers to ensure 
                an adequate supply of the workers for individuals 
                receiving benefits under the CLASS program, including 
                in rural and underserved areas; and
                    ``(C) ensure that the designation or creation of 
                such entities will not negatively alter or impede 
                existing programs, models, methods, or administration 
                of service delivery that provide for consumer 
                controlled or self-directed home and community services 
                and further ensure that such entities will not impede 
                the ability of individuals to direct and control their 
                home and community services, including the ability to 
                select, manage, dismiss, co-employ, or employ such 
                workers or inhibit such individuals from relying on 
                family members for the provision of personal care 
                services.''.
    (c) Inclusion of Information on Supplemental Coverage in the 
National Clearinghouse for Long-term Care Information; Extension of 
Funding.--Section 6021(d) of the Deficit Reduction Act of 2005 (42 
U.S.C. 1396p note) is amended--
            (1) in paragraph (2)(A)--
                    (A) in clause (ii), by striking ``and'' at the end;
                    (B) in clause (iii), by striking the period at the 
                end and inserting ``; and''; and
                    (C) by adding at the end the following:
                            ``(iv) include information regarding the 
                        CLASS program established under title XXXII of 
                        the Public Health Service Act.''; and
            (2) in paragraph (3)--
                    (A) by striking ``2010'' and inserting ``2015''; 
                and
                    (B) by adding at the end the following: ``In 
                addition to the amount appropriated under the previous 
                sentence, there are authorized to be appropriated to 
                carry out this subsection, $7,000,000 for each of 
                fiscal years 2011, 2012, and 2013.''.
    (d) Effective Date.--The amendments made by this section take 
effect on January 1, 2011.

                         Subtitle E--Financing

SEC. 1741. PAYMENTS TO PHARMACISTS.

    (a) Pharmacy Reimbursement Limits.--
            (1) In general.--Section 1927(e) of the Social Security Act 
        (42 U.S.C. 1396r-8(e)) is amended--
                    (A) by striking paragraph (5) and inserting the 
                following:
            ``(5) Use of amp in upper payment limits.--The Secretary 
        shall calculate the Federal upper reimbursement limit 
        established under paragraph (4) as 130 percent of the weighted 
        average (determined on the basis of manufacturer utilization) 
        of monthly average manufacturer prices. Nothing in the previous 
        sentence shall be construed as preventing the Secretary from 
        performing such calculation using a smoothing process in order 
        to reduce significant variations from month to month as a 
        result of rebates, discounts, and other pricing practices, such 
        as in the manner such a process is used by the Secretary in 
        determining the average sales price of a drug or biological 
        under section 1847A.''
            (2) Definition of amp.--Section 1927(k)(1)(B) of such Act 
        (42 U.S.C. 1396r-8(k)(1)(B)) is amended--
                    (B) in the heading, by striking ``extended to 
                wholesalers'' and inserting ``and other payments''; and
                    (C) by striking ``regard to'' and all that follows 
                through the period and inserting the following: 
                ``regard to--
                            ``(i) customary prompt pay discounts 
                        extended to wholesalers;
                            ``(ii) bona fide service fees paid by 
                        manufacturers;
                            ``(iii) reimbursement by manufacturers for 
                        recalled, damaged, expired, or otherwise 
                        unsalable returned goods, including 
                        reimbursement for the cost of the goods and any 
                        reimbursement of costs associated with return 
                        goods handling and processing, reverse 
                        logistics, and drug destruction;
                            ``(iv) sales directly to, or rebates, 
                        discounts, or other price concessions provided 
                        to, pharmacy benefit managers, managed care 
                        organizations, health maintenance 
                        organizations, insurers, mail order pharmacies 
                        that are not open to all members of the public, 
                        or long term care providers, provided that 
                        these rebates, discounts, or price concessions 
                        are not passed through to retail pharmacies;
                            ``(v) sales directly to, or rebates, 
                        discounts, or other price concessions provided 
                        to, hospitals, clinics, and physicians, unless 
                        the drug is an inhalation, infusion, or 
                        injectable drug, or unless the Secretary 
                        determines, as allowed for in Agency 
                        administrative procedures, that it is necessary 
                        to include such sales, rebates, discounts, and 
                        price concessions in order to obtain an 
                        accurate AMP for the drug. Such a determination 
                        shall not be subject to judicial review; or
                            ``(vi) rebates, discounts, and other price 
                        concessions required to be provided under 
                        agreements under subsections (f) and (g) of 
                        section 1860D-2(f).''.
            (3) Manufacturer reporting requirements.--Section 
        1927(b)(3)(A) of such Act (42 U.S.C. 1396r-8(b)(3)(A)) is 
        amended--
                    (A) in clause (ii), by striking ``and'' at the end;
                    (B) by striking the period at the end of clause 
                (iii) and inserting ``; and''; and
                    (C) by inserting after clause (iii) the following 
                new clause:
                            ``(iv) not later than 30 days after the 
                        last day of each month of a rebate period under 
                        the agreement, on the manufacturer's total 
                        number of units that are used to calculate the 
                        monthly average manufacturer price for each 
                        covered outpatient drug.''.
            (4) Authority to promulgate regulation.--The Secretary of 
        Health and Human Services may promulgate regulations to clarify 
        the requirements for upper payment limits and for the 
        determination of the average manufacturer price in an expedited 
        manner. Such regulations may become effective on an interim 
        final basis, pending opportunity for public comment.
            (5) Pharmacy reimbursements through december 31, 2010.--The 
        specific upper limit under section 447.332 of title 42, Code of 
        Federal Regulations (as in effect on December 31, 2006) 
        applicable to payments made by a State for multiple source 
        drugs under a State Medicaid plan shall continue to apply 
        through December 31, 2010, for purposes of the availability of 
        Federal financial participation for such payments.
    (b) Disclosure of Price Information to the Public.--Section 
1927(b)(3) of such Act (42 U.S.C. 1396r-8(b)(3)) is amended--
            (1) in subparagraph (A)--
                    (A) in clause (i), in the matter preceding 
                subclause (I), by inserting ``month of a'' after 
                ``each''; and
                    (B) in the last sentence, by striking ``and 
                shall,'' and all that follows up to the period; and
            (2) in subparagraph (D)(v), by inserting ``weighted'' 
        before ``average manufacturer prices''.

SEC. 1742. PRESCRIPTION DRUG REBATES.

    (a) Additional Rebate for New Formulations of Existing Drugs.--
            (1) In general.--Section 1927(c)(2) of the Social Security 
        Act (42 U.S.C. 1396r-8(c)(2)) is amended by adding at the end 
        the following new subparagraph:
                    ``(C) Treatment of new formulations.--In the case 
                of a drug that is a line extension of a single source 
                drug or an innovator multiple source drug that is an 
                oral solid dosage form, the rebate obligation with 
                respect to such drug under this section shall be the 
                amount computed under this section for such new drug 
                or, if greater, the product of--
                            ``(i) the average manufacturer price of the 
                        line extension of a single source drug or an 
                        innovator multiple source drug that is an oral 
                        solid dosage form;
                            ``(ii) the highest additional rebate 
                        (calculated as a percentage of average 
                        manufacturer price) under this section for any 
                        strength of the original single source drug or 
                        innovator multiple source drug; and
                            ``(iii) the total number of units of each 
                        dosage form and strength of the line extension 
                        product paid for under the State plan in the 
                        rebate period (as reported by the State).
                In this subparagraph, the term `line extension' means, 
                with respect to a drug, a new formulation of the drug, 
                such as an extended release formulation.''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply to drugs dispensed after December 31, 2009.
    (b) Increase Minimum Rebate Percentage for Single Source Drugs.--
            (1) In general.--Section 1927(c)(1)(B)(i) of the Social 
        Security Act (42 U.S.C. 1396r-8(c)(1)(B)(i)) is amended--
                    (A) in subclause (IV), by striking ``and'' at the 
                end;
                    (B) in subclause (V)--
                            (i) by inserting ``and before January 1, 
                        2010'' after ``December 31, 1995,''; and
                            (ii) by striking the period at the end and 
                        inserting ``; and''; and
                    (C) by adding at the end the following new 
                subclause:
                                    ``(VI) after December 31, 2009, is 
                                23.1 percent.''.
            (2) Recapture of total savings due to increase.--Section 
        1927(b)(1) of such Act is amended by adding at the end the 
        following new subparagraph:
                    ``(C) Special rule for increased minimum rebate 
                percentage.--
                            ``(i) In general.--In addition to the 
                        amounts applied as a reduction under 
                        subparagraph (B), for rebate periods beginning 
                        on or after January 1, 2010, during a fiscal 
                        year, the Secretary shall reduce payments to a 
                        State under section 1903(a) in the manner 
                        specified in clause (ii), in an amount equal to 
                        the product of--
                                    ``(I) 100 percent minus the Federal 
                                medical assistance percentage 
                                applicable to the rebate period for the 
                                State; and
                                    ``(II) the amounts received by the 
                                State under such subparagraph that are 
                                attributable (as estimated by the 
                                Secretary based on utilization and 
                                other data) to the increase in the 
                                minimum rebate percentage effected by 
                                the amendments made by section 
                                1742(b)(1) of the Affordable Health 
                                Care for America Act, taking into 
                                account the additional drugs included 
                                under the amendments made by section 
                                1743 of such Act.
                        The Secretary shall adjust such payment 
                        reduction for a calendar quarter to the extent 
                        the Secretary determines, based upon subsequent 
                        utilization and other data, that the reduction 
                        for such quarter was greater or less than the 
                        amount of payment reduction that should have 
                        been made.
                            ``(ii) Manner of payment reduction.--The 
                        amount of the payment reduction under clause 
                        (i) for a State for a quarter shall be deemed 
                        an overpayment to the State under this title to 
                        be disallowed against the State's regular 
                        quarterly draw for all Medicaid spending under 
                        section 1903(d)(2). Such a disallowance is not 
                        subject to a reconsideration under 1116(d).''.

SEC. 1743. EXTENSION OF PRESCRIPTION DRUG DISCOUNTS TO ENROLLEES OF 
              MEDICAID MANAGED CARE ORGANIZATIONS.

    (a) In General.--Section 1903(m)(2)(A) of the Social Security Act 
(42 U.S.C. 1396b(m)(2)(A)) is amended--
            (1) in clause (xi), by striking ``and'' at the end;
            (2) in clause (xii), by striking the period at the end and 
        inserting ``; and''; and
            (3) by adding at the end the following:
            ``(xiii) such contract provides that the entity shall 
        report to the State such information, on such timely and 
        periodic basis as specified by the Secretary, as the State may 
        require in order to include, in the information submitted by 
        the State to a manufacturer under section 1927(b)(2)(A) and to 
        the Secretary under section 1927(b)(2)(C), information on 
        covered outpatient drugs dispensed to individuals eligible for 
        medical assistance who are enrolled with the entity and for 
        which the entity is responsible for coverage of such drugs 
        under this subsection.''.
    (b) Conforming Amendments.--Section 1927 of such Act (42 U.S.C. 
1396r-8) is amended----
            (1) in the first sentence of subsection (b)(1)(A), by 
        inserting before the period at the end the following: ``, 
        including such drugs dispensed to individuals enrolled with a 
        medicaid managed care organization if the organization is 
        responsible for coverage of such drugs'';
            (2) in subsection (b)(2), by adding at the end the 
        following new subparagraph:
                    ``(C) Reporting on mmco drugs.--On a quarterly 
                basis, each State shall report to the Secretary the 
                total amount of rebates in dollars received from 
                pharmacy manufacturers for drugs provided to 
                individuals enrolled with Medicaid managed care 
                organizations that contract under section 1903(m) and 
                such other information as the Secretary may require to 
                carry out paragraph (1)(C) with respect to such 
                rebates.''; and
            (3) in subsection (j)--
                    (A) in the heading by striking ``Exemption'' and 
                inserting ``Special Rules''; and
                    (B) in paragraph (1), by striking ``are not subject 
                to the requirements of this section'' and inserting 
                ``are subject to the requirements of this section 
                unless such drugs are subject to discounts under 
                section 340B of the Public Health Service Act''.
    (c) Effective Date.--The amendments made by this section take 
effect on January 1, 2010, and shall apply to drugs dispensed on or 
after such date, without regard to whether or not final regulations to 
carry out such amendments have been promulgated by such date.

SEC. 1744. PAYMENTS FOR GRADUATE MEDICAL EDUCATION.

    (a) In General.--Section 1905 of the Social Security Act (42 U.S.C. 
1396d), as amended by sections 1701(a)(3)(B), 1711(a), and 1713(a), is 
amended by adding at the end the following new subsection:
    ``(bb) Payment for Graduate Medical Education.--
            ``(1) In general.--The term `medical assistance' includes 
        payment for costs of graduate medical education consistent with 
        this subsection, whether provided in or outside of a hospital.
            ``(2) Submission of information.--For purposes of paragraph 
        (1) and section 1902(a)(13)(A)(v), payment for such costs is 
        not consistent with this subsection unless--
                    ``(A) the State submits to the Secretary, in a 
                timely manner and on an annual basis specified by the 
                Secretary, information on total payments for graduate 
                medical education and how such payments are being used 
                for graduate medical education, including--
                            ``(i) the institutions and programs 
                        eligible for receiving the funding;
                            ``(ii) the manner in which such payments 
                        are calculated;
                            ``(iii) the types and fields of education 
                        being supported;
                            ``(iv) the workforce or other goals to 
                        which the funding is being applied;
                            ``(v) State progress in meeting such goals; 
                        and
                            ``(vi) such other information as the 
                        Secretary determines will assist in carrying 
                        out paragraphs (3) and (4); and
                    ``(B) such expenditures are made consistent with 
                such goals and requirements as are established under 
                paragraph (4).
            ``(3) Review of information.--The Secretary shall make the 
        information submitted under paragraph (2) available to the 
        Advisory Committee on Health Workforce Evaluation and 
        Assessment (established under section 2261 of the Public Health 
        Service Act). The Secretary and the Advisory Committee shall 
        independently review the information submitted under paragraph 
        (2), taking into account State and local workforce needs.
            ``(4) Specification of goals and requirements.--The 
        Secretary shall specify by rule, initially published by not 
        later than December 31, 2011--
                    ``(A) program goals for the use of funds described 
                in paragraph (1), taking into account recommendations 
                of the such Advisory Committee and the goals for 
                approved medical residency training programs described 
                in section 1886(h)(1)(B); and
                    ``(B) requirements for use of such funds consistent 
                with such goals.
        Such rule may be effective on an interim basis pending revision 
        after an opportunity for public comment.''.
    (b) Conforming Amendment.--Section 1902(a)(13)(A) of such Act (42 
U.S.C. 1396a(a)(13)(A)), as amended by section 1721(a)(1)(A), is 
amended--
            (1) by striking ``and'' at the end of clause (iii);
            (2) by striking the semicolon in clause (iv) and inserting 
        ``, and''; and
            (3) by adding at the end the following new clause:
                            ``(v) in the case of hospitals and at the 
                        option of a State, such rates may include, to 
                        the extent consistent with section 1905(bb), 
                        payment for graduate medical education; and''.
    (c) Effective Date.--The amendments made by this section shall take 
effect on the date of the enactment of this Act. Nothing in this 
section shall be construed as affecting payments made before such date 
under a State plan under title XIX of the Social Security Act for 
graduate medical education.

SEC. 1745. NURSING FACILITY SUPPLEMENTAL PAYMENT PROGRAM.

    (a) Total Amount Available for Payments.--
            (1) In general.--Out of any funds in the Treasury not 
        otherwise appropriated, there are appropriated to the Secretary 
        of Health and Human Services (in this section referred to as 
        the ``Secretary'') to carry out this section $6,000,000,000, of 
        which the following amounts shall be available for obligation 
        in the following years:
                    (A) $1,500,000,000 shall be available beginning in 
                2010.
                    (B) $1,500,000,000 shall be available beginning in 
                2011.
                    (C) $1,500,000,000 shall be available beginning in 
                2012.
                    (D) $1,500,000,000 shall be available beginning in 
                2013.
            (2) Availability.--Funds appropriated under paragraph (1) 
        shall remain available until all eligible dually-certified 
        facilities (as defined in subsection (b)(3)) have been 
        reimbursed for underpayments under this section during cost 
        reporting periods ending during calendar years 2010 through 
        2013.
            (3) Limitation of authority.--The Secretary may not may 
        payments under this section that exceed the funds appropriated 
        under paragraph (1).
            (4) Disposition of remaining funds into mif.--Any funds 
        appropriated under paragraph (1) which remain available after 
        the application of paragraph (2) shall be deposited into the 
        Medicaid Improvement Fund under section 1941 of the Social 
        Security Act.
    (b) Use of Funds.--
            (1) Authority to make payments.--From the amounts available 
        for obligation in a year under subsection (a), the Secretary, 
        acting through the Administrator of the Centers for Medicare & 
        Medicaid Services, shall pay the amount determined under 
        paragraph (2) directly to an eligible dually-certified facility 
        for the purpose of providing funding to reimburse such facility 
        for furnishing quality care to Medicaid-eligible individuals.
            (2) Determination of payment amounts.--
                    (A) In general.--Subject to subparagraphs (B) and 
                (C), the payment amount determined under this paragraph 
                for a year for an eligible dually-certified facility 
                shall be an amount determined by the Secretary as 
                reported on the facility's latest available Medicare 
                cost report.
                    (B) Limitation on payment amount.--In no case shall 
                the payment amount for an eligible dually-certified 
                facility for a year under subparagraph (A) be more than 
                the payment deficit described in paragraph (3)(D) for 
                such facility as reported on the facility's latest 
                available Medicare cost report.
                    (C) Pro-rata reduction.--If the amount available 
                for obligation under subsection (a) for a year (as 
                reduced by allowable administrative costs under this 
                section) is insufficient to ensure that each eligible 
                dually-certified facility receives the amount of 
                payment calculated under subparagraph (A), the 
                Secretary shall reduce that amount of payment with 
                respect to each such facility in a pro-rata manner to 
                ensure that the entire amount available for such 
                payments for the year be paid.
                    (D) No required match.--The Secretary may not 
                require that a State provide matching funds for any 
                payment made under this subsection.
            (3) Eligible dually-certified facility defined.--For 
        purposes of this section, the term ``eligible dually-certified 
        facility'' means, for a cost reporting period ending during a 
        year (beginning no earlier than 2010) that is covered by the 
        latest available Medicare cost report, a nursing facility that 
        meets all of the following requirements:
                    (A) The facility is participating as a nursing 
                facility under title XIX of the Social Security Act and 
                as a skilled nursing facility under title XVIII of such 
                Act during the entire year.
                    (B) The base Medicaid payment rate (excluding any 
                supplemental payments) to the facility is not less than 
                the base Medicaid payment rate (excluding any 
                supplemental payments) to such facility as of June 16, 
                2009.
                    (C) As reported on the facility's latest Medicare 
                cost report--
                            (i) the Medicaid share of patient days for 
                        such facility is not less than 60 percent of 
                        the combined Medicare and Medicaid share of 
                        resident days for such facility; and
                            (ii) the combined Medicare and Medicaid 
                        share of resident days for such facility, as 
                        reported on the facility's latest available 
                        Medicare cost report, is not less than 75 
                        percent of the total resident days for such 
                        facility.
                    (D) The facility has received Medicaid 
                reimbursement (including any supplemental payments) for 
                the provision of covered services to Medicaid eligible 
                individuals, as reported on the facility's latest 
                available Medicare cost report, that is significantly 
                less (as determined by the Secretary) than the 
                allowable costs (as determined by the Secretary) 
                incurred by the facility in providing such services.
                    (E) The facility is not in the highest quartile of 
                costs costs per day, as determined by the Secretary and 
                as adjusted for case mix, wages, and type of facility.
                    (F) The facility provides quality care, as 
                determined by the Secretary, to--
                            (i) Medicaid eligible individuals; and
                            (ii) individuals who are entitled to items 
                        and services under part A of title XVIII of the 
                        Social Security Act.
                    (G) In the most recent standard survey available, 
                the facility was not cited for any immediate jeopardy 
                deficiencies as defined by the Secretary.
                    (H) In the most recent standard survey available, 
                the facility maintains an appropriate staffing level to 
                attain or maintain the highest practicable well-being 
                of each resident as defined by the Secretary
                    (I) The facility complies with all the 
                requirements, as determined by the Secretary, contained 
                in sections 1411 through 1416 and the amendments made 
                by such sections.
                    (J) The facility was not listed as a Centers for 
                Medicare & Medicaid Services Special Focus Facility 
                (SFF) nor as a SFF on a State-based list.
            (4) Frequency of payment.--Payment of an amount under this 
        subsection to an eligible dually-certified facility shall be 
        made for a year in a lump sum or in such periodic payments in 
        such frequency as the Secretary determines appropriate.
            (5) Direct payments.--Such payment--
                    (A) shall be made directly by the Secretary to an 
                eligible dually-certified facility or a contractor 
                designated by such facility; and
                    (B) shall not be made through a State.
    (c) Administration.--
            (1) Annual applications; deadlines.--The Secretary shall 
        establish a process, including deadlines, under which 
        facilities may apply on an annual basis to qualify as eligible 
        dually-certified facilities for payment under subsection (b).
            (2) Contracting authority.--The Secretary may enter into 
        one or more contracts with entities for the purpose of 
        implementation of this section.
            (3) Limitation.--The Secretary may not spend more than 0.75 
        percent of the amount made available under subsection (a) in 
        any year on the costs of administering the program of payments 
        under this section for the year.
            (4) Implementation.--Notwithstanding any other provision of 
        law, the Secretary may implement, by program instruction or 
        otherwise, the provisions of this section.
            (5) Limitations on review.--There shall be no 
        administrative or judicial review of--
                    (A) the determination of the eligibility of a 
                facility for payments under subsection (b); or
                    (B) the determination of the amount of any payment 
                made to a facility under such subsection.
    (d) Annual Reports.--The Secretary shall submit an annual report to 
the committees with jurisdiction in the Congress on payments made under 
subsection (b). Each such report shall include information on--
            (1) the facilities receiving such payments;
            (2) the amount of such payments to such facilities; and
            (3) the basis for selecting such facilities and the amount 
        of such payments.
    (e) Reference to Report.--For report by the Medicaid and CHIP 
Payment and Access Commission on the adequacy of payments to nursing 
facilities under the Medicaid program, see section 1900(b)(2)(B) of the 
Social Security Act, as amended by section 1784.
    (f) Definitions.--For purposes of this section:
            (1) Dually-certified facility.--The term ``dually-certified 
        facility'' means a facility that is participating as a nursing 
        facility under title XIX of the Social Security Act and as a 
        skilled nursing facility under title XVIII of such Act.
            (2) Medicaid eligible individual.--The term ``Medicaid 
        eligible individual'' means an individual who is eligible for 
        medical assistance, with respect to nursing facility services 
        (as defined in section 1905(f) of the Social Security Act), 
        under title XIX of the such Act.
            (3) State.--The term ``State'' means the 50 States and the 
        District of Columbia.

SEC. 1746. REPORT ON MEDICAID PAYMENTS.

    Section 1902 of the Social Security Act (42 U.S.C. 1396), as 
amended by sections 1703(a), 1714(a), and 1731(a), is amended by adding 
at the end the following new subsection:
    ``(jj) Report on Medicaid Payments.--Each year, on or before a date 
determined by the Secretary, a State participating in the Medicaid 
program under this title shall submit to the Administrator of the 
Centers for Medicare & Medicaid Services--
            ``(1) information on the determination of rates of payment 
        to providers for covered services under the State plan, 
        including--
                    ``(A) the final rates;
                    ``(B) the methodologies used to determine such 
                rates; and
                    ``(C) justifications for the rates; and
            ``(2) an explanation of the process used by the State to 
        allow providers, beneficiaries and their representatives, and 
        other concerned State residents a reasonable opportunity to 
        review and comment on such rates, methodologies, and 
        justifications before the State made such rates final.''.

SEC. 1747. REVIEWS OF MEDICAID.

    (a) GAO Study on FMAP.--.
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study regarding federal payments made to the 
        State Medicaid programs under title XIX of the Social Security 
        Act for the purposes of making recommendations to Congress.
            (2) Report.--Not later than February 15, 2011, the 
        Comptroller General shall submit to the appropriate committees 
        of Congress a report on the study conducted under paragraph (1) 
        and the effect on the federal government, States, providers, 
        and beneficiaries of--
                    (A) removing the 50 percent floor, or 83 percent 
                ceiling, or both, in the Federal medical assistance 
                percentage under section 1905(b)(1) of the Social 
                Security Act; and
                    (B) revising the current formula for such Federal 
                medical assistance percentage to better reflect State 
                fiscal capacity and State effort to pay for health and 
                long-term care services and to better adjust for 
                national or regional economic downturns.
    (b) GAO Study on Medicaid Administrative Costs..--
            (1) Study.--The Comptroller General of the United States 
        shall conduct a study of the administration of the Medicaid 
        program by the Department of Health and Human Services, State 
        Medicaid agencies, and local government agencies. The report 
        shall address the following issues:
                    (A) The extent to which federal funds for each 
                administrative function, such as survey and 
                certification and claims processing, are being used 
                effectively and efficiently.
                    (B) The administrative functions on which federal 
                Medicaid funds are expended and the amounts of such 
                expenditures (whether spent directly or by contract).
            (2) Report.--Not later than February 15, 2011, the 
        Comptroller General shall submit to the appropriate committees 
        of Congress a report on the study conducted under paragraph 
        (1).

SEC. 1748. EXTENSION OF DELAY IN MANAGED CARE ORGANIZATION PROVIDER TAX 
              ELIMINATION.

    Effective as if included in the enactment of section 6051 of the 
Deficit Reduction Act of 2005 (Public Law 109-171), subsection 
(b)(2)(A) of such section is amended by striking ``October 1, 2009'' 
and inserting ``October 1, 2010''.

SEC. 1749. EXTENSION OF ARRA INCREASE IN FMAP.

    Section 5001 of the American Recovery and Reinvestment Act of 2009 
(Public Law 111-5) is amended--
            (1) in subsection (a)(3), by striking ``first calendar 
        quarter'' and inserting ``first 3 calendar quarters'';
            (2) in subsection (b)(2), by inserting before the period at 
        the end the following: ``and such paragraph shall not apply to 
        calendar quarters beginning on or after October 1, 2010'';
            (3) in subsection (c)(4)(C)(ii), by striking ``December 
        2009'' and ``January 2010'' and inserting ``June 2010'' and 
        ``July 2010'', respectively;
            (4) in subsection (d), by inserting ``ending before October 
        1, 2010'' after ``entire fiscal years'' and after ``with 
        respect to fiscal years'';
            (5) in subsection (g)(1), by striking ``September 30, 
        2011'' and inserting ``December 31, 2011''; and
            (6) in subsection (h)(3), by striking ``December 31, 2010'' 
        and inserting ``June 30, 2011''.

                  Subtitle F--Waste, Fraud, and Abuse

SEC. 1751. HEALTH CARE ACQUIRED CONDITIONS.

    (a) Medicaid Non-payment for Certain Health Care-acquired 
Conditions.--Section 1903(i) of the Social Security Act (42 U.S.C. 
1396b(i)) is amended--
            (1) by striking ``or'' at the end of paragraph (23);
            (2) by striking the period at the end of paragraph (24) and 
        inserting ``; or''; and
            (3) by inserting after paragraph (24) the following new 
        paragraph:
            ``(25) with respect to amounts expended for services 
        related to the presence of a condition that could be identified 
        by a secondary diagnostic code described in section 
        1886(d)(4)(D)(iv) and for any health care acquired condition 
        determined as a non-covered service under title XVIII.''.
    (b) Application to CHIP.--Section 2107(e)(1)(G) of such Act (42 
U.S.C. 1397gg(e)(1)(G)) is amended by striking ``and (17)'' and 
inserting ``(17), and (25)''.
    (c) Permission to Include Additional Health Care-acquired 
Conditions.--Nothing in this section shall prevent a State from 
including additional health care-acquired conditions for non-payment in 
its Medicaid program under title XIX of the Social Security Act.
    (d) Effective Date.--The amendments made by this section shall 
apply to discharges occurring on or after January 1, 2010.

SEC. 1752. EVALUATIONS AND REPORTS REQUIRED UNDER MEDICAID INTEGRITY 
              PROGRAM.

    Section 1936(c)(2)) of the Social Security Act (42 U.S.C. 1396u-
7(c)(2)) is amended--
            (1) by redesignating subparagraph (D) as subparagraph (E); 
        and
            (2) by inserting after subparagraph (C) the following new 
        subparagraph:
                    ``(D) For the contract year beginning in 2011 and 
                each subsequent contract year, the entity provides 
                assurances to the satisfaction of the Secretary that 
                the entity will conduct periodic evaluations of the 
                effectiveness of the activities carried out by such 
                entity under the Program and will submit to the 
                Secretary an annual report on such activities.''.

SEC. 1753. REQUIRE PROVIDERS AND SUPPLIERS TO ADOPT PROGRAMS TO REDUCE 
              WASTE, FRAUD, AND ABUSE.

    Section 1902(a) of such Act (42 U.S.C. 42 U.S.C. 1396a(a)), as 
amended by sections 1631(b)(1), 1703, and 1729, is further amended--
            (1) in paragraph (75), by striking at the end ``and'';
            (2) in paragraph (76), by striking at the end the period 
        and inserting ``; and''; and
            (3) by inserting after paragraph (76) the following new 
        paragraph:
            ``(77) provide that any provider or supplier (other than a 
        physician or nursing facility) providing services under such 
        plan shall, subject to paragraph (5) of section 1874(d), 
        establish a compliance program described in paragraph (1) of 
        such section in accordance with such section.''.

SEC. 1754. OVERPAYMENTS.

    (a) In General.--Section 1903(d)(2)(C) of the Social Security Act 
(42 U.S.C. 1396b(d)(2)(C)) is amended--
            (1) in the first sentence, by inserting ``(or of 1 year in 
        the case of overpayments due to fraud)'' after ``60 days''; and
            (2) in the second sentence, by striking ``the 60 days'' and 
        inserting ``such period''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply in the case of overpayments discovered on or after the date of 
the enactment of this Act.

SEC. 1755. MANAGED CARE ORGANIZATIONS.

    (a) Minimum Medical Loss Ratio.--
            (1) Medicaid.--Section 1903(m)(2)(A) of the Social Security 
        Act (42 U.S.C. 1396b(m)(2)(A)), as amended by section 
        1743(a)(3), is amended--
                    (A) by striking ``and'' at the end of clause (xii);
                    (B) by striking the period at the end of clause 
                (xiii) and inserting ``; and''; and
                    (C) by adding at the end the following new clause:
            ``(xiv) such contract has a medical loss ratio, as 
        determined in accordance with a methodology specified by the 
        Secretary that is a percentage (not less than 85 percent) as 
        specified by the Secretary.''.
            (2) CHIP.--Section 2107(e)(1) of such Act (42 U.S.C. 
        1397gg(e)(1)) is amended--
                    (A) by redesignating subparagraphs (H) through (L) 
                as subparagraphs (I) through (M); and
                    (B) by inserting after subparagraph (G) the 
                following new subparagraph:
                    ``(H) Section 1903(m)(2)(A)(xiv) (relating to 
                application of minimum loss ratios), with respect to 
                comparable contracts under this title.''.
            (3) Effective date.--The amendments made by this subsection 
        shall apply to contracts entered into or renewed on or after 
        July 1, 2010.
    (b) Patient Encounter Data.--
            (1) In general.--Section 1903(m)(2)(A)(xi) of the Social 
        Security Act (42 U.S.C. 1396b(m)(2)(A)(xi)) is amended by 
        inserting ``and for the provision of such data to the State at 
        a frequency and level of detail to be specified by the 
        Secretary'' after ``patients''.
            (2) Effective date.--The amendment made by paragraph (1) 
        shall apply with respect to contract years beginning on or 
        after January 1, 2010.

SEC. 1756. TERMINATION OF PROVIDER PARTICIPATION UNDER MEDICAID AND 
              CHIP IF TERMINATED UNDER MEDICARE OR OTHER STATE PLAN OR 
              CHILD HEALTH PLAN.

    (a) State Plan Requirement.--Section 1902(a)(39) of the Social 
Security Act (42 U.S.C. 42 U.S.C. 1396a(a)) is amended by inserting 
after ``1128A,'' the following: ``terminate the participation of any 
individual or entity in such program if (subject to such exceptions are 
permitted with respect to exclusion under sections 1128(b)(3)(C) and 
1128(d)(3)(B)) participation of such individual or entity is terminated 
under title XVIII, any other State plan under this title, or any child 
health plan under title XXI,''.
    (b) Application to CHIP.--Section 2107(e)(1)(A) of such Act (42 
U.S.C. 1397gg(e)(1)(A)) is amended by inserting before the period at 
the end the following: ``and section 1902(a)(39) (relating to exclusion 
and termination of participation)''.
    (c) Effective Date.--Except as provided in section 1790, the 
amendments made by this section shall apply to services furnished on or 
after January 1, 2011, without regard to whether or not final 
regulations to carry out such amendments have been promulgated by such 
date.

SEC. 1757. MEDICAID AND CHIP EXCLUSION FROM PARTICIPATION RELATING TO 
              CERTAIN OWNERSHIP, CONTROL, AND MANAGEMENT AFFILIATIONS.

    (a) State Plan Requirement.--Section 1902(a) of the Social Security 
Act (42 U.S.C. 1396a(a)), as amended by sections 1631(b)(1), 1703(a), 
1729, and 1753, is further amended--
            (1) in paragraph (76), by striking at the end ``and'';
            (2) in paragraph (77), by striking at the end the period 
        and inserting ``; and''; and
            (3) by inserting after paragraph (77) the following new 
        paragraph:
            ``(78) provide that the State agency described in paragraph 
        (9) exclude, with respect to a period, any individual or entity 
        from participation in the program under the State plan if such 
        individual or entity owns, controls, or manages an entity that 
        (or if such entity is owned, controlled, or managed by an 
        individual or entity that)--
                    ``(A) has unpaid overpayments under this title 
                during such period determined by the Secretary or the 
                State agency to be delinquent;
                    ``(B) is suspended or excluded from participation 
                under or whose participation is terminated under this 
                title during such period; or
                    ``(C) is affiliated with an individual or entity 
                that has been suspended or excluded from participation 
                under this title or whose participation is terminated 
                under this title during such period.''.
    (b) Child Health Plan Requirement.--Section 2107(e)(1)(A) of such 
Act (42 U.S.C. 1397gg(e)(1)(A)), as amended by section 1756(b), is 
amended by striking ``section 1902(a)(39)'' and inserting ``sections 
1902(a)(39) and 1902(a)(78)''.
    (c) Effective Date.--Except as provided in section 1790, the 
amendments made by this section shall apply to services furnished on or 
after January 1, 2011, without regard to whether or not final 
regulations to carry out such amendments have been promulgated by such 
date.

SEC. 1758. REQUIREMENT TO REPORT EXPANDED SET OF DATA ELEMENTS UNDER 
              MMIS TO DETECT FRAUD AND ABUSE.

    Section 1903(r)(1)(F) of the Social Security Act (42 U.S.C. 
1396b(r)(1)(F)) is amended by inserting after ``necessary'' the 
following: ``and including, for data submitted to the Secretary on or 
after July 1, 2010, data elements from the automated data system that 
the Secretary determines to be necessary for detection of waste, fraud, 
and abuse''.

SEC. 1759. BILLING AGENTS, CLEARINGHOUSES, OR OTHER ALTERNATE PAYEES 
              REQUIRED TO REGISTER UNDER MEDICAID.

    (a) In General.--Section 1902(a) of the Social Security Act (42 
U.S.C. 42 U.S.C. 1396a(a)), as amended by sections 1631(b), 1703(a), 
1729, 1753, and 1757(a), is further amended--
            (1) in paragraph (77); by striking at the end ``and'';
            (2) in paragraph (78), by striking the period at the end 
        and inserting ``and''; and
            (3) by inserting after paragraph (78) the following new 
        paragraph:
            ``(79) provide that any agent, clearinghouse, or other 
        alternate payee that submits claims on behalf of a health care 
        provider must register with the State and the Secretary in a 
        form and manner specified by the Secretary under section 
        1866(j)(1)(D).''.
    (b) Denial of Payment.--Section 1903(i) of such Act (42 U.S.C. 
1396b(i)), as amended by section 1751, is amended--
            (1) by striking ``or'' at the end of paragraph (24);
            (2) by striking the period at the end of paragraph (25) and 
        inserting ``; or''; and
            (3) by inserting after paragraph (25) the following new 
        paragraph:
            ``(26) with respect to any amount paid to a billing agent, 
        clearinghouse, or other alternate payee that is not registered 
        with the State and the Secretary as required under section 
        1902(a)(79).''.
    (c) Effective Date.--Except as provided in section 1790, the 
amendments made by this section shall apply to claims submitted on or 
after January 1, 2012, without regard to whether or not final 
regulations to carry out such amendments have been promulgated by such 
date.

SEC. 1760. DENIAL OF PAYMENTS FOR LITIGATION-RELATED MISCONDUCT.

    (a) In General.--Section 1903(i) of the Social Security Act (42 
U.S.C. 1396b(i)), as amended by sections 1751(a) and 1759(b), is 
amended--
            (1) by striking ``or'' at the end of paragraph (25);
            (2) by striking the period at the end of paragraph (26) and 
        inserting ``; or''; and
            (3) by inserting after paragraph (26) the following new 
        paragraph:
            ``(27) with respect to any amount expended--
                    ``(A) on litigation in which a court imposes 
                sanctions on the State, its employees, or its counsel 
                for litigation-related misconduct; or
                    ``(B) to reimburse (or otherwise compensate) a 
                managed care entity for payment of legal expenses 
                associated with any action in which a court imposes 
                sanctions on the managed care entity for litigation-
                related misconduct.''.
    (b) Effective Date.--The amendments made by subsection (a) shall 
apply to amounts expended on or after January 1, 2010.

SEC. 1761. MANDATORY STATE USE OF NATIONAL CORRECT CODING INITIATIVE.

    Section 1903(r) of the Social Security Act (42 U.S.C. 1396b(r)) is 
amended--
            (1) in paragraph (1)(B)--
                    (A) in clause (ii), by striking ``and'' at the end;
                    (B) in clause (iii), by adding ``and'' at the end; 
                and
                    (C) by adding at the end the following new clause:
                            ``(iv) effective for claims filed on or 
                        after October 1, 2010, incorporate compatible 
                        methodologies of the National Correct Coding 
                        Initiative administered by the Secretary (or 
                        any successor initiative to promote correct 
                        coding and to control improper coding leading 
                        to inappropriate payment) and such other 
                        methodologies of that Initiative (or such other 
                        national correct coding methodologies) as the 
                        Secretary identifies in accordance with 
                        paragraph (4);''; and
            (2) by adding at the end the following new paragraph:
    ``(4) Not later than September 1, 2010, the Secretary shall do the 
following:
            ``(A) Identify those methodologies of the National Correct 
        Coding Initiative administered by the Secretary (or any 
        successor initiative to promote correct coding and to control 
        improper coding leading to inappropriate payment) which are 
        compatible to claims filed under this title.
            ``(B) Identify those methodologies of such Initiative (or 
        such other national correct coding methodologies) that should 
        be incorporated into claims filed under this title with respect 
        to items or services for which States provide medical 
        assistance under this title and no national correct coding 
        methodologies have been established under such Initiative with 
        respect to title XVIII.
            ``(C) Notify States of--
                    ``(i) the methodologies identified under 
                subparagraphs (A) and (B) (and of any other national 
                correct coding methodologies identified under 
                subparagraph (B)); and
                    ``(ii) how States are to incorporate such 
                methodologies into claims filed under this title.
            ``(D) Submit a report to Congress that includes the notice 
        to States under subparagraph (C) and an analysis supporting the 
        identification of the methodologies made under subparagraphs 
        (A) and (B).''.

                Subtitle G--Payments to the Territories

SEC. 1771. PAYMENT TO TERRITORIES.

    (a) Increase in Cap.--Section 1108 of the Social Security Act (42 
U.S.C. 1308) is amended--
            (1) in subsection (f), by striking ``subsection (g)'' and 
        inserting ``subsections (g) and (h)'';
            (2) in subsection (g)(1), by striking ``With respect to'' 
        and inserting ``Subject to subsection (h), with respect to''; 
        and
            (3) by adding at the end the following new subsection:
    ``(h) Additional Increase for Fiscal Years 2011 Through 2019.--
Subject to section 347(b)(1) of the Affordable Health Care for America 
Act, with respect to fiscal years 2011 through 2019, the amounts 
otherwise determined under subsections (f) and (g) for Puerto Rico, the 
Virgin Islands, Guam, the Northern Mariana Islands and American Samoa 
shall be increased by the following amounts:
            ``(1) For Puerto Rico, for fiscal year 2011, $727,600,000; 
        for fiscal year 2012, $775,000,000; for fiscal year 2013, 
        $850,000,000; for fiscal year 2014, $925,000,000; for fiscal 
        year 2015, $1,000,000,000; for fiscal year 2016, 
        $1,075,000,000; for fiscal year 2017, $1,150,000,000; for 
        fiscal year 2018, $1,225,000,000; and for fiscal year 2019, 
        $1,396,400,000.
            ``(2) For the Virgin Islands, for fiscal year 2011, 
        $34,000,000; for fiscal year 2012, $37,000,000; for fiscal year 
        2013, $40,000,000; for fiscal year 2014, $43,000,000; for 
        fiscal year 2015, $46,000,000; for fiscal year 2016, 
        $49,000,000; for fiscal year 2017, $52,000,000; for fiscal year 
        2018, $55,000,000; and for fiscal year 2019, $58,000,000.
            ``(3) For Guam, for fiscal year 2011, $34,000,000; for 
        fiscal year 2012, $37,000,000; for fiscal year 2013, 
        $40,000,000; for fiscal year 2014, $43,000,000; for fiscal year 
        2015, $46,000,000; for fiscal year 2016, $49,000,000; for 
        fiscal year 2017, $52,000,000; for fiscal year 2018, 
        $55,000,000; and for fiscal year 2019, $58,000,000.
            ``(4) For the Northern Mariana Islands, for fiscal year 
        2011, $13,500,000; fiscal year 2012, $14,500,000; for fiscal 
        year 2013, $15,500,000; for fiscal year 2014, $16,500,000; for 
        fiscal year 2015, $17,500,000; for fiscal year 2016, 
        $18,500,000; for fiscal year 2017, $19,500,000; for fiscal year 
        2018, $21,000,000; and for fiscal year 2019, $22,000,000.
            ``(5) For American Samoa, fiscal year 2011, $22,000,000; 
        fiscal year 2012, $23,687,500; for fiscal year 2013, 
        $24,687,500; for fiscal year 2014, $25,687,500; for fiscal year 
        2015, $26,687,500; for fiscal year 2016, $27,687,500; for 
        fiscal year 2017, $28,687,500; for fiscal year 2018, 
        $29,687,500; and for fiscal year 2019, $30,687,500.''.
    (b) Report on Achieving Medicaid Parity Payments Beginning With 
Fiscal Year 2020.--
            (1) In general.--Not later than October 1, 2013, the 
        Secretary of Health and Human Services shall submit to Congress 
        a report that details a plan for the transition of each 
        territory to full parity in Medicaid with the 50 States and the 
        District of Columbia in fiscal year 2020 by modifying their 
        existing Medicaid programs and outlining actions the Secretary 
        and the governments of each territory must take by fiscal year 
        2020 to ensure parity in financing. Such report shall include 
        what the Federal medical assistance percentages would be for 
        each territory if the formula applicable to the 50 States were 
        applied. Such report shall also include any recommendations 
        that the Secretary may have as to whether the mandatory ceiling 
        amounts for each territory provided for in section 1108 of the 
        Social Security Act (42 U.S.C. 1308) should be increased any 
        time before fiscal year 2020 due to any factors that the 
        Secretary deems relevant.
            (2) Per capita data.--As part of such report the Secretary 
        shall include information about per capita income data that 
        could be used to calculate Federal medical assistance 
        percentages under section 1905(b) of the Social Security Act, 
        under section 1108(a)(8)(B) of such Act, for each territory on 
        how such data differ from the per capita income data used to 
        promulgate Federal medical assistance percentages for the 50 
        States. The report under this subsection shall include 
        recommendations on how the Federal medical assistance 
        percentages can be calculated for the territories beginning in 
        fiscal year 2020 to ensure parity with the 50 States.
            (3) Subsequent reports.--The Secretary shall submit 
        subsequent reports to Congress in 2015, 2017, and 2019 
        detailing the progress that the Secretary and the governments 
        of each territory have made in fulfilling the actions outlined 
        in the plan submitted under paragraph (1).
    (c) Application of FMAP for Additional Funds.--Section 1905(b) of 
such Act (42 U.S.C. 1396d(b)) is amended by adding at the end the 
following sentence: ``Notwithstanding the first sentence of this 
subsection and any other provision of law, for fiscal years 2011 
through 2019, the Federal medical assistance percentage for Puerto 
Rico, the Virgin Islands, Guam, the Northern Mariana Islands, and 
American Samoa shall be the highest Federal medical assistance 
percentage applicable to any of the 50 States or the District of 
Columbia for the fiscal year involved, taking into account the 
application of subsections (a) and (b)(1) of section 5001 of division B 
of the American Recovery and Reinvestment Act of 2009 (Public Law 111-
5) to such States and the District for calendar quarters during such 
fiscal years for which such subsections apply.''.
    (d) Waivers.--
            (1) In general.--Section 1902(j) of the Social Security Act 
        (42 U.S.C. 1396a(j)) is amended--
                    (A) by striking ``American Samoa and the Northern 
                Mariana Islands'' and inserting ``Puerto Rico, the 
                Virgin Islands, Guam, the Northern Mariana Islands, and 
                American Samoa''; and
                    (B) by striking ``American Samoa or the Northern 
                Mariana Islands'' and inserting ``Puerto Rico, the 
                Virgin Islands, Guam, the Northern Mariana Islands, or 
                American Samoa''.
            (2) Effective date.--The amendments made by paragraph (1) 
        shall apply beginning with fiscal year 2011.
    (e) Technical Assistance.--The Secretary shall provide nonmonetary 
technical assistance to the governments of Puerto Rico, the Virgin 
Islands, Guam, the Northern Mariana Islands, and American Samoa in 
upgrading their existing computer systems in order to anticipate 
meeting reporting requirements necessary to implement the plan 
contained in the report under subsection (b)(1).

                       Subtitle H--Miscellaneous

SEC. 1781. TECHNICAL CORRECTIONS.

    (a) Technical Correction to Section 1144 of the Social Security 
Act.--The first sentence of section 1144(c)(3) of the Social Security 
Act (42 U.S.C. 1320b--14(c)(3)) is amended--
            (1) by striking ``transmittal''; and
            (2) by inserting before the period the following: ``as 
        specified in section 1935(a)(4)''.
    (b) Clarifying Amendment to Section 1935 of the Social Security 
Act.--Section 1935(a)(4) of the Social Security Act (42 U.S.C. 1396u--
5(a)(4)), as amended by section 113(b) of Public Law 110-275, is 
amended--
            (1) by striking the second sentence;
            (2) by redesignating the first sentence as a subparagraph 
        (A) with appropriate indentation and with the following 
        heading: ``In general.--'';
            (3) by adding at the end the following subparagraphs:
                    ``(B) Furnishing medical assistance with reasonable 
                promptness.--For the purpose of a State's obligation 
                under section 1902(a)(8) to furnish medical assistance 
                with reasonable promptness, the date of the electronic 
                transmission of low-income subsidy program data, as 
                described in section 1144(c), from the Commissioner of 
                Social Security to the State Medicaid Agency, shall 
                constitute the date of filing of such application for 
                benefits under the Medicare Savings Program.
                    ``(C) Determining availability of medical 
                assistance.--For the purpose of determining when 
                medical assistance will be made available, the State 
                shall consider the date of the individual's application 
                for the low income subsidy program to constitute the 
                date of filing for benefits under the Medicare Savings 
                Program.''.
    (c) Effective Date Relating to Medicaid Agency Consideration of 
Low-income Subsidy Application and Data Transmittal.--The amendments 
made by subsections (a) and (b) shall be effective as if included in 
the enactment of section 113(b) of Public Law 110-275.
    (d) Technical Correction to Section 605 of CHIPRA.--Section 605 of 
the Children's Health Insurance Program Reauthorization Act of 2009 
(Public Law 111-3) is amended by striking ``legal residents'' and 
inserting ``lawfully residing in the United States''.
    (e) Technical Correction to Section 1905 of the Social Security 
Act.--Section 1905(a) of the Social Security Act (42 U.S.C. 1396d(a)) 
is amended by inserting ``or the care and services themselves, or 
both'' before ``(if provided in or after''.
    (f) Clarifying Amendment to Section 1115 of the Social Security 
Act.--Section 1115(a) of the Social Security Act (42 U.S.C. 1315(a)) is 
amended by adding at the end the following: ``If an experimental, 
pilot, or demonstration project that relates to title XIX is approved 
pursuant to any part of this subsection, such project shall be treated 
as part of the State plan, all medical assistance provided on behalf of 
any individuals affected by such project shall be medical assistance 
provided under the State plan, and all provisions of this Act not 
explicitly waived in approving such project shall remain fully 
applicable to all individuals receiving benefits under the State 
plan.''.

SEC. 1782. EXTENSION OF QI PROGRAM.

    (a) In General.--Section 1902(a)(10)(E)(iv) of the Social Security 
Act (42 U.S.C. 1396b(a)(10)(E)(iv)) is amended--
            (1) by striking ``sections 1933 and'' and by inserting 
        ``section''; and
            (2) by striking ``December 2010'' and inserting ``December 
        2012''.
    (b) Elimination of Funding Limitation.--
            (1) In general.--Section 1933 of such Act (42 U.S.C. 1396u-
        3) is amended--
                    (A) in subsection (a), by striking ``who are 
                selected to receive such assistance under subsection 
                (b)'';
                    (B) by striking subsections (b), (c), (e), and (g);
                    (C) in subsection (d), by striking ``furnished in a 
                State'' and all that follows and inserting ``the 
                Federal medical assistance percentage shall be equal to 
                100 percent.''; and
                    (D) by redesignating subsections (d) and (f) as 
                subsections (b) and (c), respectively.
            (2) Conforming amendment.--Section 1905(b) of such Act (42 
        U.S.C. 1396d(b)) is amended by striking ``1933(d)'' and 
        inserting ``1933(b)''.
            (3) Effective date.--The amendments made by paragraph (1) 
        shall take effect on January 1, 2011.

SEC. 1783. ASSURING TRANSPARENCY OF INFORMATION.

    (a) In General.--Section 1902(a) of the Social Security Act (42 
U.S.C. 1396a(a)), as amended by sections 1631(b), 1703(a), 1729, 1753, 
1757(a), 1759(a), and 1907(b), is amended--
            (1) by striking ``and'' at the end of paragraph (79);
            (2) by striking the period at the end of paragraph (80) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (80) the following new 
        paragraph:
            ``(81) provide that the State will establish and maintain 
        laws, in accordance with the requirements of section 1921A, to 
        require disclosure of information on hospital charges and 
        quality and to make such information available to the public 
        and the Secretary.''; and
            (4) by inserting after section 1921 the following new 
        section:

                     ``hospital price transparency

    ``Sec. 1921A.  (a) In General.--The requirements referred to in 
section 1902(a)(81) are that the laws of a State must--
            ``(1) require reporting to the State (or its agent) by each 
        hospital located therein, of information on,--
                    ``(A) the charges for the most common inpatient and 
                outpatient hospital services;
                    ``(B) the Medicare and Medicaid reimbursement 
                amount for such services; and
                    ``(C) if the hospitals allows for or provides 
                reduced charges for individuals based on financial 
                need, the factors considered in making determinations 
                for reductions in charges, including any formula for 
                such determination and the contact information for the 
                specific department of a hospital that responds to such 
                inquiries;
            ``(2) provide for notice to individuals seeking or 
        requiring such services of the availability of information on 
        charges described in paragraph (1);
            ``(3) provide for timely access to such information, 
        including at least through an Internet website, by individuals 
        seeking or requiring such services; and
            ``(4) provide for timely access to information regarding 
        the quality of care at each hospital made publicly available in 
        accordance with section 501 of the Medicare Prescription Drug, 
        Improvement, and Modernization Act of 2003 (Public Law 108-
        173), section 1139A, or section 1139B.
The Secretary shall consult with stakeholders (including those entities 
in section 1808(d)(6) and the National Governors Association) through a 
formal process to obtain guidance prior to issuing implementing 
policies under this section.
    ``(b) Hospital Defined.--For purposes of this section, the term 
`hospital' means an institution that meets the requirements of 
paragraphs (1) and (7) of section 1861(e) and includes those to which 
section 1820(c) applies.''.
    (b) Effective Date; Administration.--
            (1) In general.--Except as provided in paragraphs (2)(B) 
        and section 1790, the amendments made by subsection (a) shall 
        take effect on October 1, 2010.
            (2) Existing programs.--
                    (A) In general.--The Secretary of Health and Human 
                Services shall establish a process by which a State 
                with an existing program may certify to the Secretary 
                that its program satisfies the requirements of section 
                1921A of the Social Security Act, as inserted by 
                subsection (a).
                    (B) 2-year period to become in compliance.--States 
                that, as of the date of the enactment of this Act, 
                administer hospital price transparency policies that do 
                not meet such requirements shall have 2 years from such 
                date to make necessary modifications to come into 
                compliance and shall not be regarded as failing to 
                comply with such requirements during such 2-year 
                period.

SEC. 1784. MEDICAID AND CHIP PAYMENT AND ACCESS COMMISSION.

    (a) Report on Nursing Facility Payment Policies.--Section 1900(b) 
of the Social Security Act (42 U.S.C. 1396(b)) is amended by adding at 
the end the following new paragraph:
            ``(10) Reports on special topics on payment policies.--
                    ``(A) Nursing facility payment policies.--Not later 
                than January 1, 2012, the Commission shall submit to 
                Congress a report on nursing facility payment policies 
                under Medicaid that includes--
                            ``(i) information on the difference between 
                        the amount paid by each State to nursing 
                        facilities in such State under the Medicaid 
                        program under this title and the cost to such 
                        facilities of providing efficient quality care 
                        to Medicaid eligible individuals;
                            ``(ii) an evaluation of patient outcomes 
                        and quality as a result of the supplemental 
                        payments under section 1745(b) of the 
                        Affordable Health Care for America Act; and
                            ``(iii) whether adjustments should be made 
                        under the Medicaid program to the rates that 
                        States pay skilled nursing facilities to ensure 
                        that such rates are sufficient to provide 
                        efficient quality care to Medicaid eligible 
                        individuals.''.
    (b) Pediatric Subspecialist Payment Policies.--Section 1900(b)(10) 
of the Social Security Act, as added by subsection (a) is amended by 
adding at the end the following new subparagraph:
                    ``(B) Pediatric subspecialist payment policies.--
                Not later than January 1, 2011, the Commission shall 
                submit to Congress a report on payment policies for 
                pediatric subspecialist services under Medicaid that 
                includes--
                            ``(i) a comprehensive review of each 
                        State's Medicaid payment rates for inpatient 
                        and outpatient pediatric speciality services;
                            ``(ii) a comparison, on a State-by-State 
                        basis, of the rates under clause (i) to 
                        Medicare payments for similar services;
                            ``(iii) information on any limitations in 
                        patient access to pediatric speciality care, 
                        such as delays in receiving care or wait times 
                        for receiving care;
                            ``(iv) an analysis of the extent to which 
                        low Medicaid payment rates in any State 
                        contributes to limits in access to pediatric 
                        subspecialty services in such State; and
                            ``(v) recommendations to ameliorate any 
                        problems found with such payment rates or with 
                        access to such services.''.
    (c) Additional Amendments.--
            (1) Commission status.--Section 1900(a) of the Social 
        Security Act is amended by inserting ``as an agency of 
        Congress'' after ``established''.
            (2) Expansion of scope.--Section 1900(b)(1)(A) of the 
        Social Security Act is amended by striking ``children's 
        access'' and inserting ``access by low-income children and 
        other eligible individuals''.
            (3) Change in report deadlines.--Subparagraphs (C) and (D) 
        of section 1900(b)(1) of such Act are amended by striking 
        ``2010'' and inserting ``2011'' each place it appears.
            (4) Report in health reform.--Section 1900(b)(2) of such 
        Act is amended--
                    (A) in subparagraph (A)(i), by striking 
                ``skilled'';
                    (B) by striking subparagraph (B);
                    (C) by redesignating subparagraph (C) as 
                subparagraph (B); and
                    (D) by adding at the end the following new 
                subparagraph:
                    ``(C) Implementation of health reform.--The 
                implementation of the provisions of the Affordable 
                Health Care for America Act that relate to Medicaid or 
                CHIP by the Secretary, the Health Choices Commissioner, 
                and the States, including the effect of such 
                implementation on the access to needed health care 
                items and services by low-income individuals and 
                families.''.
            (5) Clarification of membership.--Section 1900(c)(2)(B) of 
        such Act is amended by striking ``consumers'' and inserting 
        ``individuals''.
            (6) Authorization of appropriations.--
                    (A) Current authorization.--Section 1900(f)(2) of 
                such Act is amended--
                            (i) in the heading, by inserting ``of 
                        appropriations prior to 2010'' after 
                        ``Authorization''; and
                            (ii) by striking ``There are'' and 
                        inserting ``Prior to January 1, 2010, there 
                        are''
                    (B) Future authorization.--Section 1900(f) of such 
                Act is further amended by adding at the end the 
                following new paragraph: after the period the 
                following:
            ``(3) Authorization of appropriations for 2010.--Beginning 
        on January 1, 2010, there is authorized to be appropriated 
        $11,800,000 to carry out the provisions of this section. Such 
        funds shall remain available until expended.''.

SEC. 1785. OUTREACH AND ENROLLMENT OF MEDICAID AND CHIP ELIGIBLE 
              INDIVIDUALS.

    (a) In General.--Not later than 12 months after date of enactment 
of this Act, the Secretary of Health and Human Services shall issue 
guidance regarding standards and best practices for conducting outreach 
to inform eligible individuals about healthcare coverage under Medicaid 
under title XIX of the Social Security Act or for child health 
assistance under CHIP under title XXI of such Act, providing assistance 
to such individuals for enrollment in applicable programs, and 
establishing methods or procedures for eliminating application and 
enrollment barriers. Such guidance shall include provisions to ensure 
that outreach, enrollment assistance, and administrative simplification 
efforts are targeted specifically to vulnerable populations such as 
children, unaccompanied homeless youth, victims of abuse or trauma, 
individuals with mental health or substance related disorders, and 
individuals with HIV/AIDS. Guidance issued pursuant to this section 
relating to methods to increase outreach and enrollment provided for 
under titles XIX and XXI of the Social Security Act shall specifically 
target such vulnerable and underserved populations and shall include, 
but not be limited to, guidance on outstationing of eligibility 
workers, express lane eligibility, residence requirements, 
documentation of income and assets, presumptive eligibility, continuous 
eligibility, and automatic renewal.
    (b) Implementation.--In implementing the requirements under 
subsection (a), the Secretary may use such authorities as are available 
under law and may work with such entities as the Secretary deems 
appropriate to facilitate effective implementation of such programs. 
Not later than 2 years after the enactment of this Act and annually 
thereafter, the Secretary shall review and report to Congress on 
progress in implementing targeted outreach, application and enrollment 
assistance, and administrative simplification methods for such 
vulnerable and underserved populations as are specified in subsection 
(a).

SEC. 1786. PROHIBITIONS ON FEDERAL MEDICAID AND CHIP PAYMENT FOR 
              UNDOCUMENTED ALIENS.

    Nothing in this title shall change current prohibitions against 
Federal Medicaid and CHIP payments under titles XIX and XXI of the 
Social Security Act on behalf of individuals who are not lawfully 
present in the United States.

SEC. 1787. DEMONSTRATION PROJECT FOR STABILIZATION OF EMERGENCY MEDICAL 
              CONDITIONS BY INSTITUTIONS FOR MENTAL DISEASES.

    (a) Authority To Conduct Demonstration Project.--The Secretary of 
Health and Human Services (in this section referred to as the 
``Secretary'') shall establish a demonstration project under which an 
eligible State (as described in subsection (c)) shall provide 
reimbursement under the State Medicaid plan under title XIX of the 
Social Security Act to an institution for mental diseases that is 
subject to the requirements of section 1867 of the Social Security Act 
(42 U.S.C. 1395dd) for the provision of medical assistance available 
under such plan to an individual who--
            (1) has attained age 21, but has not attained age 65;
            (2) is eligible for medical assistance under such plan; and
            (3) requires such medical assistance to stabilize an 
        emergency medical condition.
    (b) In-stay Review.--The Secretary shall establish a mechanism for 
in-stay review to determine whether or not the patient has been 
stabilized (as defined in subsection (h)(5)). This mechanism shall 
commence before the third day of the inpatient stay. States 
participating in the demonstration project may manage the provision of 
these benefits under the project through utilization review, 
authorization, or management practices, or the application of medical 
necessity and appropriateness criteria applicable to behavioral health.
    (c) Eligible State Defined.--
            (1) Application.--Upon approval of an application submitted 
        by a State described in paragraph (2), the State shall be an 
        eligible State for purposes of conducting a demonstration 
        project under this section.
            (2) State described.--States shall be selected by the 
        Secretary in a manner so as to provide geographic diversity on 
        the basis of the application to conduct a demonstration project 
        under this section submitted by such States.
    (d) Length of Demonstration Project.--The demonstration project 
established under this section shall be conducted for a period of 3 
consecutive years.
    (e) Limitations on Federal Funding.--
            (1) Appropriation.--
                    (A) In general.--Out of any funds in the Treasury 
                not otherwise appropriated, there is appropriated to 
                carry out this section, $75,000,000 for fiscal year 
                2010.
                    (B) Budget authority.--Subparagraph (A) constitutes 
                budget authority in advance of appropriations Act and 
                represents the obligation of the Federal Government to 
                provide for the payment of the amounts appropriated 
                under that subparagraph.
            (2) 3-year availability.--Funds appropriated under 
        paragraph (1) shall remain available for obligation through 
        December 31, 2012.
            (3) Limitation on payments.--In no case may--
                    (A) the aggregate amount of payments made by the 
                Secretary to eligible States under this section exceed 
                $75,000,000; or
                    (B) payments be provided by the Secretary under 
                this section after December 31, 2012.
            (4) Funds allocated to states.--The Secretary shall 
        allocate funds to eligible States based on their applications 
        and the availability of funds.
            (5) Payments to states.--The Secretary shall pay to each 
        eligible State, from its allocation under paragraph (4), an 
        amount each quarter equal to the Federal medical assistance 
        percentage of expenditures in the quarter for medical 
        assistance described in subsection (a).
    (f) Reports.--
            (1) Annual progress reports.--The Secretary shall submit 
        annual reports to Congress on the progress of the demonstration 
        project conducted under this section.
            (2) Final report and recommendation.--An evaluation shall 
        be conducted of the demonstration project's impact on the 
        functioning of the health and mental health service system and 
        on individuals enrolled in the Medicaid program. This 
        evaluation shall include collection of baseline data for one-
        year prior to the initiation of the demonstration project as 
        well as collection of data from matched comparison states not 
        participating in the demonstration. The evaluation measures 
        shall include the following:
                    (A) A determination, by State, as to whether the 
                demonstration project resulted in increased access to 
                inpatient mental health services under the Medicaid 
                program and whether average length of stays were longer 
                (or shorter) for individuals admitted under the 
                demonstration project compared with individuals 
                otherwise admitted in comparison sites.
                    (B) An analysis, by State, regarding whether the 
                demonstration project produced a significant reduction 
                in emergency room visits for individuals eligible for 
                assistance under the Medicaid program or in the 
                duration of emergency room lengths of stay.
                    (C) An assessment of discharge planning by 
                participating hospitals that ensures access to further 
                (non-emergency) inpatient or residential care as well 
                as continuity of care for those discharged to 
                outpatient care.
                    (D) An assessment of the impact of the 
                demonstration project on the costs of the full range of 
                mental health services (including inpatient, emergency 
                and ambulatory care) under the plan as contrasted with 
                the comparison areas.
                    (E) Data on the percentage of consumers with 
                Medicaid coverage who are admitted to inpatient 
                facilities as a result of the demonstration project as 
                compared to those admitted to these same facilities 
                through other means.
                    (F) A recommendation regarding whether the 
                demonstration project should be continued after 
                December 31, 2012, and expanded on a national basis.
    (g) Waiver Authority.--
            (1) In general.--The Secretary shall waive the limitation 
        of subdivision (B) following paragraph (28) of section 1905(a) 
        of the Social Security Act (42 U.S.C. 1396d(a)) (relating to 
        limitations on payments for care or services for individuals 
        under 65 years of age who are patients in an institution for 
        mental diseases) for purposes of carrying out the demonstration 
        project under this section.
            (2) Limited other waiver authority.--The Secretary may 
        waive other requirements of title XIX of the Social Security 
        Act (including the requirements of sections 1902(a)(1) 
        (relating to statewideness) and 1902(1)(10)(B) (relating to 
        comparability)) only to extent necessary to carry out the 
        demonstration project under this section.
    (h) Definitions.--In this section:
            (1) Emergency medical condition.--The term ``emergency 
        medical condition'' means, with respect to an individual, an 
        individual who expresses suicidal or homicidal thoughts or 
        gestures, if determined dangerous to self or others.
            (2) Federal medical assistance percentage.--The term 
        ``Federal medical assistance percentage'' has the meaning given 
        that term with respect to a State under section 1905(b) of the 
        Social Security Act (42 U.S.C. 1396d(b)).
            (3) Institution for mental diseases.--The term 
        ``institution for mental diseases'' has the meaning given to 
        that term in section 1905(i) of the Social Security Act (42 
        U.S.C. 1396d(i)).
            (4) Medical assistance.--The term ``medical assistance'' 
        has the meaning given to that term in section 1905(a) of the 
        Social Security Act (42 U.S.C. 1396d(a)).
            (5) Stabilized.--The term ``stabilized'' means, with 
        respect to an individual, that the emergency medical condition 
        no longer exists with respect to the individual and the 
        individual is no longer dangerous to self or others.
            (6) State.--The term ``State'' has the meaning given that 
        term for purposes of title XIX of the Social Security Act (42 
        U.S.C. 1396 et seq.).

SEC. 1788. APPLICATION OF MEDICAID IMPROVEMENT FUND.

    Section 1941(b)(1) of the Social Security Act (42 U.S.C. 1396w-
1(b)(1)) is amended by striking ``from the Fund'' and all that follows 
and inserting ``from the Fund, only such amounts as may be appropriated 
or otherwise made available by law.''.

SEC. 1789. TREATMENT OF CERTAIN MEDICAID BROKERS.

    Section 1903(b)(4) of the Social Security Act (42 U.S.C. 
1396b(b)(4)) is amended--
            (1) in the matter before subparagraph (A), by inserting 
        after ``respect to the broker'' the following: ``(or, in the 
        case of subparagraph (A) and subparagraph (B)(i), if the 
        Inspector General of Department of Health and Human Services 
        finds that the broker has established and maintains procedures 
        to ensure the independence of its enrollment activities from 
        the interests of any managed care entity or provider)''; and
            (2) in subparagraph (B)--
                    (A) by inserting ``(i)'' after ``either''; and
                    (B) by inserting ``(ii)'' after ``health care 
                provider or''.

SEC. 1790. RULE FOR CHANGES REQUIRING STATE LEGISLATION.

    In the case of a State plan for medical assistance under title XIX 
of the Social Security Act which the Secretary of Health and Human 
Services determines requires State legislation (other than legislation 
appropriating funds) in order for the plan to meet an additional 
requirement imposed by an amendment made by this title, the State plan 
shall not be regarded as failing to comply with the requirements of 
such title XIX solely on the basis of its failure to meet this 
additional requirement before the first day of the first calendar 
quarter beginning after the close of the first regular session of the 
State legislature that begins after the date of the enactment of this 
Act. For purposes of the previous sentence, in the case of a State that 
has a 2-year legislative session, each year of such session shall be 
deemed to be a separate regular session of the State legislature.

                 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.

    (a) In General.--Paragraph (19) of section 6103(l) of the Internal 
Revenue Code of 1986 is amended to read as follows:
            ``(19) Disclosures to facilitate identification of 
        individuals likely to be ineligible for low-income subsidies 
        under medicare prescription drug program to assist social 
        security administration's outreach to eligible individuals.--
                    ``(A) In general.--Upon written request from the 
                Commissioner of Social Security, the following return 
                information (including such information disclosed to 
                the Social Security Administration under paragraph (1) 
                or (5)) shall be disclosed to officers and employees of 
                the Social Security Administration, with respect to any 
                taxpayer identified by the Commissioner of Social 
                Security--
                            ``(i) return information for the applicable 
                        year from returns with respect to wages (as 
                        defined in section 3121(a) or 3401(a)) and 
                        payments of retirement income (as described in 
                        paragraph (1) of this subsection),
                            ``(ii) unearned income information and 
                        income information of the taxpayer from 
                        partnerships, trusts, estates, and subchapter S 
                        corporations for the applicable year,
                            ``(iii) if the individual filed an income 
                        tax return for the applicable year, the filing 
                        status, number of dependents, income from 
                        farming, and income from self-employment, on 
                        such return,
                            ``(iv) if the individual is a married 
                        individual filing a separate return for the 
                        applicable year, the social security number (if 
                        reasonably available) of the spouse on such 
                        return,
                            ``(v) if the individual files a joint 
                        return for the applicable year, the social 
                        security number, unearned income information, 
                        and income information from partnerships, 
                        trusts, estates, and subchapter S corporations 
                        of the individual's spouse on such return, and
                            ``(vi) such other return information 
                        relating to the individual (or the individual's 
                        spouse in the case of a joint return) as is 
                        prescribed by the Secretary by regulation as 
                        might indicate that the individual is likely to 
                        be ineligible for a low-income prescription 
                        drug subsidy under section 1860D-14 of the 
                        Social Security Act.
                    ``(B) Applicable year.--For the purposes of this 
                paragraph, the term `applicable year' means the most 
                recent taxable year for which information is available 
                in the Internal Revenue Service's taxpayer information 
                records.
                    ``(C) Restriction on individuals for whom 
                disclosure may be requested.--The Commissioner of 
                Social Security shall request information under this 
                paragraph only with respect to--
                            ``(i) individuals the Social Security 
                        Administration has identified, using all other 
                        reasonably available information, as likely to 
                        be eligible for a low-income prescription drug 
                        subsidy under section 1860D-14 of the Social 
                        Security Act and who have not applied for such 
                        subsidy, and
                            ``(ii) any individual the Social Security 
                        Administration has identified as a spouse of an 
                        individual described in clause (i).
                    ``(D) Restriction on use of disclosed 
                information.--Return information disclosed under this 
                paragraph may be used only by officers and employees of 
                the Social Security Administration solely for purposes 
                of identifying individuals likely to be ineligible for 
                a low-income prescription drug subsidy under section 
                1860D-14 of the Social Security Act for use in outreach 
                efforts under section 1144 of the Social Security 
                Act.''.
    (b) Safeguards.--Paragraph (4) of section 6103(p) of such Code is 
amended--
            (1) by striking ``(19),'' each place it appears, and
            (2) by striking ``or (17)'' each place it appears and 
        inserting ``(17), or (19)''.
    (c) Conforming Amendment.--Paragraph (3) of section 6103(a) of such 
Code is amended by striking ``(19),''.
    (d) Effective Date.--The amendments made by this section shall 
apply to disclosures made after the date which is 12 months after the 
date of the enactment of this Act.

SEC. 1802. COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND; FINANCING FOR 
              TRUST FUND.

    (a) Establishment of Trust Fund.--
            (1) In general.--Subchapter A of chapter 98 of the Internal 
        Revenue Code of 1986 (relating to trust fund code) is amended 
        by adding at the end the following new section:

``SEC. 9511. HEALTH CARE COMPARATIVE EFFECTIVENESS RESEARCH TRUST FUND.

    ``(a) Creation of Trust Fund.--There is established in the Treasury 
of the United States a trust fund to be known as the `Health Care 
Comparative Effectiveness Research Trust Fund' (hereinafter in this 
section referred to as the `CERTF'), consisting of such amounts as may 
be appropriated or credited to such Trust Fund as provided in this 
section and section 9602(b).
    ``(b) Transfers to Fund.--
            ``(1) In general.--There are hereby appropriated to the 
        Trust Fund the following:
                    ``(A) For fiscal year 2010, $90,000,000.
                    ``(B) For fiscal year 2011, $100,000,000.
                    ``(C) For fiscal year 2012, $110,000,000.
                    ``(D) For each fiscal year beginning with fiscal 
                year 2013--
                            ``(i) an amount equivalent to the net 
                        revenues received in the Treasury from the fees 
                        imposed under subchapter B of chapter 34 
                        (relating to fees on health insurance and self-
                        insured plans) for such fiscal year; and
                            ``(ii) subject to subsection (c)(2), 
                        amounts determined by the Secretary of Health 
                        and Human Services to be equivalent to the fair 
                        share per capita amount computed under 
                        subsection (c)(1) for the fiscal year 
                        multiplied by the average number of individuals 
                        entitled to benefits under part A, or enrolled 
                        under part B, of title XVIII of the Social 
                        Security Act during such fiscal year.
            ``(2) Administrative provisions.--
                    ``(A) Transfers from other trust funds.--The 
                amounts appropriated by subparagraphs (A), (B), (C), 
                and (D)(ii) of paragraph (1) shall be transferred from 
                the Federal Hospital Insurance Trust Fund and from the 
                Federal Supplementary Medical Insurance Trust Fund 
                (established under section 1841 of such Act), and from 
                the Medicare Prescription Drug Account within such 
                Trust Fund, in proportion (as estimated by the 
                Secretary) to the total expenditures during such fiscal 
                year that are made under title XVIII of such Act from 
                the respective trust fund or account.
                    ``(B) Appropriations not subject to fiscal year 
                limitation.--The amounts appropriated by paragraph (1) 
                shall not be subject to any fiscal year limitation.
                    ``(C) Periodic transfers, estimates, and 
                adjustments.--Except as provided in subparagraph (A), 
                the provisions of section 9601 shall apply to the 
                amounts appropriated by paragraph (1).
    ``(c) Fair Share Per Capita Amount.--
            ``(1) Computation.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                fair share per capita amount under this paragraph for a 
                fiscal year (beginning with fiscal year 2013) is an 
                amount computed by the Secretary of Health and Human 
                Services for such fiscal year that, when applied under 
                this section and subchapter B of chapter 34 of the 
                Internal Revenue Code of 1986, will result in revenues 
                to the CERTF of $375,000,000 for the fiscal year.
                    ``(B) Alternative computation.--
                            ``(i) In general.--If the Secretary is 
                        unable to compute the fair share per capita 
                        amount under subparagraph (A) for a fiscal 
                        year, the fair share per capita amount under 
                        this paragraph for the fiscal year shall be the 
                        default amount determined under clause (ii) for 
                        the fiscal year.
                            ``(ii) Default amount.--The default amount 
                        under this clause for--
                                    ``(I) fiscal year 2013 is equal to 
                                $2; or
                                    ``(II) a subsequent year is equal 
                                to the default amount under this clause 
                                for the preceding fiscal year increased 
                                by the annual percentage increase in 
                                the medical care component of the 
                                consumer price index (United States 
                                city average) for the 12-month period 
                                ending with April of the preceding 
                                fiscal year.
                        Any amount determined under subclause (II) 
                        shall be rounded to the nearest penny.
            ``(2) Limitation on medicare funding.--In no case shall the 
        amount transferred under subsection (b)(4)(B) for any fiscal 
        year exceed $90,000,000.
    ``(d) Expenditures From Fund.--
            ``(1) In general.--Subject to paragraph (2), amounts in the 
        CERTF are available, without the need for further 
        appropriations and without fiscal year limitation, to the 
        Secretary of Health and Human Services to carry out section 
        1181 of the Social Security Act.
            ``(2) Allocation for commission.--The following amounts in 
        the CERTF shall be available, without the need for further 
        appropriations and without fiscal year limitation, to the 
        Commission to carry out the activities of the Comparative 
        Effectiveness Research Commission established under section 
        1181(b) of the Social Security Act:
                    ``(A) For fiscal year 2010, $7,000,000.
                    ``(B) For fiscal year 2011, $9,000,000.
                    ``(C) For each fiscal year beginning with 2012, 2.6 
                percent of the total amount appropriated to the CERTF 
                under subsection (b) for the fiscal year.
    ``(e) Net Revenues.--For purposes of this section, the term `net 
revenues' means the amount estimated by the Secretary based on the 
excess of--
            ``(1) the fees received in the Treasury under subchapter B 
        of chapter 34, over
            ``(2) the decrease in the tax imposed by chapter 1 
        resulting from the fees imposed by such subchapter.''.
            (2) Clerical amendment.--The table of sections for such 
        subchapter A is amended by adding at the end thereof the 
        following new item:

``Sec. 9511. Health Care Comparative Effectiveness Research Trust 
                            Fund.''.
    (b) Financing for Fund From Fees on Insured and Self-Insured Health 
Plans.--
            (1) General rule.--Chapter 34 of the Internal Revenue Code 
        of 1986 is amended by adding at the end the following new 
        subchapter:

         ``Subchapter B--Insured and Self-Insured Health Plans

``Sec. 4375. Health insurance.
``Sec. 4376. Self-insured health plans.
``Sec. 4377. Definitions and special rules.

``SEC. 4375. HEALTH INSURANCE.

    ``(a) Imposition of Fee.--There is hereby imposed on each specified 
health insurance policy for each policy year a fee equal to the fair 
share per capita amount determined under section 9511(c)(1) multiplied 
by the average number of lives covered under the policy.
    ``(b) Liability for Fee.--The fee imposed by subsection (a) shall 
be paid by the issuer of the policy.
    ``(c) Specified Health Insurance Policy.--For purposes of this 
section:
            ``(1) In general.--Except as otherwise provided in this 
        section, the term `specified health insurance policy' means any 
        accident or health insurance policy issued with respect to 
        individuals residing in the United States.
            ``(2) Exemption for certain policies.--The term `specified 
        health insurance policy' does not include any insurance if 
        substantially all of its coverage is of excepted benefits 
        described in section 9832(c).
            ``(3) Treatment of prepaid health coverage arrangements.--
                    ``(A) In general.--In the case of any arrangement 
                described in subparagraph (B)--
                            ``(i) such arrangement shall be treated as 
                        a specified health insurance policy, and
                            ``(ii) the person referred to in such 
                        subparagraph shall be treated as the issuer.
                    ``(B) Description of arrangements.--An arrangement 
                is described in this subparagraph if under such 
                arrangement fixed payments or premiums are received as 
                consideration for any person's agreement to provide or 
                arrange for the provision of accident or health 
                coverage to residents of the United States, regardless 
                of how such coverage is provided or arranged to be 
                provided.

``SEC. 4376. SELF-INSURED HEALTH PLANS.

    ``(a) Imposition of Fee.--In the case of any applicable self-
insured health plan for each plan year, there is hereby imposed a fee 
equal to the fair share per capita amount determined under section 
9511(c)(1) multiplied by the average number of lives covered under the 
plan.
    ``(b) Liability for Fee.--
            ``(1) In general.--The fee imposed by subsection (a) shall 
        be paid by the plan sponsor.
            ``(2) Plan sponsor.--For purposes of paragraph (1) the term 
        `plan sponsor' means--
                    ``(A) the employer in the case of a plan 
                established or maintained by a single employer,
                    ``(B) the employee organization in the case of a 
                plan established or maintained by an employee 
                organization,
                    ``(C) in the case of--
                            ``(i) a plan established or maintained by 2 
                        or more employers or jointly by 1 or more 
                        employers and 1 or more employee organizations,
                            ``(ii) a multiple employer welfare 
                        arrangement, or
                            ``(iii) a voluntary employees' beneficiary 
                        association described in section 501(c)(9),
                the association, committee, joint board of trustees, or 
                other similar group of representatives of the parties 
                who establish or maintain the plan, or
                    ``(D) the cooperative or association described in 
                subsection (c)(2)(F) in the case of a plan established 
                or maintained by such a cooperative or association.
    ``(c) Applicable Self-Insured Health Plan.--For purposes of this 
section, the term `applicable self-insured health plan' means any plan 
for providing accident or health coverage if--
            ``(1) any portion of such coverage is provided other than 
        through an insurance policy, and
            ``(2) such plan is established or maintained--
                    ``(A) by one or more employers for the benefit of 
                their employees or former employees,
                    ``(B) by one or more employee organizations for the 
                benefit of their members or former members,
                    ``(C) jointly by 1 or more employers and 1 or more 
                employee organizations for the benefit of employees or 
                former employees,
                    ``(D) by a voluntary employees' beneficiary 
                association described in section 501(c)(9),
                    ``(E) by any organization described in section 
                501(c)(6), or
                    ``(F) in the case of a plan not described in the 
                preceding subparagraphs, by a multiple employer welfare 
                arrangement (as defined in section 3(40) of Employee 
                Retirement Income Security Act of 1974), a rural 
                electric cooperative (as defined in section 
                3(40)(B)(iv) of such Act), or a rural telephone 
                cooperative association (as defined in section 
                3(40)(B)(v) of such Act).

``SEC. 4377. DEFINITIONS AND SPECIAL RULES.

    ``(a) Definitions.--For purposes of this subchapter--
            ``(1) Accident and health coverage.--The term `accident and 
        health coverage' means any coverage which, if provided by an 
        insurance policy, would cause such policy to be a specified 
        health insurance policy (as defined in section 4375(c)).
            ``(2) Insurance policy.--The term `insurance policy' means 
        any policy or other instrument whereby a contract of insurance 
        is issued, renewed, or extended.
            ``(3) United states.--The term `United States' includes any 
        possession of the United States.
    ``(b) Treatment of Governmental Entities.--
            ``(1) In general.--For purposes of this subchapter--
                    ``(A) the term `person' includes any governmental 
                entity, and
                    ``(B) notwithstanding any other law or rule of law, 
                governmental entities shall not be exempt from the fees 
                imposed by this subchapter except as provided in 
                paragraph (2).
            ``(2) Treatment of exempt governmental programs.--In the 
        case of an exempt governmental program, no fee shall be imposed 
        under section 4375 or section 4376 on any covered life under 
        such program.
            ``(3) Exempt governmental program defined.--For purposes of 
        this subchapter, the term `exempt governmental program' means--
                    ``(A) any insurance program established under title 
                XVIII of the Social Security Act,
                    ``(B) the medical assistance program established by 
                title XIX or XXI of the Social Security Act,
                    ``(C) any program established by Federal law for 
                providing medical care (other than through insurance 
                policies) to individuals (or the spouses and dependents 
                thereof) by reason of such individuals being--
                            ``(i) members of the Armed Forces of the 
                        United States, or
                            ``(ii) veterans, and
                    ``(D) any program established by Federal law for 
                providing medical care (other than through insurance 
                policies) to members of Indian tribes (as defined in 
                section 4(d) of the Indian Health Care Improvement 
                Act).
    ``(c) Treatment as Tax.--For purposes of subtitle F, the fees 
imposed by this subchapter shall be treated as if they were taxes.
    ``(d) No Cover Over to Possessions.--Notwithstanding any other 
provision of law, no amount collected under this subchapter shall be 
covered over to any possession of the United States.''.
            (2) Clerical amendments.--
                    (A) Chapter 34 of such Code is amended by striking 
                the chapter heading and inserting the following:

           ``CHAPTER 34--TAXES ON CERTAIN INSURANCE POLICIES

          ``subchapter a. policies issued by foreign insurers

         ``subchapter b. insured and self-insured health plans

         ``Subchapter A--Policies Issued By Foreign Insurers''.

                    (B) The table of chapters for subtitle D of such 
                Code is amended by striking the item relating to 
                chapter 34 and inserting the following new item:

          ``Chapter 34--Taxes on Certain Insurance Policies''.

            (3) Effective date.--The amendments made by this subsection 
        shall apply with respect to policies and plans for portions of 
        policy or plan years beginning on or after October 1, 2012.

                   TITLE IX--MISCELLANEOUS PROVISIONS

SEC. 1901. REPEAL OF TRIGGER PROVISION.

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

SEC. 1902. REPEAL OF COMPARATIVE COST ADJUSTMENT (CCA) PROGRAM.

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

SEC. 1903. EXTENSION OF GAINSHARING DEMONSTRATION.

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

SEC. 1904. GRANTS TO STATES FOR QUALITY HOME VISITATION PROGRAMS FOR 
              FAMILIES WITH YOUNG CHILDREN AND FAMILIES EXPECTING 
              CHILDREN.

    Part B of title IV of the Social Security Act (42 U.S.C. 621-629i) 
is amended by adding at the end the following:

       ``Subpart 3--Support for Quality Home Visitation Programs

``SEC. 440. HOME VISITATION PROGRAMS FOR FAMILIES WITH YOUNG CHILDREN 
              AND FAMILIES EXPECTING CHILDREN.

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

SEC. 1905. IMPROVED COORDINATION AND PROTECTION FOR DUAL ELIGIBLES.

    Title XI of the Social Security Act is amended by inserting after 
section 1150 the following new section:

       ``improved coordination and protection for dual eligibles

    ``Sec. 1150A.  (a) In General.--The Secretary shall provide, 
through an identifiable office or program within the Centers for 
Medicare & Medicaid Services, for a focused effort to provide for 
improved coordination between Medicare and Medicaid and protection in 
the case of dual eligibles (as defined in subsection (g)). The office 
or program shall--
            ``(1) review Medicare and Medicaid policies related to 
        enrollment, benefits, service delivery, payment, and grievance 
        and appeals processes under parts A and B of title XVIII, under 
        the Medicare Advantage program under part C of such title, and 
        under title XIX;
            ``(2) identify areas of such policies where better 
        coordination and protection could improve care and costs; and
            ``(3) issue guidance to States regarding improving such 
        coordination and protection.
    ``(b) Elements.--The improved coordination and protection under 
this section shall include efforts--
            ``(1) to simplify access of dual eligibles to benefits and 
        services under Medicare and Medicaid;
            ``(2) to improve care continuity for dual eligibles and 
        ensure safe and effective care transitions;
            ``(3) to harmonize regulatory conflicts between Medicare 
        and Medicaid rules with regard to dual eligibles; and
            ``(4) to improve total cost and quality performance under 
        Medicare and Medicaid for dual eligibles.
    ``(c) Responsibilities.--In carrying out this section, the 
Secretary shall provide for the following:
            ``(1) An examination of Medicare and Medicaid payment 
        systems to develop strategies to foster more integrated and 
        higher quality care.
            ``(2) Development of methods to facilitate access to post-
        acute and community-based services and to identify actions that 
        could lead to better coordination of community-based care.
            ``(3) A study of enrollment of dual eligibles in the 
        Medicare Savings Program (as defined in section 1144(c)(7)), 
        under Medicaid, and in the low-income subsidy program under 
        section 1860D-14 to identify methods to more efficiently and 
        effectively reach and enroll dual eligibles.
            ``(4) An assessment of communication strategies for dual 
        eligibles to determine whether additional informational 
        materials or outreach is needed, including an assessment of the 
        Medicare website, 1-800-MEDICARE, and the Medicare handbook.
            ``(5) Research and evaluation of areas where service 
        utilization, quality, and access to cost sharing protection 
        could be improved and an assessment of factors related to 
        enrollee satisfaction with services and care delivery.
            ``(6) Collection (and making available to the public) of 
        data and a database that describe the eligibility, benefit and 
        cost-sharing assistance available to dual eligibles by State.
            ``(7) Support for coordination of State and Federal 
        contracting and oversight for dual coordination programs 
        supportive of the goals described in subsection (b).
            ``(8) Support for State Medicaid agencies through the 
        provision of technical assistance for Medicare and Medicaid 
        coordination initiatives designed to improve acute and long-
        term care for dual eligibles.
            ``(9) Monitoring total combined Medicare and Medicaid 
        program costs in serving dual eligibles and making 
        recommendations for optimizing total quality and cost 
        performance across both programs.
            ``(10) Coordination of activities relating to Medicare 
        Advantage plans under 1859(b)(6)(B)(ii) and Medicaid.
    ``(d) Reporting.--The Office or program shall work with relevant 
State agencies and any appropriate quality measurement entities to 
improve and coordinate reporting requirements for Medicare and 
Medicaid. In addition, the Office or program shall seek to minimize 
duplication in reporting requirements, where appropriate, and to 
identify opportunities to combine assessment requirements, where 
appropriate. The Office or program shall seek to identify quality 
metrics and assessment requirements that facilitate comparisons of the 
quality of care received by beneficiaries enrolled in or entitled to 
benefits under fee-for-service Medicare, the Medicare Advantage 
program, fee-for-service Medicaid, and Medicaid managed care, and 
combinations thereof (including integrated Medicare-Medicaid programs 
for dual eligibles).
    ``(e) Endorsement.--The Secretary shall seek endorsement by the 
entity with a contract under section 1890(a) of quality measures and 
benchmarks developed under this section.
    ``(f) Consultation With Stakeholders.--The Office or program shall 
consult with relevant stakeholders, including dual eligible 
beneficiaries representatives for dual eligible beneficiaries, health 
plans, providers, and relevant State agencies, in the development of 
policies related to integrated Medicare-Medicaid programs for dual 
eligibles.
    ``(g) Periodic Reports.--Not later than 1 year after the date of 
the enactment of this section and every 3 years thereafter the 
Secretary shall submit to Congress a report on progress in activities 
conducted under this section.
    ``(h) Definitions.--In this section:
            ``(1) Dual eligible.--The term `dual eligible' means an 
        individual who is dually eligible for benefits under title 
        XVIII, and medical assistance under title XIX, including such 
        individuals who are eligible for benefits under the Medicare 
        Savings Program (as defined in section 1144(c)(7)).
            ``(2) Medicare; medicaid.--The terms `Medicare' and 
        `Medicaid' mean the programs under titles XVIII and XIX, 
        respectively.''.

SEC. 1906. ASSESSMENT OF MEDICARE COST-INTENSIVE DISEASES AND 
              CONDITIONS.

    (a) Initial Assessment.--
            (1) In general.--The Secretary of Health and Human Services 
        shall conduct an assessment of the diseases and conditions that 
        are the most cost-intensive for the Medicare program and, to 
        the extent possible, assess the diseases and conditions that 
        could become cost-intensive for Medicare in the future. In 
        conducting the assessment, the Secretary shall include the 
        input of relevant research agencies, including the National 
        Institutes of Health, the Agency for Healthcare Research and 
        Quality, the Food and Drug Administration, and the Centers for 
        Medicare & Medicaid Services.
            (2) Report.--Not later than January 1, 2011, the Secretary 
        shall transmit a report to the Committees on Energy and 
        Commerce, Ways and Means, and Appropriations of the House of 
        Representatives and the Committees on Health, Education, Labor 
        and Pensions, Finance, and Appropriations of the Senate on the 
        assessment conducted under paragraph (1). Such report shall--
                    (A) include the assessment of current and future 
                trends of cost-intensive diseases and conditions 
                described in such paragraph;
                    (B) address whether current research priorities are 
                appropriately addressing current and future cost-
                intensive conditions so identified; and
                    (C) include recommendations concerning research in 
                the Department of Health and Human Services that should 
                be funded to improve the prevention, treatment, or cure 
                of such cost-intensive diseases and conditions.
    (b) Updates of Assessment.--Not later than January 1, 2013, and 
biennially thereafter, the Secretary shall--
            (1) review and update the assessment and recommendations 
        described in subsection (a)(1); and
            (2) submit a report described in subsection (a)(2) to the 
        Committees specified in subsection (a)(2) on such updated 
        assessment and recommendations.

SEC. 1907. ESTABLISHMENT OF CENTER FOR MEDICARE AND MEDICAID INNOVATION 
              WITHIN CMS.

    (a) In General.--Title XI of the Social Security Act is amended by 
inserting after section 1115 the following new section:

             ``center for medicare and medicaid innovation

    ``Sec. 1115A.  (a) Center for Medicare and Medicaid Innovation 
Established.--
            ``(1) In general.--There is created within the Centers for 
        Medicare & Medicaid Services a Center for Medicare and Medicaid 
        Innovation (in this section referred to as the `CMI') to carry 
        out the duties described in this section. The purpose of the 
        CMI is to test innovative payment and service delivery models 
        to improve the coordination, quality, and efficiency of health 
        care services provided to applicable individuals defined in 
        paragraph (4)(A).
            ``(2) Deadline.--The Secretary shall ensure that the CMI is 
        carrying out the duties described in this section by not later 
        than January 1, 2011.
            ``(3) Consultation.--In carrying out the duties under this 
        section, the CMI shall consult representatives of relevant 
        Federal agencies, clinical and analytical experts with 
        expertise in medicine and health care management, and States. 
        The CMI shall use open door forums or other mechanisms to seek 
        input from interested parties.
            ``(4) Definitions.--In this section:
                    ``(A) Applicable individual.--The term `applicable 
                individual' means--
                            ``(i) an individual who is enrolled under 
                        part B and entitled to benefits under part A of 
                        title XVIII;
                            ``(ii) an individual who is eligible for 
                        medical assistance under title XIX; or
                            ``(iii) an individual who meets the 
                        criteria of both clauses (i) and (ii).
                    ``(B) Applicable title.--The term `applicable 
                title' means title XVIII, title XIX, or both.
    ``(b) Testing of Models (Phase I).--
            ``(1) In general.--The CMI shall test payment and service 
        delivery models in accordance with selection criteria under 
        paragraph (2) to determine the effect of applying such models 
        under the applicable title (as defined in subsection (a)(4)(B)) 
        on program expenditures under such titles and the quality of 
        care received by individuals receiving benefits under such 
        title.
            ``(2) Selection of models to be tested.--
                    ``(A) In general.--The Secretary shall give 
                preference to testing models for which, as determined 
                by the Administrator of the Centers for Medicare & 
                Medicaid Services and using such input from outside the 
                Centers as the Administrator determines appropriate, 
                there is evidence that the model addresses a defined 
                population for which there are deficits in care leading 
                to poor clinical outcomes or potentially avoidable 
                expenditures. The Administrator shall focus on models 
                expected to reduce program costs under the applicable 
                title while preserving or enhancing the quality of care 
                received by individuals receiving benefits under such 
                title.
                    ``(B) Application to other demonstrations.--The 
                Secretary shall operate the demonstration programs 
                under sections 1222 and 1236 of the Affordable Health 
                Care for America Act through the CMI in accordance with 
                the rules applicable under this section, including 
                those relating to evaluations, terminations, and 
                expansions.
            ``(3) Budget neutrality.--
                    ``(A) Initial period.--The Secretary shall not 
                require, as a condition for testing a model under 
                paragraph (1), that the design of such model ensure 
                that such model is budget neutral initially with 
                respect to expenditures under the applicable title.
                    ``(B) Termination.--The Secretary shall terminate 
                or modify the design and implementation of a model 
                unless the Secretary determines (and the Chief Actuary 
                of the Centers for Medicare & Medicaid Services, with 
                respect to spending under the applicable title, 
                certifies), after testing has begun, that the model is 
                expected to--
                            ``(i) improve the quality of care (as 
                        determined by the Administrator of the Centers 
                        for Medicare & Medicaid Services) without 
                        increasing spending under such title;
                            ``(ii) reduce spending under such titles 
                        without reducing the quality of care; or
                            ``(iii) do both.
                Such termination may occur at any time after such 
                testing has begun and before completion of the testing.
            ``(4) Evaluation.--
                    ``(A) In general.--The Secretary shall conduct an 
                evaluation of each model tested under this subsection. 
                Such evaluation shall include an analysis of--
                            ``(i) the quality of care furnished under 
                        the model, including through the use of 
                        patient-level outcomes measures; and
                            ``(ii) the changes in spending under the 
                        applicable titles by reason of the model.
                The Secretary shall make the results of each evaluation 
                under this paragraph available to the public in a 
                timely fashion.
                    ``(B) Measure selection.--To the extent feasible, 
                the Secretary shall select measures under this 
                paragraph that reflect national priorities for quality 
                improvement and patient-centered care consistent with 
                the measures developed under section 1192(c)(1).

            ``(5) Testing period.--In no case shall a model be tested 
        under this subsection for more than a 7-year period.
    ``(c) Expansion of Models (Phase II).--The Secretary may expand the 
duration and the scope of a model that is being tested under subsection 
(b) (including implementation on a nationwide basis), to the extent 
determined appropriate by the Secretary, if--
            ``(1) the Secretary determines that such expansion is 
        expected--
                    ``(A) to improve the quality of patient care 
                without increasing spending under the applicable 
                titles;
                    ``(B) to reduce spending under applicable titles 
                without reducing the quality of care; or
                    ``(C) to do both;
            ``(2) the Chief Actuary of the Centers for Medicare & 
        Medicaid Services certifies that such expansion would reduce 
        (or not result in any increase in) net program spending under 
        applicable titles; and
            ``(3) the Secretary determines that such expansion would 
        not deny or limit the coverage or provision of benefits under 
        the applicable title for applicable individuals.
    ``(d) Implementation.--
            ``(1) Waiver authority.--The Secretary may waive such 
        requirements of titles XI and XVIII and of sections 1902 and 
        1903(m) as may be necessary solely for purposes of carrying out 
        this section with respect to testing models described in 
        subsection (b).
            ``(2) Limitations on review.--There shall be no 
        administrative or judicial review under section 1869, section 
        1878, or otherwise of--
                    ``(A) the selection of models for testing or 
                expansion under this section;
                    ``(B) the elements, parameters, scope, and duration 
                of such models for testing or dissemination;
                    ``(C) the termination or modification of the design 
                and implementation of a model under subsection 
                (b)(3)(B); and
                    ``(D) determinations about expansion of the 
                duration and scope of a model under subsection (c) 
                including the determination that a model is not 
                expected to meet criteria described in paragraphs (1) 
                or (2) of such subsection.
            ``(3) Administration.--Chapter 35 of title 44, United 
        States Code shall not apply to the testing and evaluation of 
        models or expansion of such models under this section.
            ``(4) Funding for testing items and services and 
        administrative costs.--
                    ``(A) Additional benefits.--There shall be 
                available until expended, equally divided from the 
                Federal Supplementary Hospital Insurance Trust Fund and 
                Federal Supplementary Medical Insurance Trust Fund for 
                payments for additional benefits for items and services 
                under models tested under subsection (b) not otherwise 
                covered under this title and applicable to benefits 
                under this title, and for researching, designing, 
                implementing, and evaluating such models, $350,000,000 
                for fiscal year 2010, $440,000,000 for fiscal year 
                2011, $550,000,000 for fiscal year 2012, and, for a 
                subsequent fiscal year, the amount determined under 
                this subparagraph for the preceding fiscal year 
                increased by the annual percentage rate of increase in 
                total expenditures under this title for the subsequent 
                fiscal year as estimated in the latest available Annual 
                Report of the Board of Trustees as described in section 
                1841(b)(2).
                    ``(B) Medicaid.--For administrative costs of the 
                Centers for Medicare & Medicaid Services for 
                administering this section with respect to title XIX, 
                from any amounts in the Treasury not otherwise 
                appropriated there are appropriated to the Secretary 
                for the Centers for Medicare & Medicaid Services 
                Program Management Account $25,000,000 for each fiscal 
                year beginning with fiscal year 2010. Amounts 
                appropriated under this subparagraph for a fiscal year 
                shall be available until expended.
    ``(e) Report to Congress.--Beginning in 2012, and not less than 
once every other year thereafter, the Secretary shall submit to 
Congress a report on activities under this section. Each such report 
shall describe the payment models tested under subsection (b), 
including the number of individuals described in subsection 
(a)(4)(A)(i) and of individuals described in subsection (a)(4)(A)(ii) 
participating in such models and payments made under applicable titles 
for services on behalf of such individuals, any models chosen for 
expansion under subsection (c), and the results from evaluations under 
subsection (b)(4). In addition, each such report shall provide such 
recommendations as the Secretary believes are appropriate for 
legislative action to facilitate the development and expansion of 
successful payment models.''.
    (b) Medicaid Conforming Amendment.--Section 1902(a) of the Social 
Security Act (42 U.S.C. 1396a(a)), as amended by sections 1631(b), 
1703(a), 1729, 1753, 1757(a), and 1759(a), is amended--
            (1) in paragraph (78), by striking ``and'' at the end;
            (2) in paragraph (79), by striking the period at the end 
        and inserting ``; and''; and
            (3) by inserting after paragraph (79) the following new 
        paragraph:
            ``(80) provide for implementation of the payment models 
        specified by the Secretary under section 1115A(c) for 
        implementation on a nationwide basis unless the State 
        demonstrates to the satisfaction of the Secretary that 
        implementation would not be administratively feasible or 
        appropriate to the health care delivery system of the State.''.

SEC. 1908. APPLICATION OF EMERGENCY SERVICES LAWS.

    Nothing in this Act shall be construed to relieve any health care 
provider from providing emergency services as required by State or 
Federal law, including section 1867 of the Social Security Act 
(popularly known as "EMTALA").

SEC. 1909. DISREGARD UNDER THE SUPPLEMENTAL SECURITY INCOME PROGRAM OF 
              COMPENSATION FOR PARTICIPATION IN CLINICAL TRIALS FOR 
              RARE DISEASES OR CONDITIONS.

    (a) Income Disregard.--Section 1612(b) of the Social Security Act 
(42 U.S.C. 1382a(b)) is amended--
            (1) by striking ``and'' at the end of paragraph (24);
            (2) by striking the period at the end of paragraph (25) and 
        inserting ``; and''; and
            (3) by adding at the end the following:
            ``(26) The first $2,000 per year received by such 
        individual (or such spouse) for participation in a clinical 
        trial to test a treatment for a rare disease or condition 
        (within the meaning of section 5(b)(2) of the Orphan Drug Act 
        (Public Law 97-414)), that--
                    ``(A) has been reviewed and approved by an 
                institutional review board that--
                            ``(i) is established to protect the rights 
                        and welfare of human subjects participating in 
                        research; and
                            ``(ii) meet the standards for such bodies 
                        set forth in part 46 of title 45, Code of 
                        Federal Regulations; and
                    ``(B) meets the standards for protection of human 
                subjects for clinical research (as set forth in such 
                part).''.
    (b) Resource Disregard.--Section 1613(a) of such Act (42 U.S.C. 
1382b(a)) is amended--
            (1) by striking ``and'' at the end of paragraph (15);
            (2) by striking the period at the end of paragraph (16) and 
        inserting ``; and''; and
            (3) by inserting after paragraph (16) the following:
            ``(17) the first $2,000 per year received by such 
        individual (or such spouse) for participation in a clinical 
        trial, as described in section 1612(b)(26).''.
    (c) Effective Date.--The amendments made by this section shall 
apply to benefits payable for calendar months beginning after the 
earlier of--
            (1) the date the Commissioner of Social Security 
        promulgates regulations to carry out the amendments; or
            (2) the 180-day period that begins with the date of the 
        enactment of this Act.

          DIVISION C--PUBLIC HEALTH AND WORKFORCE DEVELOPMENT

SEC. 2001. TABLE OF CONTENTS; REFERENCES.

    (a) Table of Contents.--The table of contents of 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

                   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.
     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

 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.
                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.
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. 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.
    (b) References.--Except as otherwise specified, whenever in this 
division an amendment is expressed in terms of an amendment to a 
section or other provision, the reference shall be considered to be 
made to a section or other provision of the Public Health Service Act 
(42 U.S.C. 201 et seq.).

SEC. 2002. PUBLIC HEALTH INVESTMENT FUND.

    (a) Establishment of Funds.--
            (1) In general.--Subject to section 2003, there is hereby 
        established in the Treasury a separate account to be known as 
        the ``Public Health Investment Fund'' (referred to in this 
        section and section 2003 as the ``Fund'').
            (2) Funding.--
                    (A) There shall be deposited into the Fund--
                            (i) for fiscal year 2011, $4,600,000,000;
                            (ii) for fiscal year 2012, $5,600,000,000;
                            (iii) for fiscal year 2013, $6,900,000,000;
                            (iv) for fiscal year 2014, $7,800,000,000; 
                        and
                            (v) for fiscal year 2015, $9,000,000,000.
                    (B) Amounts deposited into the Fund shall be 
                derived from general revenues of the Treasury only for 
                the fiscal years set forth in this section, and amounts 
                appropriated from the Fund shall remain available until 
                expended.
    (b) Authorization of Appropriations From the Fund.--
            (1) New funding.--
                    (A) In general.--Subject to section 2003, amounts 
                in the Fund are authorized to be appropriated for 
                carrying out activities under designated public health 
                provisions.
                    (B) Designated provisions.--For purposes of this 
                paragraph, the term ``designated public health 
                provisions'' means the provisions for which amounts are 
                authorized to be appropriated under section 330(s), 
                338(c), 338H-1, 799C, 872, or 3111 of the Public Health 
                Service Act, as added by this division.
            (2) Baseline funding.--
                    (A) In general.--Amounts in the Fund are authorized 
                to be appropriated (as described in paragraph (1)) for 
                a fiscal year only if (excluding any amounts in or 
                appropriated from the Fund)--
                            (i) the amounts specified in subparagraph 
                        (B) for the fiscal year involved are equal to 
                        or greater than the amounts specified in 
                        subparagraph (B) for fiscal year 2008; and
                            (ii) the amounts appropriated, out of the 
                        general fund of the Treasury, to the Prevention 
                        and Wellness Trust under section 3111(a)(1) of 
                        the Public Health Service Act, as added by this 
                        division, for the fiscal year involved are 
                        equal to or greater than the funds--
                                    (I) appropriated under the heading 
                                ``Prevention and Wellness Fund'' in 
                                title VIII of division A of the 
                                American Recovery and Reinvestment Act 
                                of 2009 (Public Law 111-5); and
                                    (II) allocated by the second 
                                proviso under such heading for 
                                evidence-based clinical and community-
                                based prevention and wellness 
                                strategies.
                    (B) Amounts specified.--The amounts specified in 
                this subparagraph, with respect to a fiscal year, are 
                the amounts appropriated for the following:
                            (i) Community health centers (including 
                        funds appropriated under the authority of 
                        section 330 of the Public Health Service Act 
                        (42 U.S.C. 254b)).
                            (ii) The National Health Service Corps 
                        Program (including funds appropriated under the 
                        authority of section 338 of such Act (42 U.S.C. 
                        254k)).
                            (iii) The National Health Service Corps 
                        Scholarship and Loan Repayment Programs 
                        (including funds appropriated under the 
                        authority of section 338H of such Act (42 
                        U.S.C. 254q)).
                            (iv) Primary care education programs 
                        (including funds appropriated under the 
                        authority of sections 736, 740, 741, and 747 of 
                        such Act (42 U.S.C. 293, 293d, and 293k)).
                            (v) Sections 761 and 770 of such Act (42 
                        U.S.C. 294n and 295e).
                            (vi) Nursing workforce development 
                        (including funds appropriated under the 
                        authority of title VIII of such Act (42 U.S.C. 
                        296 et seq.)).
                            (vii) The National Center for Health 
                        Statistics (including funds appropriated under 
                        the authority of sections 304, 306, 307, and 
                        308 of such Act (42 U.S.C. 242b, 242k, 242l, 
                        and 242m)).
                            (viii) The Agency for Healthcare Research 
                        and Quality (including funds appropriated under 
                        the authority of title IX of such Act (42 
                        U.S.C. 299 et seq.)).

SEC. 2003. DEFICIT NEUTRALITY.

    (a) Availability.--Funds appropriated or made available pursuant to 
sections 330(s), 338(c), 338H-1, 799C, 872, or 3111 of the Public 
Health Service Act, as added by this division, are only available for 
the purposes set forth in this Act. Appropriations shall not be 
available and are precluded from obligation for any other purpose.
    (b) Estimation of Budgetary Impact.--For the purposes of estimating 
the spending effects of this Act, the authorization of appropriations 
from the Fund, to the extent amounts in the Fund are derived from the 
general revenues of the Treasury, shall be treated as new direct 
spending and attributed to this Act.
    (c) Budgetary Treatment.--For the purposes of section 257 of the 
Balanced Budget and Emergency Deficit Control Act of 1985, the Fund, to 
the extent amounts in the Fund are derived from the general revenues of 
the Treasury, and not in excess of amounts subsequently appropriated 
from the Fund, shall be deemed to be included on the list of 
appropriations referenced under section 250(c)(17) of that Act.

                   TITLE I--COMMUNITY HEALTH CENTERS

SEC. 2101. INCREASED FUNDING.

    Section 330 of the Public Health Service Act (42 U.S.C. 254b) is 
amended--
            (1) in subsection (r)(1)--
                    (A) in subparagraph (D), by striking ``and'' at the 
                end;
                    (B) in subparagraph (E), by striking the period at 
                the end and inserting ``; and''; and
                    (C) by inserting at the end the following:
                    ``(F) such sums as may be necessary for each of 
                fiscal years 2013 through 2015.''; and
            (2) by inserting after subsection (r) the following:
    ``(s) Additional Funding.--For the purpose of carrying out this 
section, in addition to any other amounts authorized to be appropriated 
for such purpose, there are authorized to be appropriated, out of any 
monies in the Public Health Investment Fund, the following:
            ``(1) For fiscal year 2011, $1,000,000,000.
            ``(2) For fiscal year 2012, $1,500,000,000.
            ``(3) For fiscal year 2013, $2,500,000,000.
            ``(4) For fiscal year 2014, $3,000,000,000.
            ``(5) For fiscal year 2015, $4,000,000,000.''.

                          TITLE II--WORKFORCE

                   Subtitle A--Primary Care Workforce

                 PART 1--NATIONAL HEALTH SERVICE CORPS

SEC. 2201. NATIONAL HEALTH SERVICE CORPS.

    (a) Fulfillment of Obligated Service Requirement Through Half-Time 
Service.--
            (1) Waivers.--Subsection (i) of section 331 (42 U.S.C. 
        254d) is amended--
                    (A) in paragraph (1), by striking ``In carrying out 
                subpart III'' and all that follows through the period 
                and inserting ``In carrying out subpart III, the 
                Secretary may, in accordance with this subsection, 
                issue waivers to individuals who have entered into a 
                contract for obligated service under the Scholarship 
                Program or the Loan Repayment Program under which the 
                individuals are authorized to satisfy the requirement 
                of obligated service through providing clinical 
                practice that is half-time.'';
                    (B) in paragraph (2)--
                            (i) in subparagraphs (A)(ii) and (B), by 
                        striking ``less than full time'' each place it 
                        appears and inserting ``half time'';
                            (ii) in subparagraphs (C) and (F), by 
                        striking ``less than full-time service'' each 
                        place it appears and inserting ``half-time 
                        service''; and
                            (iii) by amending subparagraphs (D) and (E) 
                        to read as follows:
            ``(D) the entity and the Corps member agree in writing that 
        the Corps member will perform half-time clinical practice;
            ``(E) the Corps member agrees in writing to fulfill all of 
        the service obligations under section 338C through half-time 
        clinical practice and either--
                    ``(i) double the period of obligated service that 
                would otherwise be required; or
                    ``(ii) in the case of contracts entered into under 
                section 338B, accept a minimum service obligation of 2 
                years with an award amount equal to 50 percent of the 
                amount that would otherwise be payable for full-time 
                service; and''; and
                    (C) in paragraph (3), by striking ``In evaluating a 
                demonstration project described in paragraph (1)'' and 
                inserting ``In evaluating waivers issued under 
                paragraph (1)''.
            (2) Definitions.--Subsection (j) of section 331 (42 U.S.C. 
        254d) is amended by adding at the end the following:
            ``(5) The terms `full time' and `full-time' mean a minimum 
        of 40 hours per week in a clinical practice, for a minimum of 
        45 weeks per year.
            ``(6) The terms `half time' and `half-time' mean a minimum 
        of 20 hours per week (not to exceed 39 hours per week) in a 
        clinical practice, for a minimum of 45 weeks per year.''.
    (b) Reappointment to National Advisory Council.--Section 337(b)(1) 
(42 U.S.C. 254j(b)(1)) is amended by striking ``Members may not be 
reappointed to the Council.''.
    (c) Loan Repayment Amount.--Section 338B(g)(2)(A) (42 U.S.C. 254l-
1(g)(2)(A)) is amended by striking ``$35,000'' and inserting ``$50,000, 
plus, beginning with fiscal year 2012, an amount determined by the 
Secretary on an annual basis to reflect inflation,''.
    (d) Treatment of Teaching as Obligated Service.--Subsection (a) of 
section 338C (42 U.S.C. 254m) is amended by adding at the end the 
following: ``The Secretary may treat teaching as clinical practice for 
up to 20 percent of such period of obligated service.''.

SEC. 2202. AUTHORIZATIONS OF APPROPRIATIONS.

    (a) National Health Service Corps Program.--Section 338 (42 U.S.C. 
254k) is amended--
            (1) in subsection (a), by striking ``2012'' and inserting 
        ``2015''; and
            (2) by adding at the end the following:
    ``(c) For the purpose of carrying out this subpart, in addition to 
any other amounts authorized to be appropriated for such purpose, there 
are authorized to be appropriated, out of any monies in the Public 
Health Investment Fund, the following:
            ``(1) $63,000,000 for fiscal year 2011.
            ``(2) $66,000,000 for fiscal year 2012.
            ``(3) $70,000,000 for fiscal year 2013.
            ``(4) $73,000,000 for fiscal year 2014.
            ``(5) $77,000,000 for fiscal year 2015.''.
    (b) Scholarship and Loan Repayment Programs.--Subpart III of part D 
of title III of the Public Health Service Act (42 U.S.C. 254l et seq.) 
is amended--
            (1) in section 338H(a)--
                    (A) in paragraph (4), by striking ``and'' at the 
                end;
                    (B) in paragraph (5), by striking the period at the 
                end and inserting ``; and''; and
                    (C) by adding at the end the following:
            ``(6) for each of fiscal years 2013 through 2015, such sums 
        as may be necessary.''; and
            (2) by inserting after section 338H the following:

``SEC. 338H-1. ADDITIONAL FUNDING.

    ``For the purpose of carrying out this subpart, in addition to any 
other amounts authorized to be appropriated for such purpose, there are 
authorized to be appropriated, out of any monies in the Public Health 
Investment Fund, the following:
            ``(1) $254,000,000 for fiscal year 2011.
            ``(2) $266,000,000 for fiscal year 2012.
            ``(3) $278,000,000 for fiscal year 2013.
            ``(4) $292,000,000 for fiscal year 2014.
            ``(5) $306,000,000 for fiscal year 2015.''.

            PART 2--PROMOTION OF PRIMARY CARE AND DENTISTRY

SEC. 2211. FRONTLINE HEALTH PROVIDERS.

    Part D of title III (42 U.S.C. 254b et seq.) is amended by adding 
at the end the following:

             ``Subpart XI--Health Professional Needs Areas

``SEC. 340H. IN GENERAL.

    ``(a) Program.--The Secretary, acting through the Administrator of 
the Health Resources and Services Administration, shall establish a 
program, to be known as the Frontline Health Providers Loan Repayment 
Program, to address unmet health care needs in health professional 
needs areas through loan repayments under section 340I.
    ``(b) Designation of Health Professional Needs Areas.--
            ``(1) In general.--In this subpart, the term `health 
        professional needs area' means an area, population, or facility 
        that is designated by the Secretary in accordance with 
        paragraph (2).
            ``(2) Designation.--To be designated by the Secretary as a 
        health professional needs area under this subpart:
                    ``(A) In the case of an area, the area must be a 
                rational area for the delivery of health services.
                    ``(B) The area, population, or facility must have, 
                in one or more health disciplines, specialties, or 
                subspecialties for the population served, as determined 
                by the Secretary--
                            ``(i) insufficient capacity of health 
                        professionals; or
                            ``(ii) high needs for health services, 
                        including services to address health 
                        disparities.
                    ``(C) With respect to the delivery of primary 
                health services, the area, population, or facility must 
                not include a health professional shortage area (as 
                designated under section 332), except that the area, 
                population, or facility may include such a health 
                professional shortage area in which there is an unmet 
                need for such services.
    ``(c) Eligibility.--To be eligible to participate in the Program, 
an individual shall--
            ``(1) hold a degree in a course of study or program 
        (approved by the Secretary) from a school defined in section 
        799B(1)(A) (other than a school of public health);
            ``(2) hold a degree in a course of study or program 
        (approved by the Secretary) from a school or program defined in 
        subparagraph (C), (D), or (E)(4) of section 799B(1), as 
        designated by the Secretary;
            ``(3) be enrolled as a full-time student--
                    ``(A) in a school or program defined in 
                subparagraph (C), (D), or (E)(4) of section 799B(1), as 
                designated by the Secretary, or a school described in 
                paragraph (1); and
                    ``(B) in the final year of a course of study or 
                program, offered by such school or program and approved 
                by the Secretary, leading to a degree in a discipline 
                referred to in subparagraph (A) (other than a graduate 
                degree in public health), (C), (D), or (E)(4) of 
                section 799B(1);
            ``(4) be a practitioner described in section 1842(b)(18)(C) 
        or 1848(k)(3)(B)(iii) or (iv) of the Social Security Act; or
            ``(5) be a practitioner in the field of respiratory 
        therapy, medical technology, or radiologic technology.
    ``(d) Definitions.--In this subpart:
            ``(1) The term `health disparities' has the meaning given 
        to the term in section 3171.
            ``(2) The term `primary health services' has the meaning 
        given to such term in section 331(a)(3)(D).

``SEC. 340I. LOAN REPAYMENTS.

    ``(a) Loan Repayments.--The Secretary, acting through the 
Administrator of the Health Resources and Services Administration, 
shall enter into contracts with individuals under which--
            ``(1) the individual agrees--
                    ``(A) to serve as a full-time primary health 
                services provider or as a full-time or part-time 
                provider of other health services for a period of time 
                equal to 2 years or such longer period as the 
                individual may agree to;
                    ``(B) to serve in a health professional needs area 
                in a health discipline, specialty, or a subspecialty 
                for which the area, population, or facility is 
                designated as a health professional needs area under 
                section 340H; and
                    ``(C) in the case of an individual described in 
                section 340H(c)(3) who is in the final year of study 
                and who has accepted employment as a primary health 
                services provider or provider of other health services 
                in accordance with subparagraphs (A) and (B), to 
                complete the education or training and maintain an 
                acceptable level of academic standing (as determined by 
                the educational institution offering the course of 
                study or training); and
            ``(2) the Secretary agrees to pay, for each year of such 
        service, an amount on the principal and interest of the 
        undergraduate or graduate educational loans (or both) of the 
        individual that is not more than 50 percent of the average 
        award made under the National Health Service Corps Loan 
        Repayment Program under subpart III in that year.
    ``(b) Practice Setting.--A contract entered into under this section 
shall allow the individual receiving the loan repayment to satisfy the 
service requirement described in subsection (a)(1) through employment 
in a solo or group practice, a clinic, an accredited public or private 
nonprofit hospital, or any other health care entity, as deemed 
appropriate by the Secretary.
    ``(c) Application of Certain Provisions.--The provisions of subpart 
III of part D shall, except as inconsistent with this section, apply to 
the loan repayment program under this subpart in the same manner and to 
the same extent as such provisions apply to the National Health Service 
Corps Loan Repayment Program established under section 338B.
    ``(d) Insufficient Number of Applicants.--If there are an 
insufficient number of applicants for loan repayments under this 
section to obligate all appropriated funds, the Secretary shall 
transfer the unobligated funds to the National Health Service Corps for 
the purpose of recruiting applicants and entering into contracts with 
individuals so as to ensure a sufficient number of participants in the 
National Health Service Corps for the following year.

``SEC. 340J. REPORT.

    ``The Secretary shall submit to the Congress an annual report on 
the program carried out under this subpart.

``SEC. 340K. ALLOCATION.

    ``Of the amount of funds obligated under this subpart each fiscal 
year for loan repayments--
            ``(1) 90 percent shall be for physicians and other health 
        professionals providing primary health services; and
            ``(2) 10 percent shall be for health professionals not 
        described in paragraph (1).''.

SEC. 2212. PRIMARY CARE STUDENT LOAN FUNDS.

    (a) In General.--Section 735 (42 U.S.C. 292y) is amended--
            (1) by redesignating subsection (f) as subsection (g); and
            (2) by inserting after subsection (e) the following:
    ``(f) Determination of Financial Need.--The Secretary--
            ``(1) may require, or authorize a school or other entity to 
        require, the submission of financial information to determine 
        the financial resources available to any individual seeking 
        assistance under this subpart; and
            ``(2) shall take into account the extent to which such 
        individual is financially independent in determining whether to 
        require or authorize the submission of such information 
        regarding such individual's family members.''.
    (b) Revised Guidelines.--The Secretary of Health and Human Services 
shall--
            (1) strike the second sentence of section 57.206(b)(1) of 
        title 42, Code of Federal Regulations; and
            (2) make such other revisions to guidelines and regulations 
        in effect as of the date of the enactment of this Act as may be 
        necessary for consistency with the amendments made by paragraph 
        (1).

SEC. 2213. TRAINING IN FAMILY MEDICINE, GENERAL INTERNAL MEDICINE, 
              GENERAL PEDIATRICS, GERIATRICS, AND PHYSICIAN ASSISTANTS.

    Section 747 (42 U.S.C. 293k) is amended--
            (1) by amending the section heading to read as follows: 
        ``primary care training and enhancement'';
            (2) by redesignating subsection (e) as subsection (g); and
            (3) by striking subsections (a) through (d) and inserting 
        the following:
    ``(a) Program.--The Secretary shall establish a primary care 
training and capacity building program consisting of awarding grants 
and contracts under subsections (b) and (c).
    ``(b) Support and Development of Primary Care Training Programs.--
            ``(1) In general.--The Secretary shall make grants to, or 
        enter into contracts with, eligible entities--
                    ``(A) to plan, develop, operate, or participate in 
                an accredited professional training program, including 
                an accredited residency or internship program, in the 
                field of family medicine, general internal medicine, 
                general pediatrics, or geriatrics for medical students, 
                interns, residents, or practicing physicians;
                    ``(B) to provide financial assistance in the form 
                of traineeships and fellowships to medical students, 
                interns, residents, or practicing physicians, who are 
                participants in any such program, and who plan to 
                specialize or work in family medicine, general internal 
                medicine, general pediatrics, or geriatrics;
                    ``(C) to plan, develop, operate, or participate in 
                an accredited program for the training of physicians 
                who plan to teach in family medicine, general internal 
                medicine, general pediatrics, or geriatrics training 
                programs including in community-based settings;
                    ``(D) to provide financial assistance in the form 
                of traineeships and fellowships to practicing 
                physicians who are participants in any such programs 
                and who plan to teach in a family medicine, general 
                internal medicine, general pediatrics, or geriatrics 
                training program; and
                    ``(E) to plan, develop, operate, or participate in 
                an accredited program for physician assistant 
                education, and for the training of individuals who plan 
                to teach in programs to provide such training.
            ``(2) Eligibility.--To be eligible for a grant or contract 
        under paragraph (1), an entity shall be--
                    ``(A) an accredited school of medicine or 
                osteopathic medicine, public or nonprofit private 
                hospital, or physician assistant training program;
                    ``(B) a public or private nonprofit entity; or
                    ``(C) a consortium of 2 or more entities described 
                in subparagraphs (A) and (B).
    ``(c) Capacity Building in Primary Care.--
            ``(1) In general.--The Secretary shall make grants to or 
        enter into contracts with eligible entities to establish, 
        maintain, or improve--
                    ``(A) academic administrative units (including 
                departments, divisions, or other appropriate units) in 
                the specialties of family medicine, general internal 
                medicine, general pediatrics, or geriatrics; or
                    ``(B) programs that improve clinical teaching in 
                such specialties.
            ``(2) Eligibility.--To be eligible for a grant or contract 
        under paragraph (1), an entity shall be an accredited school of 
        medicine or osteopathic medicine.
    ``(d) Preference.--In awarding grants or contracts under this 
section, the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            ``(1) Training a high or significantly improved percentage 
        of health professionals who provide primary care.
            ``(2) Training individuals who are from disadvantaged 
        backgrounds (including racial and ethnic minorities 
        underrepresented among primary care professionals).
            ``(3) A high rate of placing graduates in practice settings 
        having the principal focus of serving in underserved areas or 
        populations experiencing health disparities (including serving 
        patients eligible for medical assistance under title XIX of the 
        Social Security Act or for child health assistance under title 
        XXI of such Act or those with special health care needs).
            ``(4) Supporting teaching programs that address the health 
        care needs of vulnerable populations.
    ``(e) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.
    ``(f) Definition.--In this section, the term `health disparities' 
has the meaning given the term in section 3171.''.

SEC. 2214. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED SETTINGS.

    Title VII (42 U.S.C. 292 et seq.) is amended--
            (1) by redesignating section 748 as 749A; and
            (2) by inserting after section 747 the following:

``SEC. 748. TRAINING OF MEDICAL RESIDENTS IN COMMUNITY-BASED SETTINGS.

    ``(a) Program.--The Secretary shall establish a program for the 
training of medical residents in community-based settings consisting of 
awarding grants and contracts under this section.
    ``(b) Development and Operation of Community-Based Programs.--The 
Secretary shall make grants to, or enter into contracts with, eligible 
entities--
            ``(1) to plan and develop a new primary care residency 
        training program, which may include--
                    ``(A) planning and developing curricula;
                    ``(B) recruiting and training residents and 
                faculty; and
                    ``(C) other activities designated to result in 
                accreditation of such a program; or
            ``(2) to operate or participate in an established primary 
        care residency training program, which may include--
                    ``(A) planning and developing curricula;
                    ``(B) recruitment and training of residents; and
                    ``(C) retention of faculty.
    ``(c) Eligible Entity.--To be eligible to receive a grant or 
contract under subsection (b), an entity shall--
            ``(1) be designated as a recipient of payment for the 
        direct costs of medical education under section 1886(k) of the 
        Social Security Act;
            ``(2) be designated as an approved teaching health center 
        under section 1502(d) of the Affordable Health Care for America 
        Act and continuing to participate in the demonstration project 
        under such section;
            ``(3) be an applicant for designation described in 
        paragraph (1) or (2) and have demonstrated to the Secretary 
        appropriate involvement of an accredited teaching hospital to 
        carry out the inpatient responsibilities associated with a 
        primary care residency training program; or
            ``(4) be eligible to be designated as described in 
        paragraph (1) or (2), not be an applicant as described in 
        paragraph (3), and have demonstrated appropriate involvement of 
        an accredited teaching hospital to carry out the inpatient 
        responsibilities associated with a primary care residency 
        training program.
    ``(d) Preferences.--In awarding grants and contracts under 
paragraph (1) or (2) of subsection (b), the Secretary shall give 
preference to entities that--
            ``(1) support teaching programs that address the health 
        care needs of vulnerable populations; or
            ``(2) are a Federally qualified health center (as defined 
        in section 1861(aa)(4) of the Social Security Act) or a rural 
        health clinic (as defined in section 1861(aa)(2) of such Act).
    ``(e) Additional Preferences for Established Programs.--In awarding 
grants and contracts under subsection (b)(2), the Secretary shall give 
preference to entities that have a demonstrated record of training--
            ``(1) a high or significantly improved percentage of health 
        professionals who provide primary care;
            ``(2) individuals who are from disadvantaged backgrounds 
        (including racial and ethnic minorities underrepresented among 
        primary care professionals); or
            ``(3) individuals who practice in settings having the 
        principal focus of serving underserved areas or populations 
        experiencing health disparities (including serving patients 
        eligible for medical assistance under title XIX of the Social 
        Security Act or for child health assistance under title XXI of 
        such Act or those with special health care needs).
    ``(f) Period of Awards.--
            ``(1) In general.--The period of a grant or contract under 
        this section--
                    ``(A) shall not exceed 3 years for awards under 
                subsection (b)(1); and
                    ``(B) shall not exceed 5 years for awards under 
                subsection (b)(2).
            ``(2) Special rules.--
                    ``(A) An award of a grant or contract under 
                subsection (b)(1) shall not be renewed.
                    ``(B) The period of a grant or contract awarded to 
                an entity under subsection (b)(2) shall not overlap 
                with the period of any grant or contact awarded to the 
                same entity under subsection (b)(1).
    ``(g) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.
    ``(h) Definitions.--In this section:
            ``(1) Health disparities.--The term `health disparities' 
        has the meaning given the term in section 3171.
            ``(2) Primary care resident.--The term `primary care 
        resident' has the meaning given the term in section 
        1886(h)(5)(H) of the Social Security Act.
            ``(3) Primary care residency training program.--The term 
        `primary care residency training program' means an approved 
        medical residency training program described in section 
        1886(h)(5)(A) of the Social Security Act for primary care 
        residents that is--
                    ``(A) in the case of entities seeking awards under 
                subsection (b)(1), actively applying to be accredited 
                by the Accreditation Council for Graduate Medical 
                Education or the American Osteopathic Association; or
                    ``(B) in the case of entities seeking awards under 
                subsection (b)(2), so accredited.
    ``(i) Allocation of Funds.--Of the amount appropriated pursuant to 
section 799C(a) for a fiscal year, not more than 17 percent of such 
amount shall be made available to carry out this section.''.

SEC. 2215. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTS 
              AND DENTAL HYGIENISTS.

    Title VII (42 U.S.C. 292 et seq.) is amended--
            (1) in section 791(a)(1), by striking ``747 and 750'' and 
        inserting ``747, 749, and 750''; and
            (2) by inserting after section 748, as added, the 
        following:

``SEC. 749. TRAINING FOR GENERAL, PEDIATRIC, AND PUBLIC HEALTH DENTISTS 
              AND DENTAL HYGIENISTS.

    ``(a) Program.--The Secretary shall establish a training program 
for oral health professionals consisting of awarding grants and 
contracts under this section.
    ``(b) Support and Development of Oral Health Training Programs.--
The Secretary shall make grants to, or enter into contracts with, 
eligible entities--
            ``(1) to plan, develop, operate, or participate in an 
        accredited professional training program for oral health 
        professionals;
            ``(2) to provide financial assistance to oral health 
        professionals who are in need thereof, who are participants in 
        any such program, and who plan to work in general, pediatric, 
        or public health dentistry, or dental hygiene;
            ``(3) to plan, develop, operate, or participate in a 
        program for the training of oral health professionals who plan 
        to teach in general, pediatric, or public health dentistry, or 
        dental hygiene;
            ``(4) to provide financial assistance in the form of 
        traineeships and fellowships to oral health professionals who 
        plan to teach in general, pediatric, or public health dentistry 
        or dental hygiene;
            ``(5) to establish, maintain, or improve--
                    ``(A) academic administrative units (including 
                departments, divisions, or other appropriate units) in 
                the specialties of general, pediatric, or public health 
                dentistry; or
                    ``(B) programs that improve clinical teaching in 
                such specialties;
            ``(6) to plan, develop, operate, or participate in 
        predoctoral and postdoctoral training in general, pediatric, or 
        public health dentistry programs;
            ``(7) to plan, develop, operate, or participate in a loan 
        repayment program for full-time faculty in a program of 
        general, pediatric, or public health dentistry; and
            ``(8) to provide technical assistance to pediatric dental 
        training programs in developing and implementing instruction 
        regarding the oral health status, dental care needs, and risk-
        based clinical disease management of all pediatric populations 
        with an emphasis on underserved children.
    ``(c) Eligibility.--To be eligible for a grant or contract under 
this section, an entity shall be--
            ``(1) an accredited school of dentistry, training program 
        in dental hygiene, or public or nonprofit private hospital;
            ``(2) a training program in dental hygiene at an accredited 
        institution of higher education;
            ``(3) a public or private nonprofit entity; or
            ``(4) a consortium of--
                    ``(A) 1 or more of the entities described in 
                paragraphs (1) through (3); and
                    ``(B) an accredited school of public health.
    ``(d) Preference.--In awarding grants or contracts under this 
section, the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            ``(1) Training a high or significantly improved percentage 
        of oral health professionals who practice general, pediatric, 
        or public health dentistry.
            ``(2) Training individuals who are from disadvantaged 
        backgrounds (including racial and ethnic minorities 
        underrepresented among oral health professionals).
            ``(3) A high rate of placing graduates in practice settings 
        having the principal focus of serving in underserved areas or 
        populations experiencing health disparities (including serving 
        patients eligible for medical assistance under title XIX of the 
        Social Security Act or for child health assistance under title 
        XXI of such Act or those with special health care needs).
            ``(4) Supporting teaching programs that address the oral 
        health needs of vulnerable populations.
            ``(5) Providing instruction regarding the oral health 
        status, oral health care needs, and risk-based clinical disease 
        management of all pediatric populations with an emphasis on 
        underserved children.
    ``(e) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.
    ``(f) Definitions.--In this section:
            ``(1) The term `health disparities' has the meaning given 
        the term in section 3171.
            ``(2) The term `oral health professional' means an 
        individual training or practicing--
                    ``(A) in general dentistry, pediatric dentistry, 
                public health dentistry, or dental hygiene; or
                    ``(B) another oral health specialty, as deemed 
                appropriate by the Secretary.''.

SEC. 2216. AUTHORIZATION OF APPROPRIATIONS.

    (a) In General.--Part F of title VII (42 U.S.C. 295j et seq.) is 
amended by adding at the end the following:

``SEC. 799C. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.

    ``(a) Promotion of Primary Care and Dentistry.--For the purpose of 
carrying out subpart XI of part D of title III and sections 747, 748, 
and 749, in addition to any other amounts authorized to be appropriated 
for such purpose, there are authorized to be appropriated, out of any 
monies in the Public Health Investment Fund, the following:
            ``(1) $240,000,000 for fiscal year 2011.
            ``(2) $253,000,000 for fiscal year 2012.
            ``(3) $265,000,000 for fiscal year 2013.
            ``(4) $278,000,000 for fiscal year 2014.
            ``(5) $292,000,000 for fiscal year 2015.''.
    (b) Existing Authorization of Appropriations.--Subsection (g)(1), 
as so redesignated, of section 747 (42 U.S.C. 293k) is amended by 
striking ``2002'' and inserting ``2015''.

SEC. 2217. STUDY ON EFFECTIVENESS OF SCHOLARSHIPS AND LOAN REPAYMENTS.

    (a) Study.--The Comptroller General of the United States shall 
conduct a study to determine the effectiveness of scholarship and loan 
repayment programs under subparts III and XI of part D of title III of 
the Public Health Service Act, as amended or added by sections 2201 and 
2211, including whether scholarships or loan repayments are more 
effective in--
            (1) incentivizing physicians, and other providers, to 
        pursue careers in primary care specialties;
            (2) retaining such primary care providers; and
            (3) encouraging such primary care providers to practice in 
        underserved areas.
    (b) Report.--Not later than 12 months after the date of the 
enactment of this Act, the Comptroller General shall submit to the 
Congress a report on the results of the study under subsection (a).

                     Subtitle B--Nursing Workforce

SEC. 2221. AMENDMENTS TO PUBLIC HEALTH SERVICE ACT.

    (a) Definitions.--Section 801 (42 U.S.C. 296 et seq.) is amended--
            (1) in paragraph (1), by inserting ``nurse-managed health 
        centers,'' after ``nursing centers,''; and
            (2) by adding at the end the following:
            ``(16) Nurse-managed health center.--The term `nurse-
        managed health center'--
                    ``(A) means a nurse-practice arrangement, managed 
                by one or more advanced practice nurses, that provides 
                primary care or wellness services to underserved or 
                vulnerable populations and is associated with an 
                accredited school of nursing, Federally qualified 
                health center, or independent nonprofit health or 
                social services agency; and
                    ``(B) shall not be construed as changing State law 
                requirements applicable to an advanced practice nurse 
                or the authorized scope of practice of such a nurse.''.
    (b) Grants for Health Professions Education.--Title VIII (42 U.S.C. 
296 et seq.) is amended by striking section 807.
    (c) Reports.--Part A of title VIII (42 U.S.C. 296 et seq.) is 
amended by adding at the end the following:

``SEC. 809. REPORTS.

    ``The Secretary shall submit to the Congress a separate annual 
report on the activities carried out under each of sections 811, 821, 
836, 846A, and 861.''.
    (d) Advanced Education Nursing Grants.--Section 811(f) (42 U.S.C. 
296j(f)) is amended--
            (1) by striking paragraph (2);
            (2) by redesignating paragraph (3) as paragraph (2); and
            (3) in paragraph (2), as so redesignated, by striking 
        ``that agrees'' and all that follows through the end and 
        inserting: ``that agrees to expend the award--
                    ``(A) to train advanced education nurses who will 
                practice in health professional shortage areas 
                designated under section 332; or
                    ``(B) to increase diversity among advanced 
                education nurses.''.
    (e) Nurse Education, Practice, and Retention Grants.--Section 831 
(42 U.S.C. 296p) is amended--
            (1) in subsection (b), by amending paragraph (3) to read as 
        follows:
            ``(3) providing coordinated care, quality care, and other 
        skills needed to practice nursing; or''; and
            (2) by striking subsection (e) and redesignating 
        subsections (f) through (h) as subsections (e) through (g), 
        respectively.
    (f) Student Loans.--Subsection (a) of section 836 (42 U.S.C. 297b) 
is amended--
            (1) by striking ``$2,500'' and inserting ``$3,300'';
            (2) by striking ``$4,000'' and inserting ``$5,200'';
            (3) by striking ``$13,000'' and inserting ``$17,000''; and
            (4) by adding at the end the following: ``Beginning with 
        fiscal year 2012, the dollar amounts specified in this 
        subsection shall be adjusted by an amount determined by the 
        Secretary on an annual basis to reflect inflation.''.
    (g) Loan Repayment.--Section 846 (42 U.S.C. 297n) is amended--
            (1) in subsection (a), by amending paragraph (3) to read as 
        follows:
            ``(3) who enters into an agreement with the Secretary to 
        serve for a period of not less than 2 years--
                    ``(A) as a nurse at a health care facility with a 
                critical shortage of nurses; or
                    ``(B) as a faculty member at an accredited school 
                of nursing;''; and
            (2) in subsection (g)(1), by striking ``to provide health 
        services'' each place it appears and inserting ``to provide 
        health services or serve as a faculty member''.
    (h) Nurse Faculty Loan Program.--Paragraph (2) of section 846A(c) 
(42 U.S.C. 297n-1(c)) is amended by striking ``$30,000'' and all that 
follows through the semicolon and inserting ``$35,000, plus, beginning 
with fiscal year 2012, an amount determined by the Secretary on an 
annual basis to reflect inflation;''.
    (i) Public Service Announcements.--Title VIII (42 U.S.C. 296 et 
seq.) is amended by striking part H.
    (j) Technical and Conforming Amendments.--Title VIII (42 U.S.C. 296 
et seq.) is amended--
            (1) by moving section 810 (relating to prohibition against 
        discrimination by schools on the basis of sex) so that it 
        follows section 809, as added by subsection (c);
            (2) in sections 835, 836, 838, 840, and 842, by striking 
        the term ``this subpart'' each place it appears and inserting 
        ``this part'';
            (3) in section 836(h), by striking the last sentence;
            (4) in section 836, by redesignating subsection (l) as 
        subsection (k);
            (5) in section 839, by striking ``839'' and all that 
        follows through ``(a)'' and inserting ``839. (a)'';
            (6) in section 835(b), by striking ``841'' each place it 
        appears and inserting ``871'';
            (7) by redesignating section 841 as section 871, moving 
        part F to the end of the title, and redesignating such part as 
        part H;
            (8) in part G--
                    (A) by redesignating section 845 as section 851; 
                and
                    (B) by redesignating part G as part F; and
            (9) in part I--
                    (A) by redesignating section 855 as section 861; 
                and
                    (B) by redesignating part I as part G.
    (k) Funding.--
            (1) In general.--Part H, as redesignated, of title VIII is 
        amended by adding at the end the following:

``SEC. 872. FUNDING THROUGH PUBLIC HEALTH INVESTMENT FUND.

    ``For the purpose of carrying out this title, in addition to any 
other amounts authorized to be appropriated for such purpose, there are 
authorized to be appropriated, out of any monies in the Public Health 
Investment Fund, the following:
            ``(1) $115,000,000 for fiscal year 2011.
            ``(2) $122,000,000 for fiscal year 2012.
            ``(3) $127,000,000 for fiscal year 2013.
            ``(4) $134,000,000 for fiscal year 2014.
            ``(5) $140,000,000 for fiscal year 2015.''.
            (2) Existing authorizations of appropriations.--
                    (A) Sections 831, 846, 846a, and 861.--Sections 
                831(g) (as so redesignated), 846(i)(1) (42 U.S.C. 
                297n(i)(1)), 846A(f) (42 U.S.C. 297n-1(f)), and 861(e) 
                (as so redesignated) are amended by striking ``2007'' 
                each place it appears and inserting ``2015''.
                    (B) Section 871.--Section 871, as so redesignated 
                by subsection (j), is amended to read as follows:

``SEC. 871. FUNDING.

    ``For the purpose of carrying out parts B, C, and D (subject to 
section 851(g)), there are authorized to be appropriated such sums as 
may be necessary for each fiscal year through fiscal year 2015.''.

                  Subtitle C--Public Health Workforce

SEC. 2231. PUBLIC HEALTH WORKFORCE CORPS.

    Part D of title III (42 U.S.C. 254b et seq.), as amended by section 
2211, is amended by adding at the end the following:

                 ``Subpart XII--Public Health Workforce

``SEC. 340L. PUBLIC HEALTH WORKFORCE CORPS.

    ``(a) Establishment.--There is established, within the Service, the 
Public Health Workforce Corps (in this subpart referred to as the 
`Corps'), for the purpose of ensuring an adequate supply of public 
health professionals throughout the Nation. The Corps shall consist 
of--
            ``(1) such officers of the Regular and Reserve Corps of the 
        Service as the Secretary may designate;
            ``(2) such civilian employees of the United States as the 
        Secretary may appoint; and
            ``(3) such other individuals who are not employees of the 
        United States.
    ``(b) Administration.--Except as provided in subsection (c), the 
Secretary shall carry out this subpart acting through the Administrator 
of the Health Resources and Services Administration.
    ``(c) Placement and Assignment.--The Secretary, acting through the 
Director of the Centers for Disease Control and Prevention, shall 
develop a methodology for placing and assigning Corps participants as 
public health professionals. Such methodology may allow for placing and 
assigning such participants in State, local, and tribal health 
departments and Federally qualified health centers (as defined in 
section 1861(aa)(4) of the Social Security Act).
    ``(d) Application of Certain Provisions.--The provisions of subpart 
II shall, except as inconsistent with this subpart, apply to the Public 
Health Workforce Corps in the same manner and to the same extent as 
such provisions apply to the National Health Service Corps established 
under section 331.
    ``(e) Report.--The Secretary shall submit to the Congress an annual 
report on the programs carried out under this subpart.

``SEC. 340M. PUBLIC HEALTH WORKFORCE SCHOLARSHIP PROGRAM.

    ``(a) Establishment.--The Secretary shall establish the Public 
Health Workforce Scholarship Program (referred to in this section as 
the `Program') for the purpose described in section 340L(a).
    ``(b) Eligibility.--To be eligible to participate in the Program, 
an individual shall--
            ``(1)(A) be accepted for enrollment, or be enrolled, as a 
        full-time or part-time student in a course of study or program 
        (approved by the Secretary) at an accredited graduate school or 
        program of public health; or
            ``(B) have demonstrated expertise in public health and be 
        accepted for enrollment, or be enrolled, as a full-time or 
        part-time student in a course of study or program (approved by 
        the Secretary) at--
                    ``(i) an accredited graduate school or program of 
                nursing; health administration, management, or policy; 
                preventive medicine; laboratory science; veterinary 
                medicine; or dental medicine; or
                    ``(ii) another accredited graduate school or 
                program, as deemed appropriate by the Secretary;
            ``(2) be eligible for, or hold, an appointment as a 
        commissioned officer in the Regular or Reserve Corps of the 
        Service or be eligible for selection for civilian service in 
        the Corps; and
            ``(3) sign and submit to the Secretary a written contract 
        (described in subsection (c)) to serve full-time as a public 
        health professional, upon the completion of the course of study 
        or program involved, for the period of obligated service 
        described in subsection (c)(2)(E).
    ``(c) Contract.--The written contract between the Secretary and an 
individual under subsection (b)(3) shall contain--
            ``(1) an agreement on the part of the Secretary that the 
        Secretary will--
                    ``(A) provide the individual with a scholarship for 
                a period of years (not to exceed 4 academic years) 
                during which the individual shall pursue an approved 
                course of study or program to prepare the individual to 
                serve in the public health workforce; and
                    ``(B) accept (subject to the availability of 
                appropriated funds) the individual into the Corps;
            ``(2) an agreement on the part of the individual that the 
        individual will--
                    ``(A) accept provision of such scholarship to the 
                individual;
                    ``(B) maintain full-time or part-time enrollment in 
                the approved course of study or program described in 
                subsection (b)(1) until the individual completes that 
                course of study or program;
                    ``(C) while enrolled in the approved course of 
                study or program, maintain an acceptable level of 
                academic standing (as determined by the educational 
                institution offering such course of study or program);
                    ``(D) if applicable, complete a residency or 
                internship; and
                    ``(E) serve full-time as a public health 
                professional for a period of time equal to the greater 
                of--
                            ``(i) 1 year for each academic year for 
                        which the individual was provided a scholarship 
                        under the Program; or
                            ``(ii) 2 years; and
            ``(3) an agreement by both parties as to the nature and 
        extent of the scholarship assistance, which may include--
                    ``(A) payment of reasonable educational expenses of 
                the individual, including tuition, fees, books, 
                equipment, and laboratory expenses; and
                    ``(B) payment of a stipend of not more than $1,269 
                (plus, beginning with fiscal year 2012, an amount 
                determined by the Secretary on an annual basis to 
                reflect inflation) per month for each month of the 
                academic year involved, with the dollar amount of such 
                a stipend determined by the Secretary taking into 
                consideration whether the individual is enrolled full-
                time or part-time.
    ``(d) Application of Certain Provisions.--The provisions of subpart 
III shall, except as inconsistent with this subpart, apply to the 
scholarship program under this section in the same manner and to the 
same extent as such provisions apply to the National Health Service 
Corps Scholarship Program established under section 338A.

``SEC. 340N. PUBLIC HEALTH WORKFORCE LOAN REPAYMENT PROGRAM.

    ``(a) Establishment.--The Secretary shall establish the Public 
Health Workforce Loan Repayment Program (referred to in this section as 
the `Program') for the purpose described in section 340L(a).
    ``(b) Eligibility.--To be eligible to participate in the Program, 
an individual shall--
            ``(1)(A) have a graduate degree from an accredited school 
        or program of public health;
            ``(B) have demonstrated expertise in public health and have 
        a graduate degree in a course of study or program (approved by 
        the Secretary) from--
                    ``(i) an accredited school or program of nursing; 
                health administration, management, or policy; 
                preventive medicine; laboratory science; veterinary 
                medicine; or dental medicine; or
                    ``(ii) another accredited school or program 
                approved by the Secretary; or
            ``(C) be enrolled as a full-time or part-time student in 
        the final year of a course of study or program (approved by the 
        Secretary) offered by a school or program described in 
        subparagraph (A) or (B), leading to a graduate degree;
            ``(2) be eligible for, or hold, an appointment as a 
        commissioned officer in the Regular or Reserve Corps of the 
        Service or be eligible for selection for civilian service in 
        the Corps;
            ``(3) if applicable, complete a residency or internship; 
        and
            ``(4) sign and submit to the Secretary a written contract 
        (described in subsection (c)) to serve full-time as a public 
        health professional for the period of obligated service 
        described in subsection (c)(2).
    ``(c) Contract.--The written contract between the Secretary and an 
individual under subsection (b)(4) shall contain--
            ``(1) an agreement by the Secretary to repay on behalf of 
        the individual loans incurred by the individual in the pursuit 
        of the relevant public health workforce educational degree in 
        accordance with the terms of the contract;
            ``(2) an agreement by the individual to serve full-time as 
        a public health professional for a period of time equal to 2 
        years or such longer period as the individual may agree to; and
            ``(3) in the case of an individual described in subsection 
        (b)(1)(C) who is in the final year of study and who has 
        accepted employment as a public health professional, in 
        accordance with section 340L(c), an agreement on the part of 
        the individual to complete the education or training, maintain 
        an acceptable level of academic standing (as determined by the 
        educational institution offering the course of study or 
        training), and serve the period of obligated service described 
        in paragraph (2).
    ``(d) Payments.--
            ``(1) In general.--A loan repayment provided for an 
        individual under a written contract under the Program shall 
        consist of payment, in accordance with paragraph (2), on behalf 
        of the individual of the principal, interest, and related 
        expenses on government and commercial loans received by the 
        individual regarding the undergraduate or graduate education of 
        the individual (or both), which loans were made for reasonable 
        educational expenses, including tuition, fees, books, 
        equipment, and laboratory expenses, incurred by the individual.
            ``(2) Payments for years served.--
                    ``(A) In general.--For each year of obligated 
                service that an individual contracts to serve under 
                subsection (c), the Secretary may pay up to $35,000 
                (plus, beginning with fiscal year 2012, an amount 
                determined by the Secretary on an annual basis to 
                reflect inflation) on behalf of the individual for 
                loans described in paragraph (1).
                    ``(B) Repayment schedule.--Any arrangement made by 
                the Secretary for the making of loan repayments in 
                accordance with this subsection shall provide that any 
                repayments for a year of obligated service shall be 
                made no later than the end of the fiscal year in which 
                the individual completes such year of service.
    ``(e) Application of Certain Provisions.--The provisions of subpart 
III shall, except as inconsistent with this subpart, apply to the loan 
repayment program under this section in the same manner and to the same 
extent as such provisions apply to the National Health Service Corps 
Loan Repayment Program established under section 338B.''.

SEC. 2232. ENHANCING THE PUBLIC HEALTH WORKFORCE.

    Section 765 (42 U.S.C. 295) is amended to read as follows:

``SEC. 765. ENHANCING THE PUBLIC HEALTH WORKFORCE.

    ``(a) Program.--The Secretary, acting through the Administrator of 
the Health Resources and Services Administration and in consultation 
with the Director of the Centers for Disease Control and Prevention, 
shall establish a public health workforce training and enhancement 
program consisting of awarding grants and contracts under subsection 
(b).
    ``(b) Grants and Contracts.--The Secretary shall award grants to, 
or enter into contracts with, eligible entities--
            ``(1) to plan, develop, operate, or participate in, an 
        accredited professional training program in the field of public 
        health (including such a program in nursing; health 
        administration, management, or policy; preventive medicine; 
        laboratory science; veterinary medicine; or dental medicine) 
        for members of the public health workforce, including midcareer 
        professionals;
            ``(2) to provide financial assistance in the form of 
        traineeships and fellowships to students who are participants 
        in any such program and who plan to specialize or work in the 
        field of public health;
            ``(3) to plan, develop, operate, or participate in a 
        program for the training of public health professionals who 
        plan to teach in any program described in paragraph (1); and
            ``(4) to provide financial assistance in the form of 
        traineeships and fellowships to public health professionals who 
        are participants in any program described in paragraph (1) and 
        who plan to teach in the field of public health, including 
        nursing; health administration, management, or policy; 
        preventive medicine; laboratory science; veterinary medicine; 
        or dental medicine.
    ``(c) Eligibility.--To be eligible for a grant or contract under 
this section, an entity shall be--
            ``(1) an accredited health professions school, including an 
        accredited school or program of public health; nursing; health 
        administration, management, or policy; preventive medicine; 
        laboratory science; veterinary medicine; or dental medicine;
            ``(2) a State, local, or tribal health department;
            ``(3) a public or private nonprofit entity; or
            ``(4) a consortium of 2 or more entities described in 
        paragraphs (1) through (3).
    ``(d) Preference.--In awarding grants or contracts under this 
section, the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            ``(1) Training a high or significantly improved percentage 
        of public health professionals who serve in underserved 
        communities.
            ``(2) Training individuals who are from disadvantaged 
        backgrounds (including racial and ethnic minorities 
        underrepresented among public health professionals).
            ``(3) Training individuals in public health specialties 
        experiencing a significant shortage of public health 
        professionals (as determined by the Secretary).
            ``(4) Training a high or significantly improved percentage 
        of public health professionals serving in the Federal 
        Government or a State, local, or tribal government.
    ``(e) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.''.

SEC. 2233. PUBLIC HEALTH TRAINING CENTERS.

    Section 766 (42 U.S.C. 295a) is amended--
            (1) in subsection (b)(1), by striking ``in furtherance of 
        the goals established by the Secretary for the year 2000'' and 
        inserting ``in furtherance of the goals established by the 
        Secretary in the national prevention and wellness strategy 
        under section 3121''; and
            (2) by adding at the end the following:
    ``(d) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.''.

SEC. 2234. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT 
              PROGRAM.

    Section 768 (42 U.S.C. 295c) is amended to read as follows:

``SEC. 768. PREVENTIVE MEDICINE AND PUBLIC HEALTH TRAINING GRANT 
              PROGRAM.

    ``(a) Grants.--The Secretary, acting through the Administrator of 
the Health Resources and Services Administration and in consultation 
with the Director of the Centers for Disease Control and Prevention, 
shall award grants to, or enter into contracts with, eligible entities 
to provide training to graduate medical residents in preventive 
medicine specialties.
    ``(b) Eligibility.--To be eligible for a grant or contract under 
subsection (a), an entity shall be--
            ``(1) an accredited school of public health or school of 
        medicine or osteopathic medicine;
            ``(2) an accredited public or private nonprofit hospital;
            ``(3) a State, local, or tribal health department; or
            ``(4) a consortium of 2 or more entities described in 
        paragraphs (1) through (3).
    ``(c) Use of Funds.--Amounts received under a grant or contract 
under this section shall be used to--
            ``(1) plan, develop (including the development of 
        curricula), operate, or participate in an accredited residency 
        or internship program in preventive medicine or public health;
            ``(2) defray the costs of practicum experiences, as 
        required in such a program; and
            ``(3) establish, maintain, or improve--
                    ``(A) academic administrative units (including 
                departments, divisions, or other appropriate units) in 
                preventive medicine and public health; or
                    ``(B) programs that improve clinical teaching in 
                preventive medicine and public health.
    ``(d) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.''.

SEC. 2235. AUTHORIZATION OF APPROPRIATIONS.

    (a) In General.--Section 799C, as added by section 2216 of this 
Act, is amended by adding at the end the following:
    ``(b) Public Health Workforce.--For the purpose of carrying out 
subpart XII of part D of title III and sections 765, 766, and 768, in 
addition to any other amounts authorized to be appropriated for such 
purpose, there are authorized to be appropriated, out of any monies in 
the Public Health Investment Fund, the following:
            ``(1) $51,000,000 for fiscal year 2011.
            ``(2) $54,000,000 for fiscal year 2012.
            ``(3) $57,000,000 for fiscal year 2013.
            ``(4) $59,000,000 for fiscal year 2014.
            ``(5) $62,000,000 for fiscal year 2015.''.
    (b) Existing Authorization of Appropriations.--Subsection (a) of 
section 770 (42 U.S.C. 295e) is amended by striking ``2002'' and 
inserting ``2015''.

     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.

    Paragraph (1) of section 738(a) (42 U.S.C. 293b(a)) is amended by 
striking ``not more than $20,000'' and all that follows through the end 
of the paragraph and inserting: ``not more than $35,000 (plus, 
beginning with fiscal year 2012, an amount determined by the Secretary 
on an annual basis to reflect inflation) of the principal and interest 
of the educational loans of such individuals.''.

SEC. 2242. NURSING WORKFORCE DIVERSITY GRANTS.

    Subsection (b) of section 821 (42 U.S.C. 296m) is amended--
            (1) in the heading, by striking ``Guidance'' and inserting 
        ``Consultation''; and
            (2) by striking ``shall take into consideration'' and all 
        that follows through ``consult with nursing associations'' and 
        inserting ``shall, as appropriate, consult with nursing 
        associations''.

SEC. 2243. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY PROGRAMS.

    (a) In General.--Title VII (42 U.S.C. 292 et seq.) is amended by 
inserting after section 739 the following:

``SEC. 739A. COORDINATION OF DIVERSITY AND CULTURAL COMPETENCY 
              PROGRAMS.

    ``The Secretary shall, to the extent practicable, coordinate the 
activities carried out under this part and section 821 in order to 
enhance the effectiveness of such activities and avoid duplication of 
effort.''.
    (b) Report.--Section 736 (42 U.S.C. 293) is amended--
            (1) by redesignating subsection (h) as subsection (i); and
            (2) by inserting after subsection (g) the following:
    ``(h) Report.--The Secretary shall submit to the Congress an annual 
report on the activities carried out under this section.''.

              PART 2--INTERDISCIPLINARY TRAINING PROGRAMS

SEC. 2251. CULTURAL AND LINGUISTIC COMPETENCY TRAINING FOR HEALTH 
              PROFESSIONALS.

    Section 741 (42 U.S.C. 293e) is amended--
            (1) in the section heading, by striking ``grants for health 
        professions education'' and inserting ``cultural and linguistic 
        competency training for health professionals'';
            (2) by redesignating subsection (b) as subsection (h); and
            (3) by striking subsection (a) and inserting the following:
    ``(a) Program.--The Secretary shall establish a cultural and 
linguistic competency training program for health professionals, 
including nurse professionals, consisting of awarding grants and 
contracts under subsection (b).
    ``(b) Cultural and Linguistic Competency Training.--The Secretary 
shall award grants to, or enter into contracts with, eligible 
entities--
            ``(1) to test, develop, and evaluate models of cultural and 
        linguistic competency training (including continuing education) 
        for health professionals; and
            ``(2) to implement cultural and linguistic competency 
        training programs for health professionals developed under 
        paragraph (1) or otherwise.
    ``(c) Eligibility.--To be eligible for a grant or contract under 
subsection (b), an entity shall be--
            ``(1) an accredited health professions school or program;
            ``(2) an academic health center;
            ``(3) a public or private nonprofit entity; or
            ``(4) a consortium of 2 or more entities described in 
        paragraphs (1) through (3).
    ``(d) Preference.--In awarding grants and contracts under this 
section, the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            ``(1) Addressing, or partnering with an entity with 
        experience addressing, the cultural and linguistic competency 
        needs of the population to be served through the grant or 
        contract.
            ``(2) Addressing health disparities.
            ``(3) Placing health professionals in regions experiencing 
        significant changes in the cultural and linguistic demographics 
        of populations, including communities along the United States-
        Mexico border.
            ``(4) Carrying out activities described in subsection (b) 
        with respect to more than one health profession discipline, 
        specialty, or subspecialty.
    ``(e) Consultation.--The Secretary shall carry out this section in 
consultation with the heads of appropriate health agencies and offices 
in the Department of Health and Human Services, including the Office of 
Minority Health and the National Center on Minority Health and Health 
Disparities.
    ``(f) Definition.--In this section, the term `health disparities' 
has the meaning given to the term in section 3171.
    ``(g) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.''.

SEC. 2252. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.

    Part D of title VII (42 U.S.C. 294 et seq.) is amended by adding at 
the end the following:

``SEC. 759. INNOVATIONS IN INTERDISCIPLINARY CARE TRAINING.

    ``(a) Program.--The Secretary shall establish an innovations in 
interdisciplinary care training program consisting of awarding grants 
and contracts under subsection (b).
    ``(b) Training Programs.--The Secretary shall award grants to, or 
enter into contracts with, eligible entities--
            ``(1) to test, develop, and evaluate health professional 
        training programs (including continuing education) designed to 
        promote--
                    ``(A) the delivery of health services through 
                interdisciplinary and team-based models, which may 
                include patient-centered medical home models, 
                medication therapy management models, and models 
                integrating physical, mental, or oral health services; 
                and
                    ``(B) coordination of the delivery of health care 
                within and across settings, including health care 
                institutions, community-based settings, and the 
                patient's home; and
            ``(2) to implement such training programs developed under 
        paragraph (1) or otherwise.
    ``(c) Eligibility.--To be eligible for a grant or contract under 
subsection (b), an entity shall be--
            ``(1) an accredited health professions school or program;
            ``(2) an academic health center;
            ``(3) a public or private nonprofit entity (including an 
        area health education center or a geriatric education center); 
        or
            ``(4) a consortium of 2 or more entities described in 
        paragraphs (1) through (3).
    ``(d) Preferences.--In awarding grants and contracts under this 
section, the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            ``(1) Training a high or significantly improved percentage 
        of health professionals who serve in underserved communities.
            ``(2) Broad interdisciplinary team-based collaborations.
            ``(3) Addressing health disparities.
    ``(e) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.
    ``(f) Definitions.--In this section:
            ``(1) The term `health disparities' has the meaning given 
        the term in section 3171.
            ``(2) The term `interdisciplinary' means collaboration 
        across health professions and specialties, which may include 
        public health, nursing, allied health, dietetics or nutrition, 
        and appropriate health specialties.''.

     PART 3--ADVISORY COMMITTEE ON HEALTH WORKFORCE EVALUATION AND 
                               ASSESSMENT

SEC. 2261. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.

    Subpart 1 of part E of title VII (42 U.S.C. 294n et seq.) is 
amended by adding at the end the following:

``SEC. 764. HEALTH WORKFORCE EVALUATION AND ASSESSMENT.

    ``(a) Advisory Committee.--The Secretary, acting through the 
Assistant Secretary for Health, shall establish a permanent advisory 
committee to be known as the Advisory Committee on Health Workforce 
Evaluation and Assessment (referred to in this section as the `Advisory 
Committee') to develop and implement an integrated, coordinated, and 
strategic national health workforce policy reflective of current and 
evolving health workforce needs.
    ``(b) Responsibilities.--The Advisory Committee shall--
            ``(1) not later than 1 year after the date of the 
        establishment of the Advisory Committee, submit recommendations 
        to the Secretary on--
                    ``(A) classifications of the health workforce to 
                ensure consistency of data collection on the health 
                workforce; and
                    ``(B) based on such classifications, standardized 
                methodologies and procedures to enumerate the health 
                workforce;
            ``(2) not later than 2 years after the date of the 
        establishment of the Advisory Committee, submit recommendations 
        to the Secretary on--
                    ``(A) the supply, diversity, and geographic 
                distribution of the health workforce;
                    ``(B) the retention and expansion of the health 
                workforce (on a short- and long-term basis) to ensure 
                quality and adequacy of such workforce; and
                    ``(C) policies to carry out the recommendations 
                made pursuant to subparagraphs (A) and (B); and
            ``(3) not later than 4 years after the date of the 
        establishment of the Advisory Committee, and every 2 years 
        thereafter, submit updated recommendations to the Secretary 
        under paragraphs (1) and (2).
    ``(c) Role of Agency.--The Secretary shall provide ongoing 
administrative, research, and technical support for the operations of 
the Advisory Committee, including coordinating and supporting the 
dissemination of the recommendations of the Advisory Committee.
    ``(d) Membership.--
            ``(1) Number; appointment.--The Secretary shall appoint 15 
        members to serve on the Advisory Committee.
            ``(2) Terms.--
                    ``(A) In general.--The Secretary shall appoint 
                members of the Advisory Committee for a term of 3 years 
                and may reappoint such members, but the Secretary may 
                not appoint any member to serve more than a total of 6 
                years.
                    ``(B) Staggered terms.--Notwithstanding 
                subparagraph (A), of the members first appointed to the 
                Advisory Committee under paragraph (1)--
                            ``(i) 5 shall be appointed for a term of 1 
                        year;
                            ``(ii) 5 shall be appointed for a term of 2 
                        years; and
                            ``(iii) 5 shall be appointed for a term of 
                        3 years.
            ``(3) Qualifications.--Members of the Advisory Committee 
        shall be appointed from among individuals who possess expertise 
        in at least one of the following areas:
                    ``(A) Conducting and interpreting health workforce 
                market analysis, including health care labor workforce 
                analysis.
                    ``(B) Conducting and interpreting health finance 
                and economics research.
                    ``(C) Delivering and administering health care 
                services.
                    ``(D) Delivering and administering health workforce 
                education and training.
            ``(4) Representation.--In appointing members of the 
        Advisory Committee, the Secretary shall--
                    ``(A) include no less than one representative of 
                each of--
                            ``(i) health professionals within the 
                        health workforce;
                            ``(ii) health care patients and consumers;
                            ``(iii) employers;
                            ``(iv) labor unions; and
                            ``(v) third-party health payors; and
                    ``(B) ensure that--
                            ``(i) all areas of expertise described in 
                        paragraph (3) are represented;
                            ``(ii) the members of the Advisory 
                        Committee include members who, collectively, 
                        have significant experience working with--
                                    ``(I) populations in urban and 
                                federally designated rural and 
                                nonmetropolitan areas; and
                                    ``(II) populations who are 
                                underrepresented in the health 
                                professions, including underrepresented 
                                minority groups; and
                            ``(iii) individuals who are directly 
                        involved in health professions education or 
                        practice do not constitute a majority of the 
                        members of the Advisory Committee.
            ``(5) Disclosure and conflicts of interest.--Members of the 
        Advisory Committee shall not be considered employees of the 
        Federal Government by reason of service on the Advisory 
        Committee, except members of the Advisory Committee shall be 
        considered to be special Government employees within the 
        meaning of section 107 of the Ethics in Government Act of 1978 
        (5 U.S.C. App.) and section 208 of title 18, United States 
        Code, for the purposes of disclosure and management of 
        conflicts of interest under those sections.
            ``(6) No pay; receipt of travel expenses.--Members of the 
        Advisory Committee shall not receive any pay for service on the 
        Committee, but may receive travel expenses, including a per 
        diem, in accordance with applicable provisions of subchapter I 
        of chapter 57 of title 5, United States Code.
    ``(e) Consultation.--In carrying out this section, the Secretary 
shall consult with the Secretary of Education and the Secretary of 
Labor.
    ``(f) Collaboration.--The Advisory Committee shall collaborate with 
the advisory bodies at the Health Resources and Services 
Administration, the National Advisory Council (as authorized in section 
337), the Advisory Committee on Training in Primary Care Medicine and 
Dentistry (as authorized in section 749A), the Advisory Committee on 
Interdisciplinary, Community-Based Linkages (as authorized in section 
756), the Advisory Council on Graduate Medical Education (as authorized 
in section 762), and the National Advisory Council on Nurse Education 
and Practice (as authorized in section 851).
    ``(g) FACA.--The Federal Advisory Committee Act (5 U.S.C. App.) 
except for section 14 of such Act shall apply to the Advisory Committee 
under this section only to the extent that the provisions of such Act 
do not conflict with the requirements of this section.
    ``(h) Report.--The Secretary shall submit to the Congress an annual 
report on the activities of the Advisory Committee.
    ``(i) Definition.--In this section, the term `health workforce' 
includes all health care providers with direct patient care and support 
responsibilities, including physicians, nurses, physician assistants, 
pharmacists, oral health professionals (as defined in section 
749(f)(2)), allied health professionals, mental and behavioral health 
professionals (as defined in section 775(f)(2)), and public health 
professionals (including veterinarians engaged in public health 
practice).''.

                  PART 4--HEALTH WORKFORCE ASSESSMENT

SEC. 2271. HEALTH WORKFORCE ASSESSMENT.

    (a) In General.--Section 761 (42 U.S.C. 294n) is amended--
            (1) by redesignating subsection (c) as subsection (e); and
            (2) by striking subsections (a) and (b) and inserting the 
        following:
    ``(a) In General.--The Secretary shall, based upon the 
classifications and standardized methodologies and procedures developed 
by the Advisory Committee on Health Workforce Evaluation and Assessment 
under section 764(b)--
            ``(1) collect data on the health workforce (as defined in 
        section 764(i)), disaggregated by field, discipline, and 
        specialty, with respect to--
                    ``(A) the supply (including retention) of health 
                professionals relative to the demand for such 
                professionals;
                    ``(B) the diversity of health professionals 
                (including with respect to race, ethnic background, and 
                sex); and
                    ``(C) the geographic distribution of health 
                professionals; and
            ``(2) collect such data on individuals participating in the 
        programs authorized by subtitles A, B, and C and part 1 of 
        subtitle D of title II of division C of the Affordable Health 
        Care for America Act.
    ``(b) Grants and Contracts for Health Workforce Analysis.--
            ``(1) In general.--The Secretary may award grants to, or 
        enter into contracts with, eligible entities to carry out 
        subsection (a).
            ``(2) Eligibility.--To be eligible for a grant or contract 
        under this subsection, an entity shall be--
                    ``(A) an accredited health professions school or 
                program;
                    ``(B) an academic health center;
                    ``(C) a State, local, or tribal government;
                    ``(D) a public or private entity; or
                    ``(E) a consortium of 2 or more entities described 
                in subparagraphs (A) through (D).
    ``(c) Collaboration and Data Sharing.--The Secretary shall 
collaborate with Federal departments and agencies, health professions 
organizations (including health professions education organizations), 
and professional medical societies for the purpose of carrying out 
subsection (a).
    ``(d) Report.--The Secretary shall submit to the Congress an annual 
report on the data collected under subsection (a).''.
    (b) Period Before Completion of National Strategy.--Pending 
completion of the classifications and standardized methodologies and 
procedures developed by the Advisory Committee on Health Workforce 
Evaluation and Assessment under section 764(b) of the Public Health 
Service Act, as added by section 2261, the Secretary of Health and 
Human Services, acting through the Administrator of the Health 
Resources and Services Administration and in consultation with such 
Advisory Committee, may make a judgment about the classifications, 
methodologies, and procedures to be used for collection of data under 
section 761(a) of the Public Health Service Act, as amended by this 
section.

                PART 5--AUTHORIZATION OF APPROPRIATIONS

SEC. 2281. AUTHORIZATION OF APPROPRIATIONS.

    (a) In General.--Section 799C, as added and amended, is further 
amended by adding at the end the following:
    ``(c) Health Professions Training for Diversity.--For the purpose 
of carrying out sections 736, 737, 738, 739, and 739A, in addition to 
any other amounts authorized to be appropriated for such purpose, there 
are authorized to be appropriated, out of any monies in the Public 
Health Investment Fund, the following:
            ``(1) $90,000,000 for fiscal year 2011.
            ``(2) $97,000,000 for fiscal year 2012.
            ``(3) $100,000,000 for fiscal year 2013.
            ``(4) $104,000,000 for fiscal year 2014.
            ``(5) $110,000,000 for fiscal year 2015.
    ``(d) Interdisciplinary Training Programs, Advisory Committee on 
Health Workforce Evaluation and Assessment, and Health Workforce 
Assessment.--For the purpose of carrying out sections 741, 759, 761, 
and 764, in addition to any other amounts authorized to be appropriated 
for such purpose, there are authorized to be appropriated, out of any 
monies in the Public Health Investment Fund, the following:
            ``(1) $87,000,000 for fiscal year 2011.
            ``(2) $97,000,000 for fiscal year 2012.
            ``(3) $103,000,000 for fiscal year 2013.
            ``(4) $105,000,000 for fiscal year 2014.
            ``(5) $113,000,000 for fiscal year 2015.''.
    (b) Existing Authorizations of Appropriations.--
            (1) Section 736.--Paragraph (1) of section 736(i) (42 
        U.S.C. 293(h)), as redesignated, is amended by striking 
        ``2002'' and inserting ``2015''.
            (2) Sections 737, 738, and 739.--Subsections (a), (b), and 
        (c) of section 740 are amended by striking ``2002'' each place 
        it appears and inserting ``2015''.
            (3) Section 741.--Subsection (h), as so redesignated, of 
        section 741 is amended--
                    (A) by striking ``and'' after ``fiscal year 
                2003,''; and
                    (B) by inserting ``, and such sums as may be 
                necessary for each subsequent fiscal year through the 
                end of fiscal year 2015'' before the period at the end.
            (4) Section 761.--Subsection (e)(1), as so redesignated, of 
        section 761 is amended by striking ``2002'' and inserting 
        ``2015''.

                   TITLE III--PREVENTION AND WELLNESS

SEC. 2301. PREVENTION AND WELLNESS.

    (a) In General.--The Public Health Service Act (42 U.S.C. 201 et 
seq.) is amended by inserting after title XXX the following:

                 ``TITLE XXXI--PREVENTION AND WELLNESS

              ``Subtitle A--Prevention and Wellness Trust

``SEC. 3111. PREVENTION AND WELLNESS TRUST.

    ``(a) Deposits Into Trust.--There is established a Prevention and 
Wellness Trust. There are authorized to be appropriated to the Trust--
            ``(1) out of the general fund of the Treasury, amounts 
        described in section 2002(b)(2)(A)(ii) of the Affordable Health 
        Care for America Act for each fiscal year; and
            ``(2) in addition, out of any monies in the Public Health 
        Investment Fund--
                    ``(A) for fiscal year 2011, $2,400,000,000;
                    ``(B) for fiscal year 2012, $2,845,000,000;
                    ``(C) for fiscal year 2013, $3,100,000,000;
                    ``(D) for fiscal year 2014, $3,455,000,000; and
                    ``(E) for fiscal year 2015, $3,600,000,000.
    ``(b) Availability of Funds.--Amounts in the Prevention and 
Wellness Trust shall be available, as provided in advance in 
appropriation Acts, for carrying out this title.
    ``(c) Allocation.--Of the amounts authorized to be appropriated in 
subsection (a)(2), there are authorized to be appropriated--
            ``(1) for carrying out subtitle C (Prevention Task Forces), 
        $30,000,000 for each of fiscal years 2011 through 2015;
            ``(2) for carrying out subtitle D (Prevention and Wellness 
        Research)--
                    ``(A) for fiscal year 2011, $155,000,000;
                    ``(B) for fiscal year 2012, $205,000,000;
                    ``(C) for fiscal year 2013, $255,000,000;
                    ``(D) for fiscal year 2014, $305,000,000; and
                    ``(E) for fiscal year 2015, $355,000,000;
            ``(3) for carrying out subtitle E (Delivery of Community 
        Preventive and Wellness Services)--
                    ``(A) for fiscal year 2011, $1,065,000,000;
                    ``(B) for fiscal year 2012, $1,260,000,000;
                    ``(C) for fiscal year 2013, $1,365,000,000;
                    ``(D) for fiscal year 2014, $1,570,000,000; and
                    ``(E) for fiscal year 2015, $1,600,000,000;
            ``(4) for carrying out section 3161 (Core Public Health 
        Infrastructure for State, Local, and Tribal Health 
        Departments)--
                    ``(A) for fiscal year 2011, $800,000,000;
                    ``(B) for fiscal year 2012, $1,000,000,000;
                    ``(C) for fiscal year 2013, $1,100,000,000;
                    ``(D) for fiscal year 2014, $1,200,000,000; and
                    ``(E) for fiscal year 2015, $1,265,000,000; and
            ``(5) for carrying out section 3162 (Core Public Health 
        Infrastructure and Activities for CDC), $350,000,000 for each 
        of fiscal years 2011 through 2015.

        ``Subtitle B--National Prevention and Wellness Strategy

``SEC. 3121. NATIONAL PREVENTION AND WELLNESS STRATEGY.

    ``(a) In General.--The Secretary shall submit to the Congress 
within one year after the date of the enactment of this section, and at 
least every 2 years thereafter, a national strategy that is designed to 
improve the Nation's health through evidence-based clinical and 
community prevention and wellness activities (in this section referred 
to as `prevention and wellness activities'), including core public 
health infrastructure improvement activities.
    ``(b) Contents.--The strategy under subsection (a) shall include 
each of the following:
            ``(1) Identification of specific national goals and 
        objectives in prevention and wellness activities that take into 
        account appropriate public health measures and standards, 
        including departmental measures and standards (including 
        Healthy People and National Public Health Performance 
        Standards).
            ``(2) Establishment of national priorities for prevention 
        and wellness, taking into account unmet prevention and wellness 
        needs.
            ``(3) Establishment of national priorities for research on 
        prevention and wellness, taking into account unanswered 
        research questions on prevention and wellness.
            ``(4) Identification of health disparities in prevention 
        and wellness.
            ``(5) Review of prevention payment incentives, the 
        prevention workforce, and prevention delivery system capacity.
            ``(6) A plan for addressing and implementing paragraphs (1) 
        through (5).
    ``(c) Consultation.--In developing or revising the strategy under 
subsection (a), the Secretary shall consult with the following:
            ``(1) The heads of appropriate health agencies and offices 
        in the Department, including the Office of the Surgeon General 
        of the Public Health Service, the Office of Minority Health, 
        the Office on Women's Health, and the Substance Abuse and 
        Mental Health Services Administration.
            ``(2) As appropriate, the heads of other Federal 
        departments and agencies whose programs have a significant 
        impact upon health (as determined by the Secretary).
            ``(3) As appropriate, nonprofit and for-profit entities.
            ``(4) The Association of State and Territorial Health 
        Officials and the National Association of County and City 
        Health Officials.
            ``(5) The Task Force on Community Preventive Services and 
        the Task Force on Clinical Preventive Services.

                  ``Subtitle C--Prevention Task Forces

``SEC. 3131. TASK FORCE ON CLINICAL PREVENTIVE SERVICES.

    ``(a) In General.--The Secretary, acting through the Director of 
the Agency for Healthcare Research and Quality, shall establish a 
permanent task force to be known as the Task Force on Clinical 
Preventive Services (in this section referred to as the `Task Force').
    ``(b) Responsibilities.--The Task Force shall--
            ``(1) identify clinical preventive services for review;
            ``(2) review the scientific evidence related to the 
        benefits, effectiveness, appropriateness, and costs of clinical 
        preventive services identified under paragraph (1) for the 
        purpose of developing, updating, publishing, and disseminating 
        evidence-based recommendations on the use of such services;
            ``(3) as appropriate, take into account health disparities 
        in developing, updating, publishing, and disseminating 
        evidence-based recommendations on the use of such services;
            ``(4) identify gaps in clinical preventive services 
        research and evaluation and recommend priority areas for such 
        research and evaluation;
            ``(5) pursuant to section 3143(c), determine whether 
        subsidies and rewards meet the Task Force's standards for a 
        grade of A or B;
            ``(6) as appropriate, consult with the clinical prevention 
        stakeholders board in accordance with subsection (f);
            ``(7) consult with the Task Force on Community Preventive 
        Services established under section 3132; and
            ``(8) as appropriate, in carrying out this section, 
        consider the national strategy under section 3121.
    ``(c) Role of Agency.--The Secretary shall provide ongoing 
administrative, research, and technical support for the operations of 
the Task Force, including coordinating and supporting the dissemination 
of the recommendations of the Task Force.
    ``(d) Membership.--
            ``(1) Number; appointment.--The Task Force shall be 
        composed of 30 members, appointed by the Secretary.
            ``(2) Terms.--
                    ``(A) In general.--The Secretary shall appoint 
                members of the Task Force for a term of 6 years and may 
                reappoint such members, but the Secretary may not 
                appoint any member to serve more than a total of 12 
                years.
                    ``(B) Staggered terms.--Notwithstanding 
                subparagraph (A), of the members first appointed to 
                serve on the Task Force after the enactment of this 
                title--
                            ``(i) 10 shall be appointed for a term of 2 
                        years;
                            ``(ii) 10 shall be appointed for a term of 
                        4 years; and
                            ``(iii) 10 shall be appointed for a term of 
                        6 years.
            ``(3) Qualifications.--Members of the Task Force shall be 
        appointed from among individuals who possess expertise in at 
        least one of the following areas:
                    ``(A) Health promotion and disease prevention.
                    ``(B) Evaluation of research and systematic 
                evidence reviews.
                    ``(C) Application of systematic evidence reviews to 
                clinical decisionmaking or health policy.
                    ``(D) Clinical primary care in child and adolescent 
                health.
                    ``(E) Clinical primary care in adult health, 
                including women's health.
                    ``(F) Clinical primary care in geriatrics.
                    ``(G) Clinical counseling and behavioral services 
                for primary care patients.
            ``(4) Representation.--In appointing members of the Task 
        Force, the Secretary shall ensure that--
                    ``(A) all areas of expertise described in paragraph 
                (3) are represented; and
                    ``(B) the members of the Task Force include 
                individuals with expertise in health disparities.
    ``(e) Subgroups.--As appropriate to maximize efficiency, the Task 
Force may delegate authority for conducting reviews and making 
recommendations to subgroups consisting of Task Force members, subject 
to final approval by the Task Force.
    ``(f) Clinical Prevention Stakeholders Board.--
            ``(1) In general.--The Task Force shall convene a clinical 
        prevention stakeholders board composed of representatives of 
        appropriate public and private entities with an interest in 
        clinical preventive services to advise the Task Force on 
        developing, updating, publishing, and disseminating evidence-
        based recommendations on the use of clinical preventive 
        services.
            ``(2) Membership.--The members of the clinical prevention 
        stakeholders board shall include representatives of the 
        following:
                    ``(A) Health care consumers and patient groups.
                    ``(B) Providers of clinical preventive services, 
                including community-based providers.
                    ``(C) Federal departments and agencies, including--
                            ``(i) appropriate health agencies and 
                        offices in the Department, including the Office 
                        of the Surgeon General of the Public Health 
                        Service, the Office of Minority Health, the 
                        National Center on Minority Health and Health 
                        Disparities, and the Office on Women's Health; 
                        and
                            ``(ii) as appropriate, other Federal 
                        departments and agencies whose programs have a 
                        significant impact upon health (as determined 
                        by the Secretary).
                    ``(D) Private health care payors.
            ``(3) Responsibilities.--In accordance with subsection 
        (b)(6), the clinical prevention stakeholders board shall--
                    ``(A) recommend clinical preventive services for 
                review by the Task Force;
                    ``(B) suggest scientific evidence for consideration 
                by the Task Force related to reviews undertaken by the 
                Task Force;
                    ``(C) provide feedback regarding draft 
                recommendations by the Task Force; and
                    ``(D) assist with efforts regarding dissemination 
                of recommendations by the Director of the Agency for 
                Healthcare Research and Quality.
    ``(g) Disclosure and Conflicts of Interest.--Members of the Task 
Force or the clinical prevention stakeholders board shall not be 
considered employees of the Federal Government by reason of service on 
the Task Force or the clinical prevention stakeholders board, except 
members of the Task Force or the clinical prevention stakeholders board 
shall be considered to be special Government employees within the 
meaning of section 107 of the Ethics in Government Act of 1978 (5 
U.S.C. App.) and section 208 of title 18, United States Code, for the 
purposes of disclosure and management of conflicts of interest under 
those sections.
    ``(h) No Pay; Receipt of Travel Expenses.--Members of the Task 
Force or the clinical prevention stakeholders board shall not receive 
any pay for service on the Task Force, but may receive travel expenses, 
including a per diem, in accordance with applicable provisions of 
subchapter I of chapter 57 of title 5, United States Code.
    ``(i) Application of FACA.--The Federal Advisory Committee Act (5 
U.S.C. App.) except for section 14 of such Act shall apply to the Task 
Force to the extent that the provisions of such Act do not conflict 
with the provisions of this title.
    ``(j) Report.--The Secretary shall submit to the Congress an annual 
report on the Task Force, including with respect to gaps identified and 
recommendations made under subsection (b)(4).

``SEC. 3132. TASK FORCE ON COMMUNITY PREVENTIVE SERVICES.

    ``(a) In General.--The Secretary, acting through the Director of 
the Centers for Disease Control and Prevention, shall establish a 
permanent task force to be known as the Task Force on Community 
Preventive Services (in this section referred to as the `Task Force').
    ``(b) Responsibilities.--The Task Force shall--
            ``(1) identify community preventive services for review;
            ``(2) review the scientific evidence related to the 
        benefits, effectiveness, appropriateness, and costs of 
        community preventive services identified under paragraph (1) 
        for the purpose of developing, updating, publishing, and 
        disseminating evidence-based recommendations on the use of such 
        services;
            ``(3) as appropriate, take into account health disparities 
        in developing, updating, publishing, and disseminating 
        evidence-based recommendations on the use of such services;
            ``(4) identify gaps in community preventive services 
        research and evaluation and recommend priority areas for such 
        research and evaluation;
            ``(5) pursuant to section 3143(d), determine whether 
        subsidies and rewards are effective;
            ``(6) as appropriate, consult with the community prevention 
        stakeholders board in accordance with subsection (f);
            ``(7) consult with the Task Force on Clinical Preventive 
        Services established under section 3131; and
            ``(8) as appropriate, in carrying out this section, 
        consider the national strategy under section 3121.
    ``(c) Role of Agency.--The Secretary shall provide ongoing 
administrative, research, and technical support for the operations of 
the Task Force, including coordinating and supporting the dissemination 
of the recommendations of the Task Force.
    ``(d) Membership.--
            ``(1) Number; appointment.--The Task Force shall be 
        composed of 30 members, appointed by the Secretary.
            ``(2) Terms.--
                    ``(A) In general.--The Secretary shall appoint 
                members of the Task Force for a term of 6 years and may 
                reappoint such members, but the Secretary may not 
                appoint any member to serve more than a total of 12 
                years.
                    ``(B) Staggered terms.--Notwithstanding 
                subparagraph (A), of the members first appointed to 
                serve on the Task Force after the enactment of this 
                section--
                            ``(i) 10 shall be appointed for a term of 2 
                        years;
                            ``(ii) 10 shall be appointed for a term of 
                        4 years; and
                            ``(iii) 10 shall be appointed for a term of 
                        6 years.
            ``(3) Qualifications.--Members of the Task Force shall be 
        appointed from among individuals who possess expertise in at 
        least one of the following areas:
                    ``(A) Public health.
                    ``(B) Evaluation of research and systematic 
                evidence reviews.
                    ``(C) Disciplines relevant to community preventive 
                services, including health promotion; disease 
                prevention; chronic disease; worksite health; school-
                site health; qualitative and quantitative analysis; and 
                health economics, policy, law, and statistics.
            ``(4) Representation.--In appointing members of the Task 
        Force, the Secretary--
                    ``(A) shall ensure that all areas of expertise 
                described in paragraph (3) are represented;
                    ``(B) shall ensure that such members include 
                sufficient representatives of each of--
                            ``(i) State health officers;
                            ``(ii) local health officers;
                            ``(iii) health care practitioners; and
                            ``(iv) public health practitioners; and
                    ``(C) shall appoint individuals who have expertise 
                in health disparities.
    ``(e) Subgroups.--As appropriate to maximize efficiency, the Task 
Force may delegate authority for conducting reviews and making 
recommendations to subgroups consisting of Task Force members, subject 
to final approval by the Task Force.
    ``(f) Community Prevention Stakeholders Board.--
            ``(1) In general.--The Task Force shall convene a community 
        prevention stakeholders board composed of representatives of 
        appropriate public and private entities with an interest in 
        community preventive services to advise the Task Force on 
        developing, updating, publishing, and disseminating evidence-
        based recommendations on the use of community preventive 
        services.
            ``(2) Membership.--The members of the community prevention 
        stakeholders board shall include representatives of the 
        following:
                    ``(A) Health care consumers and patient groups.
                    ``(B) Providers of community preventive services, 
                including community-based providers.
                    ``(C) Federal departments and agencies, including--
                            ``(i) appropriate health agencies and 
                        offices in the Department, including the Office 
                        of the Surgeon General of the Public Health 
                        Service, the Office of Minority Health, the 
                        National Center on Minority Health and Health 
                        Disparities, and the Office on Women's Health; 
                        and
                            ``(ii) as appropriate, other Federal 
                        departments and agencies whose programs have a 
                        significant impact upon health (as determined 
                        by the Secretary).
                    ``(D) Private health care payors.
            ``(3) Responsibilities.--In accordance with subsection 
        (b)(6), the community prevention stakeholders board shall--
                    ``(A) recommend community preventive services for 
                review by the Task Force;
                    ``(B) suggest scientific evidence for consideration 
                by the Task Force related to reviews undertaken by the 
                Task Force;
                    ``(C) provide feedback regarding draft 
                recommendations by the Task Force; and
                    ``(D) assist with efforts regarding dissemination 
                of recommendations by the Director of the Centers for 
                Disease Control and Prevention.
    ``(g) Disclosure and Conflicts of Interest.--Members of the Task 
Force or the community prevention stakeholders board shall not be 
considered employees of the Federal Government by reason of service on 
the Task Force or the community prevention stakeholders board, except 
members of the Task Force or the community prevention stakeholders 
board shall be considered to be special Government employees within the 
meaning of section 107 of the Ethics in Government Act of 1978 (5 
U.S.C. App.) and section 208 of title 18, United States Code, for the 
purposes of disclosure and management of conflicts of interest under 
those sections.
    ``(h) No Pay; Receipt of Travel Expenses.--Members of the Task 
Force or the community prevention stakeholders board shall not receive 
any pay for service on the Task Force, but may receive travel expenses, 
including a per diem, in accordance with applicable provisions of 
subchapter I of chapter 57 of title 5, United States Code.
    ``(i) Application of FACA.--The Federal Advisory Committee Act (5 
U.S.C. App.) except for section 14 of such Act shall apply to the Task 
Force to the extent that the provisions of such Act do not conflict 
with the provisions of this title.
    ``(j) Report.--The Secretary shall submit to the Congress an annual 
report on the Task Force, including with respect to gaps identified and 
recommendations made under subsection (b)(4).

             ``Subtitle D--Prevention and Wellness Research

``SEC. 3141. PREVENTION AND WELLNESS RESEARCH ACTIVITY COORDINATION.

    ``In conducting or supporting research on prevention and wellness, 
the Director of the Centers for Disease Control and Prevention, the 
Director of the National Institutes of Health, and the heads of other 
agencies within the Department of Health and Human Services conducting 
or supporting such research, shall take into consideration the national 
strategy under section 3121 and the recommendations of the Task Force 
on Clinical Preventive Services under section 3131 and the Task Force 
on Community Preventive Services under section 3132.

``SEC. 3142. COMMUNITY PREVENTION AND WELLNESS RESEARCH GRANTS.

    ``(a) In General.--The Secretary, acting through the Director of 
the Centers for Disease Control and Prevention, shall conduct, or award 
grants to eligible entities to conduct, research in priority areas 
identified by the Secretary in the national strategy under section 3121 
or by the Task Force on Community Preventive Services as required by 
section 3132.
    ``(b) Eligibility.--To be eligible for a grant under this section, 
an entity shall be--
            ``(1) a State, local, or tribal department of health;
            ``(2) a public or private nonprofit entity; or
            ``(3) a consortium of 2 or more entities described in 
        paragraphs (1) and (2).
    ``(c) Report.--The Secretary shall submit to the Congress an annual 
report on the program of research under this section.

``SEC. 3143. RESEARCH ON SUBSIDIES AND REWARDS TO ENCOURAGE WELLNESS 
              AND HEALTHY BEHAVIORS.

    ``(a) Research and Demonstration Projects.--
            ``(1) In general.--The Secretary shall conduct, or award 
        grants to public or nonprofit private entities to conduct, 
        research and demonstration projects on the use of financial and 
        in-kind subsidies and rewards to encourage individuals and 
        communities to promote wellness, adopt healthy behaviors, and 
        use evidence-based preventive health services.
            ``(2) Focus.--Research and demonstration projects under 
        paragraph (1) shall focus on--
                    ``(A) tobacco use, obesity, and other prevention 
                and wellness priorities identified by the Secretary in 
                the national strategy under section 3121;
                    ``(B) the initiation, maintenance, and long-term 
                sustainability of wellness promotion; adoption of 
                healthy behaviors; and use of evidence-based preventive 
                health services; and
                    ``(C) populations at high risk of preventable 
                diseases and conditions.
    ``(b) Findings; Report.--
            ``(1) Submission of findings.--The Secretary shall submit 
        the findings of research and demonstration projects under 
        subsection (a) to--
                    ``(A) the Task Force on Clinical Preventive 
                Services established under section 3131 or the Task 
                Force on Community Preventive Services established 
                under section 3132, as appropriate; and
                    ``(B) the Health Benefits Advisory Committee 
                established by section 223 of the Affordable Health 
                Care for America Act.
            ``(2) Report to congress.--Not later than 18 months after 
        the initiation of research and demonstration projects under 
        subsection (a), the Secretary shall submit a report to the 
        Congress on the progress of such research and projects, 
        including any preliminary findings.
    ``(c) Inclusion in Essential Benefits Package.--If, on the basis of 
the findings of research and demonstration projects under subsection 
(a) or other sources consistent with section 3131, the Task Force on 
Clinical Preventive Services determines that a subsidy or reward meets 
the Task Force's standards for a grade A or B, the Secretary shall 
ensure that the subsidy or reward is included in the essential benefits 
package under section 222.
    ``(d) Inclusion as Allowable Use of Community Prevention and 
Wellness Services Grants.--If, on the basis of the findings of research 
and demonstration projects under subsection (a) or other sources 
consistent with section 3132, the Task Force on Community Preventive 
Services determines that a subsidy or reward is effective, the 
Secretary shall ensure that the subsidy or reward becomes an allowable 
use of grant funds under section 3151.
    ``(e) Nondiscrimination; No Tie to Premium or Cost Sharing.--In 
carrying out this section, the Secretary shall ensure that any subsidy 
or reward--
            ``(1) does not have a discriminatory effect on the basis of 
        any personal characteristic extraneous to the provision of 
        high-quality health care or related services; and
            ``(2) is not tied to the premium or cost sharing of an 
        individual under any qualified health benefits plan (as defined 
        in section 100(c)).

  ``Subtitle E--Delivery of Community Prevention and Wellness Services

``SEC. 3151. COMMUNITY PREVENTION AND WELLNESS SERVICES GRANTS.

    ``(a) In General.--The Secretary, acting through the Director of 
the Centers for Disease Control and Prevention, shall establish a 
program for the delivery of community prevention and wellness services 
consisting of awarding grants to eligible entities--
            ``(1) to provide evidence-based, community prevention and 
        wellness services in priority areas identified by the Secretary 
        in the national strategy under section 3121; or
            ``(2) to plan such services.
    ``(b) Eligibility.--
            ``(1) Definition.--To be eligible for a grant under this 
        section, an entity shall be--
                    ``(A) a State, local, or tribal department of 
                health;
                    ``(B) a public or private entity; or
                    ``(C) a consortium that--
                            ``(i) consists of 2 or more entities 
                        described in subparagraph (A) or (B); and
                            ``(ii) may be a community partnership 
                        representing a Health Empowerment Zone.
            ``(2) Health empowerment zone.--In this subsection, the 
        term `Health Empowerment Zone' means an area--
                    ``(A) in which multiple community prevention and 
                wellness services are implemented in order to address 
                one or more health disparities, including those 
                identified by the Secretary in the national strategy 
                under section 3121; and
                    ``(B) which is represented by a community 
                partnership that demonstrates community support and 
                coordination with State, local, or tribal health 
                departments and includes--
                            ``(i) a broad cross section of 
                        stakeholders;
                            ``(ii) residents of the community; and
                            ``(iii) representatives of entities that 
                        have a history of working within and serving 
                        the community.
    ``(c) Preferences.--In awarding grants under this section, the 
Secretary shall give preference to entities that--
            ``(1) will address one or more goals or objectives 
        identified by the Secretary in the national strategy under 
        section 3121;
            ``(2) will address significant health disparities, 
        including those identified by the Secretary in the national 
        strategy under section 3121;
            ``(3) will address unmet community prevention and wellness 
        needs and avoid duplication of effort;
            ``(4) have been demonstrated to be effective in communities 
        comparable to the proposed target community;
            ``(5) will contribute to the evidence base for community 
        prevention and wellness services;
            ``(6) demonstrate that the community prevention and 
        wellness services to be funded will be sustainable; and
            ``(7) demonstrate coordination or collaboration across 
        governmental and nongovernmental partners.
    ``(d) Health Disparities.--Of the funds awarded under this section 
for a fiscal year, the Secretary shall award not less than 50 percent 
for planning or implementing community prevention and wellness services 
whose primary purpose is to achieve a measurable reduction in one or 
more health disparities, including those identified by the Secretary in 
the national strategy under section 3121.
    ``(e) Emphasis on Recommended Services.--For fiscal year 2014 and 
subsequent fiscal years, the Secretary shall award grants under this 
section only for planning or implementing services recommended by the 
Task Force on Community Preventive Services under section 3132 or 
deemed effective based on a review of comparable rigor (as determined 
by the Director of the Centers for Disease Control and Prevention).
    ``(f) Prohibited Uses of Funds.--An entity that receives a grant 
under this section may not use funds provided through the grant--
            ``(1) to build or acquire real property or for 
        construction; or
            ``(2) for services or planning to the extent that payment 
        has been made, or can reasonably be expected to be made--
                    ``(A) under any insurance policy;
                    ``(B) under any Federal or State health benefits 
                program (including titles XIX and XXI of the Social 
                Security Act); or
                    ``(C) by an entity which provides health services 
                on a prepaid basis.
    ``(g) Report.--The Secretary shall submit to the Congress an annual 
report on the program of grants awarded under this section.
    ``(h) Definitions.--In this section, the term `evidence-based' 
means that methodologically sound research has demonstrated a 
beneficial health effect, in the judgment of the Director of the 
Centers for Disease Control and Prevention.

            ``Subtitle F--Core Public Health Infrastructure

``SEC. 3161. CORE PUBLIC HEALTH INFRASTRUCTURE FOR STATE, LOCAL, AND 
              TRIBAL HEALTH DEPARTMENTS.

    ``(a) Program.--The Secretary, acting through the Director of the 
Centers for Disease Control and Prevention, shall establish a core 
public health infrastructure program consisting of awarding grants 
under subsection (b).
    ``(b) Grants.--
            ``(1) Award.--For the purpose of addressing core public 
        health infrastructure needs, the Secretary--
                    ``(A) shall award a grant to each State health 
                department; and
                    ``(B) may award grants on a competitive basis to 
                State, local, or tribal health departments.
            ``(2) Allocation.--Of the total amount of funds awarded as 
        grants under this subsection for a fiscal year--
                    ``(A) not less than 50 percent shall be for grants 
                to State health departments under paragraph (1)(A); and
                    ``(B) not less than 30 percent shall be for grants 
                to State, local, or tribal health departments under 
                paragraph (1)(B).
    ``(c) Use of Funds.--The Secretary may award a grant to an entity 
under subsection (b)(1) only if the entity agrees to use the grant to 
address core public health infrastructure needs, including those 
identified in the accreditation process under subsection (g).
    ``(d) Formula Grants to State Health Departments.--In making grants 
under subsection (b)(1)(A), the Secretary shall award funds to each 
State health department in accordance with--
            ``(1) a formula based on population size; burden of 
        preventable disease and disability; and core public health 
        infrastructure gaps, including those identified in the 
        accreditation process under subsection (g); and
            ``(2) application requirements established by the 
        Secretary, including a requirement that the State submit a plan 
        that demonstrates to the satisfaction of the Secretary that the 
        State's health department will--
                    ``(A) address its highest priority core public 
                health infrastructure needs; and
                    ``(B) as appropriate, allocate funds to local 
                health departments within the State.
    ``(e) Competitive Grants to State, Local, and Tribal Health 
Departments.--In making grants under subsection (b)(1)(B), the 
Secretary shall give priority to applicants demonstrating core public 
health infrastructure needs identified in the accreditation process 
under subsection (g).
    ``(f) Maintenance of Effort.--The Secretary may award a grant to an 
entity under subsection (b) only if the entity demonstrates to the 
satisfaction of the Secretary that--
            ``(1) funds received through the grant will be expended 
        only to supplement, and not supplant, non-Federal and Federal 
        funds otherwise available to the entity for the purpose of 
        addressing core public health infrastructure needs; and
            ``(2) with respect to activities for which the grant is 
        awarded, the entity will maintain expenditures of non-Federal 
        amounts for such activities at a level not less than the level 
        of such expenditures maintained by the entity for the fiscal 
        year preceding the fiscal year for which the entity receives 
        the grant.
    ``(g) Establishment of a Public Health Accreditation Program.--
            ``(1) In general.--The Secretary, acting through the 
        Director of the Centers for Disease Control and Prevention, 
        shall--
                    ``(A) develop, and periodically review and update, 
                standards for voluntary accreditation of State, local, 
                or tribal health departments and public health 
                laboratories for the purpose of advancing the quality 
                and performance of such departments and laboratories; 
                and
                    ``(B) implement a program to accredit such health 
                departments and laboratories in accordance with such 
                standards.
            ``(2) Cooperative agreement.--The Secretary may enter into 
        a cooperative agreement with a private nonprofit entity to 
        carry out paragraph (1).
    ``(h) Report.--The Secretary shall submit to the Congress an annual 
report on progress being made to accredit entities under subsection 
(g), including--
            ``(1) a strategy, including goals and objectives, for 
        accrediting entities under subsection (g) and achieving the 
        purpose described in subsection (g)(1); and
            ``(2) identification of gaps in research related to core 
        public health infrastructure and recommendations of priority 
        areas for such research.

``SEC. 3162. CORE PUBLIC HEALTH INFRASTRUCTURE AND ACTIVITIES FOR CDC.

    ``(a) In General.--The Secretary, acting through the Director of 
the Centers for Disease Control and Prevention, shall expand and 
improve the core public health infrastructure and activities of the 
Centers for Disease Control and Prevention to address unmet and 
emerging public health needs.
    ``(b) Report.--The Secretary shall submit to the Congress an annual 
report on the activities funded through this section.

                    ``Subtitle G--General Provisions

``SEC. 3171. DEFINITIONS.

    ``In this title:
            ``(1) The term `core public health infrastructure' includes 
        workforce capacity and competency; laboratory systems; health 
        information, health information systems, and health information 
        analysis; communications; financing; other relevant components 
        of organizational capacity; and other related activities.
            ``(2) The terms `Department' and `departmental' refer to 
        the Department of Health and Human Services.
            ``(3) The term `health disparities' includes health and 
        health care disparities and means population-specific 
        differences in the presence of disease, health outcomes, or 
        access to health care. For purposes of the preceding sentence, 
        a population may be delineated by race, ethnicity, primary 
        language, sex, sexual orientation, gender identity, disability, 
        socioeconomic status, or rural, urban, or other geographic 
        setting, and any other population or subpopulation determined 
        by the Secretary to experience significant gaps in disease, 
        health outcomes, or access to health care.
            ``(4) The term `tribal' refers to an Indian tribe, a Tribal 
        organization, or an Urban Indian organization, as such terms 
        are defined in section 4 of the Indian Health Care Improvement 
        Act.''.
    (b) Transition Provisions Applicable to Task Forces.--
            (1) Functions, personnel, assets, liabilities, and 
        administrative actions.--All functions, personnel, assets, and 
        liabilities of, and administrative actions applicable to, the 
        Preventive Services Task Force convened under section 915(a) of 
        the Public Health Service Act and the Task Force on Community 
        Preventive Services (as such section and Task Forces were in 
        existence on the day before the date of the enactment of this 
        Act) shall be transferred to the Task Force on Clinical 
        Preventive Services and the Task Force on Community Preventive 
        Services, respectively, established under sections 3131 and 
        3132 of the Public Health Service Act, as added by subsection 
        (a).
            (2) Recommendations.--All recommendations of the Preventive 
        Services Task Force and the Task Force on Community Preventive 
        Services, as in existence on the day before the date of the 
        enactment of this Act, shall be considered to be 
        recommendations of the Task Force on Clinical Preventive 
        Services and the Task Force on Community Preventive Services, 
        respectively, established under sections 3131 and 3132 of the 
        Public Health Service Act, as added by subsection (a).
            (3) Members already serving.--
                    (A) Initial members.--The Secretary of Health and 
                Human Services may select those individuals already 
                serving on the Preventive Services Task Force and the 
                Task Force on Community Preventive Services, as in 
                existence on the day before the date of the enactment 
                of this Act, to be among the first members appointed to 
                the Task Force on Clinical Preventive Services and the 
                Task Force on Community Preventive Services, 
                respectively, under sections 3131 and 3132 of the 
                Public Health Service Act, as added by subsection (a).
                    (B) Calculation of total service.--In calculating 
                the total years of service of a member of a task force 
                for purposes of section 3131(d)(2)(A) or 3132(d)(2)(A) 
                of the Public Health Service Act, as added by 
                subsection (a), the Secretary of Health and Human 
                Services shall not include any period of service by the 
                member on the Preventive Services Task Force or the 
                Task Force on Community Preventive Services, 
                respectively, as in existence on the day before the 
                date of the enactment of this Act.
    (c) Period Before Completion of National Strategy.--Pending 
completion of the national strategy under section 3121 of the Public 
Health Service Act, as added by subsection (a), the Secretary of Health 
and Human Services, acting through the relevant agency head, may make a 
judgment about how the strategy will address an issue and rely on such 
judgment in carrying out any provision of subtitle C, D, E, or F of 
title XXXI of such Act, as added by subsection (a), that requires the 
Secretary--
            (1) to take into consideration such strategy;
            (2) to conduct or support research or provide services in 
        priority areas identified in such strategy; or
            (3) to take any other action in reliance on such strategy.
    (d) Conforming Amendments.--
            (1) Paragraph (61) of section 3(b) of the Indian Health 
        Care Improvement Act (25 U.S.C. 1602) is amended by striking 
        ``United States Preventive Services Task Force'' and inserting 
        ``Task Force on Clinical Preventive Services''.
            (2) Section 126 of the Medicare, Medicaid, and SCHIP 
        Benefits Improvement and Protection Act of 2000 (Appendix F of 
        Public Law 106-554) is amended by striking ``United States 
        Preventive Services Task Force'' each place it appears and 
        inserting ``Task Force on Clinical Preventive Services''.
            (3) Paragraph (7) of section 317D(a) of the Public Health 
        Service Act (42 U.S.C. 247b-5(a)) is amended by striking 
        ``United States Preventive Services Task Force'' and inserting 
        ``Task Force on Clinical Preventive Services''.
            (4) Section 915 of the Public Health Service Act (42 U.S.C. 
        299b-4) is amended by striking subsection (a).
            (5) Subsections (s)(2)(AA)(iii)(II), (xx)(1), and 
        (ddd)(1)(B) of section 1861 of the Social Security Act (42 
        U.S.C. 1395x) are amended by striking ``United States 
        Preventive Services Task Force'' each place it appears and 
        inserting ``Task Force on Clinical Preventive Services''.

                   TITLE IV--QUALITY AND SURVEILLANCE

SEC. 2401. IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH 
              CARE.

    (a) In General.--Title IX of the Public Health Service Act (42 
U.S.C. 299 et seq.) is amended--
            (1) by redesignating part D as part E;
            (2) by redesignating sections 931 through 938 as sections 
        941 through 948, respectively;
            (3) in section 948(1), as redesignated, by striking ``931'' 
        and inserting ``941''; and
            (4) by inserting after part C the following:

 ``PART D--IMPLEMENTATION OF BEST PRACTICES IN THE DELIVERY OF HEALTH 
                                  CARE

``SEC. 931. CENTER FOR QUALITY IMPROVEMENT.

    ``(a) In General.--There is established the Center for Quality 
Improvement (referred to in this part as the `Center'), to be headed by 
the Director.
    ``(b) Prioritization.--
            ``(1) In general.--The Director shall prioritize areas for 
        the identification, development, evaluation, and implementation 
        of best practices (including innovative methodologies and 
        strategies) for quality improvement activities in the delivery 
        of health care services (in this section referred to as `best 
        practices').
            ``(2) Considerations.--In prioritizing areas under 
        paragraph (1), the Director shall consider--
                    ``(A) the priorities established under section 1191 
                of the Social Security Act; and
                    ``(B) the key health indicators identified by the 
                Assistant Secretary for Health Information under 
                section 1709.
            ``(3) Limitations.--In conducting its duties under this 
        subsection, the Center for Quality Improvement shall not 
        develop quality-adjusted life year measures or any other 
        methodologies that can be used to deny benefits to a 
        beneficiary against the beneficiary's wishes on the basis of 
        the beneficiary's age, life expectancy, present or predicted 
        disability, or expected quality of life.
    ``(c) Other Responsibilities.--The Director, acting directly or by 
awarding a grant or contract to an eligible entity, shall--
            ``(1) identify existing best practices under subsection 
        (e);
            ``(2) develop new best practices under subsection (f);
            ``(3) evaluate best practices under subsection (g);
            ``(4) implement best practices under subsection (h);
            ``(5) ensure that best practices are identified, developed, 
        evaluated, and implemented under this section consistent with 
        standards adopted by the Secretary under section 3004 for 
        health information technology used in the collection and 
        reporting of quality information (including for purposes of the 
        demonstration of meaningful use of certified electronic health 
        record (EHR) technology by physicians and hospitals under the 
        Medicare program (under sections 1848(o)(2) and 1886(n)(3), 
        respectively, of the Social Security Act)); and
            ``(6) provide for dissemination of information and 
        reporting under subsections (i) and (j).
    ``(d) Eligibility.--To be eligible for a grant or contract under 
subsection (c), an entity shall--
            ``(1) be a nonprofit entity;
            ``(2) agree to work with a variety of institutional health 
        care providers, physicians, nurses, and other health care 
        practitioners; and
            ``(3) if the entity is not the organization holding a 
        contract under section 1153 of the Social Security Act for the 
        area to be served, agree to cooperate with and avoid 
        duplication of the activities of such organization.
    ``(e) Identifying Existing Best Practices.--The Director shall 
identify best practices that are--
            ``(1) currently utilized by health care providers 
        (including hospitals, physician and other clinician practices, 
        community cooperatives, and other health care entities) that 
        deliver consistently high-quality, efficient health care 
        services; and
            ``(2) easily adapted for use by other health care providers 
        and for use across a variety of health care settings.
    ``(f) Developing New Best Practices.--The Director shall develop 
best practices that are--
            ``(1) based on a review of existing scientific evidence;
            ``(2) sufficiently detailed for implementation and 
        incorporation into the workflow of health care providers; and
            ``(3) designed to be easily adapted for use by health care 
        providers across a variety of health care settings.
    ``(g) Evaluation of Best Practices.--The Director shall evaluate 
best practices identified or developed under this section. Such 
evaluation--
            ``(1) shall include determinations of which best 
        practices--
                    ``(A) most reliably and effectively achieve 
                significant progress in improving the quality of 
                patient care; and
                    ``(B) are easily adapted for use by health care 
                providers across a variety of health care settings;
            ``(2) shall include regular review, updating, and 
        improvement of such best practices; and
            ``(3) may include in-depth case studies or empirical 
        assessments of health care providers (including hospitals, 
        physician and other clinician practices, community 
        cooperatives, and other health care entities) and simulations 
        of such best practices for determinations under paragraph (1).
    ``(h) Implementation of Best Practices.--
            ``(1) In general.--The Director shall enter into 
        arrangements with entities in a State or region to implement 
        best practices identified or developed under this section. Such 
        implementation--
                    ``(A) may include forming collaborative multi-
                institutional teams; and
                    ``(B) shall include an evaluation of the best 
                practices being implemented, including the measurement 
                of patient outcomes before, during, and after 
                implementation of such best practices.
            ``(2) Preferences.--In carrying out this subsection, the 
        Director shall give priority to health care providers 
        implementing best practices that--
                    ``(A) have the greatest impact on patient outcomes 
                and satisfaction;
                    ``(B) are the most easily adapted for use by health 
                care providers across a variety of health care 
                settings;
                    ``(C) promote coordination of health care 
                practitioners across the continuum of care; and
                    ``(D) engage patients and their families in 
                improving patient care and outcomes.
    ``(i) Public Dissemination of Information.--The Director shall 
provide for the public dissemination of information with respect to 
best practices and activities under this section. Such information 
shall be made available in appropriate formats and languages to reflect 
the varying needs of consumers and diverse levels of health literacy.
    ``(j) Report.--
            ``(1) In general.--The Director shall submit an annual 
        report to the Congress and the Secretary on activities under 
        this section.
            ``(2) Content.--Each report under paragraph (1) shall 
        include--
                    ``(A) information on activities conducted pursuant 
                to grants and contracts awarded;
                    ``(B) summary data on patient outcomes before, 
                during, and after implementation of best practices; and
                    ``(C) recommendations on the adaptability of best 
                practices for use by health providers.''.
    (b) Initial Quality Improvement Activities and Initiatives To Be 
Implemented.--Until the Director of the Agency for Healthcare Research 
and Quality has established initial priorities under section 931(b) of 
the Public Health Service Act, as added by subsection (a), the Director 
shall, for purposes of such section, prioritize the following:
            (1) Health care-associated infections.--Reducing health 
        care-associated infections, including infections in nursing 
        homes and outpatient settings.
            (2) Surgery.--Increasing hospital and outpatient 
        perioperative patient safety, including reducing surgical-site 
        infections and surgical errors (such as wrong-site surgery and 
        retained foreign bodies).
            (3) Emergency room.--Improving care in hospital emergency 
        rooms, including through the use of principles of efficiency of 
        design and delivery to improve patient flow.
            (4) Obstetrics.--Improving the provision of obstetrical and 
        neonatal care, including the identification of interventions 
        that are effective in reducing the risk of preterm and 
        premature labor and the implementation of best practices for 
        labor and delivery care.
            (5) Pediatrics.--Improving the provision of preventive and 
        developmental child health services, including interventions 
        that can reduce child health disparities (as defined in section 
        3171 of the Public Health Service Act, as added by section 
        2301) and reduce the risk of developing chronic health-
        threatening conditions that affect an individual's life course 
        development.
    (c) Report.--Not later than 18 months after the date of the 
enactment of this Act, the Director of the Agency for Healthcare 
Research and Quality shall submit a report to the Congress on the 
impact of the nurse-to-patient ratio on the quality of care and patient 
outcomes, including recommendations for further integration into 
quality measurement and quality improvement activities.

SEC. 2402. ASSISTANT SECRETARY FOR HEALTH INFORMATION.

    (a) Establishment.--Title XVII (42 U.S.C. 300u et seq.) is 
amended--
            (1) by redesignating sections 1709 and 1710 as sections 
        1710 and 1711, respectively; and
            (2) by inserting after section 1708 the following:

``SEC. 1709. ASSISTANT SECRETARY FOR HEALTH INFORMATION.

    ``(a) In General.--There is established within the Department an 
Assistant Secretary for Health Information (in this section referred to 
as the `Assistant Secretary'), to be appointed by the Secretary.
    ``(b) Responsibilities.--The Assistant Secretary shall--
            ``(1) ensure the collection, collation, reporting, and 
        publishing of information (including full and complete 
        statistics) on key health indicators regarding the Nation's 
        health and the performance of the Nation's health care;
            ``(2) facilitate and coordinate the collection, collation, 
        reporting, and publishing of information regarding the Nation's 
        health and the performance of the Nation's health care (other 
        than information described in paragraph (1));
            ``(3)(A) develop standards for the collection of data 
        regarding the Nation's health and the performance of the 
        Nation's health care; and
            ``(B) in carrying out subparagraph (A)--
                    ``(i) ensure appropriate specificity and 
                standardization for data collection at the national, 
                regional, State, and local levels;
                    ``(ii) include standards, as appropriate, for the 
                collection of accurate data on health disparities;
                    ``(iii) ensure, with respect to data on race and 
                ethnicity, consistency with the 1997 Office of 
                Management and Budget Standards for Maintaining, 
                Collecting and Presenting Federal Data on Race and 
                Ethnicity (or any successor standards); and
                    ``(iv) in consultation with the Director of the 
                Office of Minority Health, and the Director of the 
                Office of Civil Rights of the Department, develop 
                standards for the collection of data on health and 
                health care with respect to primary language;
            ``(4) provide support to Federal departments and agencies 
        whose programs have a significant impact upon health (as 
        determined by the Secretary) for the collection and collation 
        of information described in paragraphs (1) and (2);
            ``(5) ensure the sharing of information described in 
        paragraphs (1) and (2) among the agencies of the Department;
            ``(6) facilitate the sharing of information described in 
        paragraphs (1) and (2) by Federal departments and agencies 
        whose programs have a significant impact upon health (as 
        determined by the Secretary);
            ``(7) identify gaps in information described in paragraphs 
        (1) and (2) and the appropriate agency or entity to address 
        such gaps;
            ``(8) facilitate and coordinate identification and 
        monitoring of health disparities by the agencies of the 
        Department to inform program and policy efforts to reduce such 
        disparities, including facilitating and funding analyses 
        conducted in cooperation with the Social Security 
        Administration, the Bureau of the Census, and other appropriate 
        agencies and entities;
            ``(9) consistent with privacy, proprietary, and other 
        appropriate safeguards, facilitate public accessibility of 
        datasets (such as de-identified Medicare datasets or publicly 
        available data on key health indicators) by means of the 
        Internet; and
            ``(10) award grants or contracts for the collection and 
        collation of information described in paragraphs (1) and (2) 
        (including through statewide surveys that provide standardized 
        information).
    ``(c) Key Health Indicators.--
            ``(1) In general.--In carrying out subsection (b)(1), the 
        Assistant Secretary shall--
                    ``(A) identify, and reassess at least once every 3 
                years, key health indicators described in such 
                subsection;
                    ``(B) publish statistics on such key health 
                indicators for the public--
                            ``(i) not less than annually; and
                            ``(ii) on a supplemental basis whenever 
                        warranted by--
                                    ``(I) the rate of change for a key 
                                health indicator; or
                                    ``(II) the need to inform policy 
                                regarding the Nation's health and the 
                                performance of the Nation's health 
                                care; and
                    ``(C) ensure consistency with the national strategy 
                developed by the Secretary under section 3121 and 
                consideration of the indicators specified in the 
                reports under sections 308, 903(a)(6), and 913(b)(2).
            ``(2) Release of key health indicators.--The regulations, 
        rules, processes, and procedures of the Office of Management 
        and Budget governing the review, release, and dissemination of 
        key health indicators shall be the same as the regulations, 
        rules, processes, and procedures of the Office of Management 
        and Budget governing the review, release, and dissemination of 
        Principal Federal Economic Indicators (or equivalent 
        statistical data) by the Bureau of Labor Statistics.
    ``(d) Coordination.--In carrying out this section, the Assistant 
Secretary shall coordinate with--
            ``(1) public and private entities that collect and 
        disseminate information on health and health care, including 
        foundations; and
            ``(2) the head of the Office of the National Coordinator 
        for Health Information Technology to ensure optimal use of 
        health information technology.
    ``(e) Request for Information From Departments and Agencies.--
Consistent with applicable law, the Assistant Secretary may secure 
directly from any Federal department or agency information necessary to 
enable the Assistant Secretary to carry out this section.
    ``(f) Report.--
            ``(1) Submission.--The Assistant Secretary shall submit to 
        the Secretary and the Congress an annual report containing--
                    ``(A) a description of national, regional, or State 
                changes in health or health care, as reflected by the 
                key health indicators identified under subsection 
                (c)(1);
                    ``(B) a description of gaps in the collection, 
                collation, reporting, and publishing of information 
                regarding the Nation's health and the performance of 
                the Nation's health care;
                    ``(C) recommendations for addressing such gaps and 
                identification of the appropriate agency within the 
                Department or other entity to address such gaps;
                    ``(D) a description of analyses of health 
                disparities, including the results of completed 
                analyses, the status of ongoing longitudinal studies, 
                and proposed or planned research; and
                    ``(E) a plan for actions to be taken by the 
                Assistant Secretary to address gaps described in 
                subparagraph (B).
            ``(2) Consideration.--In preparing a report under paragraph 
        (1), the Assistant Secretary shall take into consideration the 
        findings and conclusions in the reports under sections 308, 
        903(a)(6), and 913(b)(2).
    ``(g) Proprietary and Privacy Protections.--Nothing in this section 
shall be construed to affect applicable proprietary or privacy 
protections.
    ``(h) Consultation.--In carrying out this section, the Assistant 
Secretary shall consult with--
            ``(1) the heads of appropriate health agencies and offices 
        in the Department, including the Office of the Surgeon General 
        of the Public Health Service, the Office of Minority Health, 
        and the Office on Women's Health; and
            ``(2) as appropriate, the heads of other Federal 
        departments and agencies whose programs have a significant 
        impact upon health (as determined by the Secretary).
    ``(i) Definition.--In this section:
            ``(1) The terms `agency' and `agencies' include an 
        epidemiology center established under section 214 of the Indian 
        Health Care Improvement Act.
            ``(2) The term `Department' means the Department of Health 
        and Human Services.
            ``(3) The term `health disparities' has the meaning given 
        to such term in section 3171.''.
    (b) Other Coordination Responsibilities.--Title III (42 U.S.C. 241 
et seq.) is amended--
            (1) in paragraphs (1) and (2) of section 304(c) (42 U.S.C. 
        242b(c)), by inserting ``, acting through the Assistant 
        Secretary for Health Information,'' after ``The Secretary'' 
        each place it appears; and
            (2) in section 306(j) (42 U.S.C. 242k(j)), by inserting ``, 
        acting through the Assistant Secretary for Health 
        Information,'' after ``of this section, the Secretary''.

SEC. 2403. AUTHORIZATION OF APPROPRIATIONS.

    Section 799C, as added and amended, is further amended by adding at 
the end the following:
    ``(e) Quality and Surveillance.--For the purpose of carrying out 
part D of title IX and section 1709, in addition to any other amounts 
authorized to be appropriated for such purpose, there are authorized to 
be appropriated, out of any monies in the Public Health Investment 
Fund, $300,000,000 for each of fiscal years 2011 through 2015.''.

                       TITLE V--OTHER PROVISIONS

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

SEC. 2501. EXPANDED PARTICIPATION IN 340B PROGRAM.

    (a) Expansion of Covered Entities Receiving Discounted Prices.--
Section 340B(a)(4) (42 U.S.C. 256b(a)(4)) is amended by adding at the 
end the following:
                    ``(M) A children's hospital excluded from the 
                Medicare prospective payment system pursuant to section 
                1886(d)(1)(B)(iii) of the Social Security Act, or a 
                free-standing cancer hospital excluded from the 
                Medicare prospective payment system pursuant to section 
                1886(d)(1)(B)(v) of the Social Security Act that would 
                meet the requirements of subparagraph (L), including 
                the disproportionate share adjustment percentage 
                requirement under clause (ii) of such subparagraph, if 
                the hospital were a subsection (d) hospital as defined 
                by section 1886(d)(1)(B) of the Social Security Act.
                    ``(N) An entity that is a critical access hospital 
                (as determined under section 1820(c)(2) of the Social 
                Security Act).
                    ``(O) An entity receiving funds under title V of 
                the Social Security Act (relating to maternal and child 
                health) for the provision of health services.
                    ``(P) An entity receiving funds under subpart I of 
                part B of title XIX of the Public Health Service Act 
                (relating to comprehensive mental health services) for 
                the provision of community mental health services.
                    ``(Q) An entity receiving funds under subpart II of 
                such part B (relating to the prevention and treatment 
                of substance abuse) for the provision of treatment 
                services for substance abuse.
                    ``(R) An entity that is a Medicare-dependent, small 
                rural hospital (as defined in section 1886(d)(5)(G)(iv) 
                of the Social Security Act).
                    ``(S) An entity that is a sole community hospital 
                (as defined in section 1886(d)(5)(D)(iii) of the Social 
                Security Act).
                    ``(T) An entity that is classified as a rural 
                referral center under section 1886(d)(5)(C) of the 
                Social Security Act.''.
    (b) Prohibition on Group Purchasing Arrangements.--Section 340B(a) 
(42 U.S.C. 256b(a)) is amended--
            (1) in paragraph (4)(L)--
                    (A) by adding ``and'' at the end of clause (i);
                    (B) by striking ``; and'' at the end of clause (ii) 
                and inserting a period; and
                    (C) by striking clause (iii); and
            (2) in paragraph (5), by redesignating subparagraphs (C) 
        and (D) as subparagraphs (D) and (E), respectively, and by 
        inserting after subparagraph (B) the following:
                    ``(C) Prohibiting use of group purchasing 
                arrangements.--A hospital described in subparagraph 
                (L), (M), (N), (R), (S), or (T) of paragraph (4) shall 
                not obtain covered outpatient drugs through a group 
                purchasing organization or other group purchasing 
                arrangement.''.

SEC. 2502. IMPROVEMENTS TO 340B PROGRAM INTEGRITY.

    (a) Integrity Improvements.--Section 340B (42 U.S.C. 256b) is 
amended--
            (1) by striking subsections (c) and (d); and
            (2) by inserting after subsection (b) the following:
    ``(c) Improvements in Program Integrity.--
            ``(1) Manufacturer compliance.--
                    ``(A) In general.--From amounts appropriated under 
                paragraph (4), the Secretary shall provide for 
                improvements in compliance by manufacturers with the 
                requirements of this section in order to prevent 
                overcharges and other violations of the discounted 
                pricing requirements specified in this section.
                    ``(B) Improvements.--The improvements described in 
                subparagraph (A) shall include the following:
                            ``(i) The establishment of a process to 
                        enable the Secretary to verify the accuracy of 
                        ceiling prices calculated by manufacturers 
                        under subsection (a)(1) and charged to covered 
                        entities, which shall include the following:
                                    ``(I) Developing and publishing, 
                                through an appropriate policy or 
                                regulatory issuance, standards and 
                                methodology for the calculation of 
                                ceiling prices under such subsection.
                                    ``(II) Comparing regularly the 
                                ceiling prices calculated by the 
                                Secretary with the quarterly pricing 
                                data that is reported by manufacturers 
                                to the Secretary.
                                    ``(III) Conducting periodic 
                                monitoring of sales transactions to 
                                covered entities.
                                    ``(IV) Inquiring into any 
                                discrepancies between ceiling prices 
                                and manufacturer pricing data that may 
                                be identified and taking, or requiring 
                                manufacturers to take, corrective 
                                action in response to such 
                                discrepancies, including the issuance 
                                of refunds pursuant to the procedures 
                                set forth in clause (ii).
                            ``(ii) The establishment of procedures for 
                        the issuance of refunds to covered entities by 
                        manufacturers in the event that the Secretary 
                        finds there has been an overcharge, including 
                        the following:
                                    ``(I) Submission to the Secretary 
                                by manufacturers of an explanation of 
                                why and how the overcharge occurred, 
                                how the refunds will be calculated, and 
                                to whom the refunds will be issued.
                                    ``(II) Oversight by the Secretary 
                                to ensure that the refunds are issued 
                                accurately and within a reasonable 
                                period of time.
                            ``(iii) Notwithstanding any other provision 
                        of law prohibiting the disclosure of ceiling 
                        prices or data used to calculate the ceiling 
                        price, the provision of access to covered 
                        entities and State Medicaid agencies through an 
                        Internet website of the Department of Health 
                        and Human Services or contractor to the 
                        applicable ceiling prices for covered drugs as 
                        calculated and verified by the Secretary in a 
                        manner that ensures protection of privileged 
                        pricing data from unauthorized disclosure.
                            ``(iv) The development of a mechanism by 
                        which--
                                    ``(I) rebates, discounts, or other 
                                price concessions provided by 
                                manufacturers to other purchasers 
                                subsequent to the sale of covered drugs 
                                to covered entities are reported to the 
                                Secretary; and
                                    ``(II) appropriate credits and 
                                refunds are issued to covered entities 
                                if such rebates, discounts, or other 
                                price concessions have the effect of 
                                lowering the applicable ceiling price 
                                for the relevant quarter for the drugs 
                                involved.
                            ``(v) In addition to authorities under 
                        section 1927(b)(3) of the Social Security Act, 
                        the Secretary may conduct audits of 
                        manufacturers and wholesalers to ensure the 
                        integrity of the program under this section, 
                        including audits on the market price of covered 
                        drugs.
                            ``(vi) The establishment of a requirement 
                        that manufacturers and wholesalers use the 
                        identification system developed by the 
                        Secretary for purposes of facilitating the 
                        ordering, purchasing, and delivery of covered 
                        drugs under this section, including the 
                        processing of chargebacks for such drugs.
                            ``(vii) The imposition of sanctions in the 
                        form of civil monetary penalties, which--
                                    ``(I) shall be assessed according 
                                to standards and procedures established 
                                in regulations to be promulgated by the 
                                Secretary within one year of the date 
                                of the enactment of the Affordable 
                                Health Care for America Act; and
                                    ``(II) shall apply to any 
                                manufacturer with an agreement under 
                                this section and shall not exceed 
                                $100,000 for each instance where a 
                                manufacturer knowingly charges a 
                                covered entity a price for purchase of 
                                a drug that exceeds the maximum 
                                applicable price under subsection 
                                (a)(1) or that knowingly violates any 
                                other provision of this section, or 
                                withholds or provides false information 
                                to the Secretary or to covered entities 
                                under this section.
            ``(2) Covered entity compliance.--
                    ``(A) In general.--From amounts appropriated under 
                paragraph (4), the Secretary shall provide for 
                improvements in compliance by covered entities with the 
                requirements of this section in order to prevent 
                diversion and violations of the duplicate discount 
                provision and other requirements under subsection 
                (a)(5).
                    ``(B) Improvements.--The improvements described in 
                subparagraph (A) shall include the following:
                            ``(i) The development of procedures to 
                        enable and require covered entities to update 
                        at least annually the information on the 
                        Internet Web site of the Department of Health 
                        and Human Services relating to this section.
                            ``(ii) The development of procedures for 
                        the Secretary to verify the accuracy of 
                        information regarding covered entities that is 
                        listed on the Web site described in clause (i).
                            ``(iii) The development of more detailed 
                        guidance describing methodologies and options 
                        available to covered entities for billing 
                        covered drugs to State Medicaid agencies in a 
                        manner that avoids duplicate discounts pursuant 
                        to subsection (a)(5)(A).
                            ``(iv) The establishment of a single, 
                        universal, and standardized identification 
                        system by which each covered entity site can be 
                        identified by manufacturers, distributors, 
                        covered entities, and the Secretary for 
                        purposes of facilitating the ordering, 
                        purchasing, and delivery of covered drugs under 
                        this section, including the processing of 
                        chargebacks for such drugs.
                            ``(v) The imposition of sanctions in the 
                        form of civil monetary penalties, which--
                                    ``(I) shall be assessed according 
                                to standards and procedures established 
                                in regulations promulgated by the 
                                Secretary;
                                    ``(II) shall not exceed $5,000 for 
                                each violation; and
                                    ``(III) shall apply to any covered 
                                entity that knowingly violates 
                                subparagraph (a)(5)(B) or knowingly 
                                violates any other provision of this 
                                section.
                            ``(vi) The exclusion of a covered entity 
                        from participation in the program under this 
                        section, for a period of time to be determined 
                        by the Secretary, in cases in which the 
                        Secretary determines, in accordance with 
                        standards and procedures established in 
                        regulations, that--
                                    ``(I) a violation of a requirement 
                                of this section was repeated and 
                                knowing; and
                                    ``(II) imposition of a monetary 
                                penalty would be insufficient to 
                                reasonably ensure compliance.
                            ``(vii) The referral of matters as 
                        appropriate to the Food and Drug 
                        Administration, the Office of Inspector General 
                        of Department of Health and Human Services, or 
                        other Federal agencies.
            ``(3) Administrative dispute resolution process.--From 
        amounts appropriated under paragraph (4), the Secretary may 
        establish and implement an administrative process for the 
        resolution of the following:
                    ``(A) Claims by covered entities that manufacturers 
                have violated the terms of their agreement with the 
                Secretary under subsection (a)(1).
                    ``(B) Claims by manufacturers that covered entities 
                have violated subsection (a)(5)(A) or (a)(5)(B).
            ``(4) Authorization of appropriations.--There are 
        authorized to be appropriated to carry out this subsection, 
        such sums as may be necessary for fiscal year 2011 and each 
        succeeding fiscal year.''.
    (b) Conforming Amendments.--
            (1) Section 340B(a) (42 U.S.C. 256b(a)) is amended--
                    (A) by adding at the end of paragraph (1) the 
                following: ``Such agreement shall require that the 
                manufacturer offer each covered entity covered drugs 
                for purchase at or below the applicable ceiling price 
                if such drug is made available to any other purchaser 
                at any price. Such agreement shall require that, if the 
                supply of a covered drug is insufficient to meet 
                demand, then the manufacturer may utilize an allocation 
                method that is reported in writing to the Secretary and 
                does not discriminate on the basis of the price paid by 
                covered entities or on any other basis related to an 
                entity's participation in the program under this 
                section. Notwithstanding any other provision of law, if 
                the Secretary requests a manufacturer to enter into a 
                new or amended agreement under this section that 
                complies with current law and if the manufacturer opts 
                not to sign the new or amended agreement, then any 
                existing agreement between the manufacturer and the 
                Secretary under this section is deemed to no longer 
                meet the requirements of this section for purposes of 
                this section and section 1927 of the Social Security 
                Act.''; and
                    (B) by adding at the end the following paragraph:
            ``(11) Quarterly reports.--An agreement described in 
        paragraph (1) shall require that the manufacturer furnish the 
        Secretary with reports on a quarterly basis that include the 
        following information:
                    ``(A) The price for each covered drug subject to 
                the agreement that, according to the manufacturer, 
                represents the maximum price that covered entities may 
                permissibly be required to pay for the drug (referred 
                to in this section as the `ceiling price').
                    ``(B) The component information used to calculate 
                the ceiling price as determined necessary to administer 
                the requirements of the program under this section.
                    ``(C) Rebates, discounts, and other price 
                concessions provided by manufacturers to other 
                purchasers subsequent to the sale of covered drugs to 
                covered entities.''.
            (2) Section 1927(a)(5) of the Social Security Act (42 
        U.S.C. 1396r-8(a)(5)) is amended by striking subparagraph (D).

SEC. 2503. EFFECTIVE DATE.

    (a) In General.--The amendments made by this subtitle shall take 
effect on the date of the enactment of this Act, and sections 2501, 
2502(a)(1), and 2502(b)(2) shall apply to drugs dispensed on or after 
such date.
    (b) Effectiveness.--The amendments made by this subtitle shall be 
effective, and shall be taken into account in determining whether a 
manufacturer is deemed to meet the requirements of section 340B(a) of 
the Public Health Service Act (42 U.S.C. 256b(a)), and of section 
1927(a)(5) of the Social Security Act (42 U.S.C. 1396r-8(a)(5)), 
notwithstanding any other provision of law.

                          Subtitle B--Programs

                 PART 1--GRANTS FOR CLINICS AND CENTERS

SEC. 2511. SCHOOL-BASED HEALTH CLINICS.

    (a) In General.--Part Q of title III (42 U.S.C. 280h et seq.) is 
amended by adding at the end the following:

``SEC. 399Z-1. SCHOOL-BASED HEALTH CLINICS.

    ``(a) Program.--The Secretary shall establish a school-based health 
clinic program consisting of awarding grants to eligible entities to 
support the operation of school-based health clinics (referred to in 
this section as `SBHCs').
    ``(b) Eligibility.--To be eligible for a grant under this section, 
an entity shall--
            ``(1) be an SBHC (as defined in subsection (l)(3)); and
            ``(2) submit an application at such time, in such manner, 
        and containing such information as the Secretary may require, 
        including at a minimum--
                    ``(A) evidence that the applicant meets all 
                criteria necessary to be designated as an SBHC;
                    ``(B) evidence of local need for the services to be 
                provided by the SBHC;
                    ``(C) an assurance that--
                            ``(i) SBHC services will be provided in 
                        accordance with Federal, State, and local laws;
                            ``(ii) the SBHC has established and 
                        maintains collaborative relationships with 
                        other health care providers in the catchment 
                        area of the SBHC;
                            ``(iii) the SBHC will provide onsite access 
                        during the academic day when school is in 
                        session and has an established network of 
                        support and access to services with backup 
                        health providers when the school or SBHC is 
                        closed;
                            ``(iv) the SBHC will be integrated into the 
                        school environment and will coordinate health 
                        services with appropriate school personnel and 
                        other community providers co-located at the 
                        school; and
                            ``(v) the SBHC sponsoring facility assumes 
                        all responsibility for the SBHC administration, 
                        operations, and oversight; and
                    ``(D) such other information as the Secretary may 
                require.
    ``(c) Use of Funds.--Funds awarded under a grant under this 
section--
            ``(1) may be used for--
                    ``(A) providing training related to the provision 
                of comprehensive primary health services and additional 
                health services;
                    ``(B) the management and operation of SBHC 
                programs, including through subcontracts; and
                    ``(C) the payment of salaries for health 
                professionals and other appropriate SBHC personnel; and
            ``(2) may not be used to provide abortions.
    ``(d) Consideration of Need.--In determining the amount of a grant 
under this section, the Secretary shall take into consideration--
            ``(1) the financial need of the SBHC;
            ``(2) State, local, or other sources of funding provided to 
        the SBHC; and
            ``(3) other factors as determined appropriate by the 
        Secretary.
    ``(e) Preferences.--In awarding grants under this section, the 
Secretary shall give preference to SBHCs that have a demonstrated 
record of service to at least one of the following:
            ``(1) A high percentage of medically underserved children 
        and adolescents.
            ``(2) Communities or populations in which children and 
        adolescents have difficulty accessing health and mental health 
        services.
            ``(3) Communities with high percentages of children and 
        adolescents who are uninsured, underinsured, or eligible for 
        medical assistance under Federal or State health benefits 
        programs (including titles XIX and XXI of the Social Security 
        Act).
    ``(f) Matching Requirement.--The Secretary may award a grant to an 
SBHC under this section only if the SBHC agrees to provide, from non-
Federal sources, an amount equal to 20 percent of the amount of the 
grant (which may be provided in cash or in kind) to carry out the 
activities supported by the grant.
    ``(g) Supplement, Not Supplant.--The Secretary may award a grant to 
an SBHC under this section only if the SBHC demonstrates to the 
satisfaction of the Secretary that funds received through the grant 
will be expended only to supplement, and not supplant, non-Federal and 
Federal funds otherwise available to the SBHC for operation of the SBHC 
(including each activity described in paragraph (1) or (2) of 
subsection (c)).
    ``(h) Payor of Last Resort.--The Secretary may award a grant to an 
SBHC under this section only if the SBHC demonstrates to the 
satisfaction of the Secretary that funds received through the grant 
will not be expended for any activity to the extent that payment has 
been made, or can reasonably be expected to be made--
            ``(1) under any insurance policy;
            ``(2) under any Federal or State health benefits program 
        (including titles XIX and XXI of the Social Security Act); or
            ``(3) by an entity which provides health services on a 
        prepaid basis.
    ``(i) Regulations Regarding Reimbursement for Health Services.--The 
Secretary shall issue regulations regarding the reimbursement for 
health services provided by SBHCs to individuals eligible to receive 
such services through the program under this section, including 
reimbursement under any insurance policy or any Federal or State health 
benefits program (including titles XIX and XXI of the Social Security 
Act).
    ``(j) Technical Assistance.--The Secretary shall provide (either 
directly or by grant or contract) technical and other assistance to 
SBHCs to assist such SBHCs to meet the requirements of this section. 
Such assistance may include fiscal and program management assistance, 
training in fiscal and program management, operational and 
administrative support, and the provision of information to the SBHCs 
of the variety of resources available under this title and how those 
resources can be best used to meet the health needs of the communities 
served by the SBHCs.
    ``(k) Evaluation; Report.--The Secretary shall--
            ``(1) develop and implement a plan for evaluating SBHCs and 
        monitoring quality performances under the awards made under 
        this section; and
            ``(2) submit to the Congress on an annual basis a report on 
        the program under this section.
    ``(l) Definitions.--In this section:
            ``(1) Comprehensive primary health services.--The term 
        `comprehensive primary health services' means the core services 
        offered by SBHCs, which--
                    ``(A) shall include--
                            ``(i) comprehensive health assessments, 
                        diagnosis, and treatment of minor, acute, and 
                        chronic medical conditions and referrals to, 
                        and followup for, specialty care; and
                            ``(ii) mental health assessments, crisis 
                        intervention, counseling, treatment, and 
                        referral to a continuum of services including 
                        emergency psychiatric care, community support 
                        programs, inpatient care, and outpatient 
                        programs; and
                    ``(B) may include additional services, such as oral 
                health, social, and age-appropriate health education 
                services, including nutritional counseling.
            ``(2) Medically underserved children and adolescents.--The 
        term `medically underserved children and adolescents' means a 
        population of children and adolescents who are residents of an 
        area designated by the Secretary as an area with a shortage of 
        personal health services and health infrastructure for such 
        children and adolescents.
            ``(3) School-based health clinic.--The term `school-based 
        health clinic' means a health clinic that--
                    ``(A) is located in, or is adjacent to, a school 
                facility of a local educational agency;
                    ``(B) is organized through school, community, and 
                health provider relationships;
                    ``(C) is administered by a sponsoring facility;
                    ``(D) provides comprehensive primary health 
                services during school hours to children and 
                adolescents by health professionals in accordance with 
                State and local laws and regulations, established 
                standards, and community practice; and
                    ``(E) does not perform abortion services.
            ``(4) Sponsoring facility.--The term `sponsoring facility' 
        is--
                    ``(A) a hospital;
                    ``(B) a public health department;
                    ``(C) a community health center;
                    ``(D) a nonprofit health care entity whose mission 
                is to provide access to comprehensive primary health 
                care services;
                    ``(E) a local educational agency; or
                    ``(F) a program administered by the Indian Health 
                Service or the Bureau of Indian Affairs or operated by 
                an Indian tribe or a tribal organization under the 
                Indian Self-Determination and Education Assistance Act, 
                a Native Hawaiian entity, or an urban Indian program 
                under title V of the Indian Health Care Improvement 
                Act.
    ``(m) Authorization of Appropriations.--For purposes of carrying 
out this section, there are authorized to be appropriated $50,000,000 
for fiscal year 2011 and such sums as may be necessary for each of 
fiscal years 2012 through 2015.''.
    (b) Effective Date.--The Secretary of Health and Human Services 
shall begin awarding grants under section 399Z-1 of the Public Health 
Service Act, as added by subsection (a), not later than July 1, 2010, 
without regard to whether or not final regulations have been issued 
under section 399Z-1(i) of such Act.
    (c) Termination of Study.--Section 2(b) of the Health Care Safety 
Net Act of 2008 (42 U.S.C. 254b note) is amended by striking paragraph 
(2) (relating to a school-based health center study).

SEC. 2512. NURSE-MANAGED HEALTH CENTERS.

    Title III (42 U.S.C. 241 et seq.) is amended by adding at the end 
the following:

                 ``PART S--NURSE-MANAGED HEALTH CENTERS

``SEC. 399FF. NURSE-MANAGED HEALTH CENTERS.

    ``(a) Program.--The Secretary, acting through the Administrator of 
the Health Resources and Services Administration, shall establish a 
nurse-managed health center program consisting of awarding grants to 
entities under subsection (b).
    ``(b) Grant.--The Secretary shall award grants to entities--
            ``(1) to plan and develop a nurse-managed health center; or
            ``(2) to operate a nurse-managed health center.
    ``(c) Use of Funds.--Amounts received as a grant under subsection 
(b) may be used for activities including the following:
            ``(1) Purchasing or leasing equipment.
            ``(2) Training and technical assistance related to the 
        provision of comprehensive primary care services and wellness 
        services.
            ``(3) Other activities for planning, developing, or 
        operating, as applicable, a nurse-managed health center.
    ``(d) Assurances Applicable to Both Planning and Operation 
Grants.--
            ``(1) In general.--The Secretary may award a grant under 
        this section to an entity only if the entity demonstrates to 
        the Secretary's satisfaction that--
                    ``(A) nurses, in addition to managing the center, 
                will be adequately represented as providers at the 
                center; and
                    ``(B) not later than 90 days after receiving the 
                grant, the entity will establish a community advisory 
                committee composed of individuals, a majority of whom 
                are being served by the center, to provide input into 
                the nurse-managed health center's operations.
            ``(2) Matching requirement.--The Secretary may award a 
        grant under this section to an entity only if the entity agrees 
        to provide, from non-Federal sources, an amount equal to 20 
        percent of the amount of the grant (which may be provided in 
        cash or in kind) to carry out the activities supported by the 
        grant.
            ``(3) Payor of last resort.--The Secretary may award a 
        grant under this section to an entity only if the entity 
        demonstrates to the satisfaction of the Secretary that funds 
        received through the grant will not be expended for any 
        activity to the extent that payment has been made, or can 
        reasonably be expected to be made--
                    ``(A) under any insurance policy;
                    ``(B) under any Federal or State health benefits 
                program (including titles XIX and XXI of the Social 
                Security Act); or
                    ``(C) by an entity which provides health services 
                on a prepaid basis.
            ``(4) Maintenance of effort.--The Secretary may award a 
        grant under this section to an entity only if the entity 
        demonstrates to the satisfaction of the Secretary that--
                    ``(A) funds received through the grant will be 
                expended only to supplement, and not supplant, non-
                Federal and Federal funds otherwise available to the 
                entity for the activities to be funded through the 
                grant; and
                    ``(B) with respect to such activities, the entity 
                will maintain expenditures of non-Federal amounts for 
                such activities at a level not less than the lesser of 
                such expenditures maintained by the entity for the 
                fiscal year preceding the fiscal year for which the 
                entity receives the grant.
    ``(e) Additional Assurance for Planning Grants.--The Secretary may 
award a grant under subsection (b)(1) to an entity only if the entity 
agrees--
            ``(1) to assess the needs of the medically underserved 
        populations proposed to be served by the nurse-managed health 
        center; and
            ``(2) to design services and operations of the nurse-
        managed health center for such populations based on such 
        assessment.
    ``(f) Additional Assurance for Operation Grants.--The Secretary may 
award a grant under subsection (b)(2) to an entity only if the entity 
assures that the nurse-managed health center will provide--
            ``(1) comprehensive primary care services, wellness 
        services, and other health care services deemed appropriate by 
        the Secretary;
            ``(2) care without respect to insurance status or income of 
        the patient; and
            ``(3) direct access to client-centered services offered by 
        advanced practice nurses, other nurses, physicians, physician 
        assistants, or other qualified health professionals.
    ``(g) Technical Assistance.--The Secretary shall provide (either 
directly or by grant or contract) technical and other assistance to 
nurse-managed health centers to assist such centers in meeting the 
requirements of this section. Such assistance may include fiscal and 
program management assistance, training in fiscal and program 
management, operational and administrative support, and the provision 
of information to nurse-managed health centers regarding the various 
resources available under this section and how those resources can best 
be used to meet the health needs of the communities served by nurse-
managed health centers.
    ``(h) Report.--The Secretary shall submit to the Congress an annual 
report on the program under this section.
    ``(i) Definitions.--In this section:
            ``(1) Comprehensive primary care services.--The term 
        `comprehensive primary care services' has the meaning given to 
        the term `required primary health services' in section 
        330(b)(1).
            ``(2) Medically underserved population.--The term 
        `medically underserved population' has the meaning given to 
        such term in section 330(b)(3).
            ``(3) Nurse-managed health center.--The term `nurse-managed 
        health center' has the meaning given to such term in section 
        801.
            ``(4) Wellness services.--The term `wellness services' 
        means any health-related service or intervention, not including 
        primary care, which is designed to reduce identifiable health 
        risks and increase healthy behaviors intended to prevent the 
        onset of disease or lessen the impact of existing chronic 
        conditions by teaching more effective management techniques 
        that focus on individual self-care and patient-driven 
        decisionmaking.
    ``(j) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.''.

SEC. 2513. FEDERALLY QUALIFIED BEHAVIORAL HEALTH CENTERS.

    Section 1913 (42 U.S.C. 300x-3) is amended--
            (1) in subsection (a)(2)(A), by striking ``community mental 
        health services'' and inserting ``behavioral health services 
        (of the type offered by federally qualified behavioral health 
        centers consistent with subsection (c)(3))'';
            (2) in subsection (b)--
                    (A) by striking paragraph (1) and inserting the 
                following:
            ``(1) services under the plan will be provided only through 
        appropriate, qualified community programs (which may include 
        federally qualified behavioral health centers, child mental 
        health programs, psychosocial rehabilitation programs, mental 
        health peer-support programs, and mental health primary 
        consumer-directed programs); and''; and
                    (B) in paragraph (2), by striking ``community 
                mental health centers'' and inserting ``federally 
                qualified behavioral health centers''; and
            (3) by striking subsection (c) and inserting the following:
    ``(c) Criteria for Federally Qualified Behavioral Health Centers.--
            ``(1) In general.--The Administrator shall certify, and 
        recertify at least every 5 years, federally qualified 
        behavioral health centers as meeting the criteria specified in 
        this subsection.
            ``(2) Regulations.--Not later than 18 months after the date 
        of the enactment of the Affordable Health Care for America Act, 
        the Administrator shall issue final regulations for certifying 
        centers under paragraph (1).
            ``(3) Criteria.--The criteria referred to in subsection 
        (b)(2) are that the center performs each of the following:
                    ``(A) Provide services in locations that ensure 
                services will be available and accessible promptly and 
                in a manner which preserves human dignity and assures 
                continuity of care.
                    ``(B) Provide services in a mode of service 
                delivery appropriate for the target population.
                    ``(C) Provide individuals with a choice of service 
                options where there is more than one efficacious 
                treatment.
                    ``(D) Employ a core staff of clinical staff that is 
                multidisciplinary and culturally and linguistically 
                competent.
                    ``(E) Provide services, within the limits of the 
                capacities of the center, to any individual residing or 
                employed in the service area of the center.
                    ``(F) Provide, directly or through contract, to the 
                extent covered for adults in the State Medicaid plan 
                and for children in accordance with section 1905(r) of 
                the Social Security Act regarding early and periodic 
                screening, diagnosis, and treatment, each of the 
                following services:
                            ``(i) Screening, assessment, and diagnosis, 
                        including risk assessment.
                            ``(ii) Person-centered treatment planning 
                        or similar processes, including risk assessment 
                        and crisis planning.
                            ``(iii) Outpatient clinic mental health 
                        services, including screening, assessment, 
                        diagnosis, psychotherapy, substance abuse 
                        counseling, medication management, and 
                        integrated treatment for mental illness and 
                        substance abuse which shall be evidence-based 
                        (including cognitive behavioral therapy, 
                        dialectical behavioral therapy, motivational 
                        interviewing, and other such therapies which 
                        are evidence-based).
                            ``(iv) Outpatient clinic primary care 
                        services, including screening and monitoring of 
                        key health indicators and health risk 
                        (including screening for diabetes, 
                        hypertension, and cardiovascular disease and 
                        monitoring of weight, height, body mass index 
                        (BMI), blood pressure, blood glucose or HbA1C, 
                        and lipid profile).
                            ``(v) Crisis mental health services, 
                        including 24-hour mobile crisis teams, 
                        emergency crisis intervention services, and 
                        crisis stabilization.
                            ``(vi) Targeted case management (services 
                        to assist individuals gaining access to needed 
                        medical, social, educational, and other 
                        services and applying for income security and 
                        other benefits to which they may be entitled).
                            ``(vii) Psychiatric rehabilitation services 
                        including skills training, assertive community 
                        treatment, family psychoeducation, disability 
                        self-management, supported employment, 
                        supported housing services, therapeutic foster 
                        care services, multisystemic therapy, and such 
                        other evidence-based practices as the Secretary 
                        may require.
                            ``(viii) Peer support and counselor 
                        services and family supports.
                    ``(G) Maintain linkages, and where possible enter 
                into formal contracts with, inpatient psychiatric 
                facilities and substance abuse detoxification and 
                residential programs.
                    ``(H) Make available to individuals served by the 
                center, directly, through contract, or through linkages 
                with other programs, each of the following:
                            ``(i) Adult and youth peer support and 
                        counselor services.
                            ``(ii) Family support services for families 
                        of children with serious mental disorders.
                            ``(iii) Other community or regional 
                        services, supports, and providers, including 
                        schools, child welfare agencies, juvenile and 
                        criminal justice agencies and facilities, 
                        housing agencies and programs, employers, and 
                        other social services.
                            ``(iv) Onsite or offsite access to primary 
                        care services.
                            ``(v) Enabling services, including 
                        outreach, transportation, and translation.
                            ``(vi) Health and wellness services, 
                        including services for tobacco cessation.''.

                      PART 2--OTHER GRANT PROGRAMS

SEC. 2521. COMPREHENSIVE PROGRAMS TO PROVIDE EDUCATION TO NURSES AND 
              CREATE A PIPELINE TO NURSING.

    (a) Purposes.--It is the purpose of this section to authorize 
grants to--
            (1) address the projected shortage of nurses by funding 
        comprehensive programs to create a career ladder to nursing 
        (including certified nurse assistants, licensed practical 
        nurses, licensed vocational nurses, and registered nurses) for 
        incumbent ancillary health care workers;
            (2) increase the capacity for educating nurses by 
        increasing both nurse faculty and clinical opportunities 
        through collaborative programs between staff nurse 
        organizations, health care providers, and accredited schools of 
        nursing; and
            (3) provide training programs through education and 
        training organizations jointly administered by health care 
        providers and health care labor organizations or other 
        organizations representing staff nurses and frontline health 
        care workers, working in collaboration with accredited schools 
        of nursing and academic institutions.
    (b) Grants.--Not later than 6 months after the date of the 
enactment of this Act, the Secretary of Labor (referred to in this 
section as the ``Secretary'') shall establish a partnership grant 
program to award grants to eligible entities to carry out comprehensive 
programs to provide education to nurses and create a pipeline to 
nursing for incumbent ancillary health care workers who wish to advance 
their careers, and to otherwise carry out the purposes of this section.
    (c) Eligibility.--To be eligible for a grant under this section, an 
entity shall be--
            (1) a health care entity that is jointly administered by a 
        health care employer and a labor union representing the health 
        care employees of the employer and that carries out activities 
        using labor-management training funds as provided for under 
        section 302(c)(6) of the Labor Management Relations Act, 1947 
        (29 U.S.C. 186(c)(6));
            (2) an entity that operates a training program that is 
        jointly administered by--
                    (A) one or more health care providers or 
                facilities, or a trade association of health care 
                providers; and
                    (B) one or more organizations which represent the 
                interests of direct care health care workers or staff 
                nurses and in which the direct care health care workers 
                or staff nurses have direct input as to the leadership 
                of the organization;
            (3) a State training partnership program that consists of 
        nonprofit organizations that include equal participation from 
        industry, including public or private employers, and labor 
        organizations including joint labor-management training 
        programs, and which may include representatives from local 
        governments, worker investment agency one-stop career centers, 
        community-based organizations, community colleges, and 
        accredited schools of nursing; or
            (4) a school of nursing (as defined in section 801 of the 
        Public Health Service Act (42 U.S.C. 296)).
    (d) Additional Requirements for Health Care Employer Described in 
Subsection (c).--To be eligible for a grant under this section, a 
health care employer described in subsection (c) shall demonstrate that 
it--
            (1) has an established program within its facility to 
        encourage the retention of existing nurses;
            (2) provides wages and benefits to its nurses that are 
        competitive for its market or that have been collectively 
        bargained with a labor organization; and
            (3) supports programs funded under this section through 1 
        or more of the following:
                    (A) The provision of paid leave time and continued 
                health coverage to incumbent health care workers to 
                allow their participation in nursing career ladder 
                programs, including certified nurse assistants, 
                licensed practical nurses, licensed vocational nurses, 
                and registered nurses.
                    (B) Contributions to a joint labor-management 
                training fund which administers the program involved.
                    (C) The provision of paid release time, incentive 
                compensation, or continued health coverage to staff 
                nurses who desire to work full- or part-time in a 
                faculty position.
                    (D) The provision of paid release time for staff 
                nurses to enable them to obtain a bachelor of science 
                in nursing degree, other advanced nursing degrees, 
                specialty training, or certification program.
                    (E) The payment of tuition assistance which is 
                managed by a joint labor-management training fund or 
                other jointly administered program.
    (e) Other Requirements.--
            (1) Matching requirement.--
                    (A) In general.--The Secretary may not make a grant 
                under this section unless the applicant involved 
                agrees, with respect to the costs to be incurred by the 
                applicant in carrying out the program under the grant, 
                to make available non-Federal contributions (in cash or 
                in kind under subparagraph (B)) toward such costs in an 
                amount equal to not less than $1 for each $1 of Federal 
                funds provided in the grant. Such contributions may be 
                made directly or through donations from public or 
                private entities, or may be provided through the cash 
                equivalent of paid release time provided to incumbent 
                worker students.
                    (B) Determination of amount of non-federal 
                contribution.--Non-Federal contributions required in 
                subparagraph (A) may be in cash or in kind (including 
                paid release time), fairly evaluated, including 
                equipment or services (and excluding indirect or 
                overhead costs). Amounts provided by the Federal 
                Government, or services assisted or subsidized to any 
                significant extent by the Federal Government, may not 
                be included in determining the amount of such non-
                Federal contributions.
            (2) Required collaboration.--Entities carrying out or 
        overseeing programs carried out with assistance provided under 
        this section shall demonstrate collaboration with accredited 
        schools of nursing which may include community colleges and 
        other academic institutions providing associate's, bachelor's, 
        or advanced nursing degree programs or specialty training or 
        certification programs.
    (f) Use of Funds.--Amounts awarded to an entity under a grant under 
this section shall be used for the following:
            (1) To carry out programs that provide education and 
        training to establish nursing career ladders to educate 
        incumbent health care workers to become nurses (including 
        certified nurse assistants, licensed practical nurses, licensed 
        vocational nurses, and registered nurses). Such programs shall 
        include one or more of the following:
                    (A) Preparing incumbent workers to return to the 
                classroom through English-as-a-second-language 
                education, GED education, precollege counseling, 
                college preparation classes, and support with entry 
                level college classes that are a prerequisite to 
                nursing.
                    (B) Providing tuition assistance with preference 
                for dedicated cohort classes in community colleges, 
                universities, and accredited schools of nursing with 
                supportive services including tutoring and counseling.
                    (C) Providing assistance in preparing for and 
                meeting all nursing licensure tests and requirements.
                    (D) Carrying out orientation and mentorship 
                programs that assist newly graduated nurses in 
                adjusting to working at the bedside to ensure their 
                retention postgraduation, and ongoing programs to 
                support nurse retention.
                    (E) Providing stipends for release time and 
                continued health care coverage to enable incumbent 
                health care workers to participate in these programs.
            (2) To carry out programs that assist nurses in obtaining 
        advanced degrees and completing specialty training or 
        certification programs and to establish incentives for nurses 
        to assume nurse faculty positions on a part-time or full-time 
        basis. Such programs shall include one or more of the 
        following:
                    (A) Increasing the pool of nurses with advanced 
                degrees who are interested in teaching by funding 
                programs that enable incumbent nurses to return to 
                school.
                    (B) Establishing incentives for advanced degree 
                bedside nurses who wish to teach in nursing programs so 
                they can obtain a leave from their bedside position to 
                assume a full- or part-time position as adjunct or 
                full-time faculty without the loss of salary or 
                benefits.
                    (C) Collaboration with accredited schools of 
                nursing which may include community colleges and other 
                academic institutions providing associate's, 
                bachelor's, or advanced nursing degree programs, or 
                specialty training or certification programs, for 
                nurses to carry out innovative nursing programs which 
                meet the needs of bedside nursing and health care 
                providers.
    (g) Preference.--In awarding grants under this section the 
Secretary shall give preference to programs that--
            (1) provide for improving nurse retention;
            (2) provide for improving the diversity of the new nurse 
        graduates to reflect changes in the demographics of the patient 
        population;
            (3) provide for improving the quality of nursing education 
        to improve patient care and safety;
            (4) have demonstrated success in upgrading incumbent health 
        care workers to become nurses or which have established 
        effective programs or pilots to increase nurse faculty; or
            (5) are modeled after or affiliated with such programs 
        described in paragraph (4).
    (h) Evaluation.--
            (1) Program evaluations.--An entity that receives a grant 
        under this section shall annually evaluate, and submit to the 
        Secretary a report on, the activities carried out under the 
        grant and the outcomes of such activities. Such outcomes may 
        include--
                    (A) an increased number of incumbent workers 
                entering an accredited school of nursing and in the 
                pipeline for nursing programs;
                    (B) an increasing number of graduating nurses and 
                improved nurse graduation and licensure rates;
                    (C) improved nurse retention;
                    (D) an increase in the number of staff nurses at 
                the health care facility involved;
                    (E) an increase in the number of nurses with 
                advanced degrees in nursing;
                    (F) an increase in the number of nurse faculty;
                    (G) improved measures of patient quality (which may 
                include staffing ratios of nurses, patient satisfaction 
                rates, and patient safety measures); and
                    (H) an increase in the diversity of new nurse 
                graduates relative to the patient population.
            (2) General report.--Not later than 2 years after the date 
        of the enactment of this Act, and annually thereafter, the 
        Secretary of Labor shall, using data and information from the 
        reports received under paragraph (1), submit to the Congress a 
        report concerning the overall effectiveness of the grant 
        program carried out under this section.
    (i) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section such sums as may be necessary 
for each of fiscal years 2011 through 2015.

SEC. 2522. MENTAL AND BEHAVIORAL HEALTH TRAINING.

    Part E of title VII (42 U.S.C. 294n et seq.) is amended by adding 
at the end the following:

           ``Subpart 3--Mental and Behavioral Health Training

``SEC. 775. MENTAL AND BEHAVIORAL HEALTH TRAINING PROGRAM.

    ``(a) Program.--The Secretary, acting through the Administrator of 
the Health Resources and Services Administration and in consultation 
with the Administrator of the Substance Abuse and Mental Health 
Services Administration, shall establish an interdisciplinary mental 
and behavioral health training program consisting of awarding grants 
and contracts under subsection (b).
    ``(b) Support and Development of Mental and Behavioral Health 
Training Programs.--The Secretary shall make grants to, or enter into 
contracts with, eligible entities--
            ``(1) to plan, develop, operate, or participate in an 
        accredited professional training program for mental and 
        behavioral health professionals to promote--
                    ``(A) interdisciplinary training; and
                    ``(B) coordination of the delivery of health care 
                within and across settings, including health care 
                institutions, community-based settings, and the 
                patient's home;
            ``(2) to provide financial assistance to mental and 
        behavioral health professionals, who are participants in any 
        such program, and who plan to work in the field of mental and 
        behavioral health;
            ``(3) to plan, develop, operate, or participate in an 
        accredited program for the training of mental and behavioral 
        health professionals who plan to teach in the field of mental 
        and behavioral health; and
            ``(4) to provide financial assistance in the form of 
        traineeships and fellowships to mental and behavioral health 
        professionals who are participants in any such program and who 
        plan to teach in the field of mental and behavioral health.
    ``(c) Eligibility.--To be eligible for a grant or contract under 
subsection (b), an entity shall be--
            ``(1) an accredited health professions school, including an 
        accredited school or program of psychology, psychiatry, social 
        work, marriage and family therapy, professional mental health 
        or substance abuse counseling, or addiction medicine;
            ``(2) an accredited public or nonprofit private hospital;
            ``(3) a public or private nonprofit entity; or
            ``(4) a consortium of 2 or more entities described in 
        paragraphs (1) through (3).
    ``(d) Preference.--In awarding grants or contracts under this 
section, the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            ``(1) Training a high or significantly improved percentage 
        of health professionals who serve in underserved communities.
            ``(2) Supporting teaching programs that address the health 
        care needs of vulnerable populations.
            ``(3) Training individuals who are from disadvantaged 
        backgrounds (including racial and ethnic minorities 
        underrepresented among mental and behavioral health 
        professionals).
            ``(4) Training individuals who serve geriatric populations 
        with an emphasis on underserved elderly.
            ``(5) Training individuals who serve pediatric populations 
        with an emphasis on underserved children.
    ``(e) Report.--The Secretary shall submit to the Congress an annual 
report on the program under this section.
    ``(f) Definition.--In this section:
            ``(1) The term `interdisciplinary' means collaboration 
        across health professions, specialties, and subspecialties, 
        which may include public health, nursing, allied health, 
        dietetics or nutrition, and appropriate health specialties.
            ``(2) The term `mental and behavioral health professional' 
        means an individual training or practicing--
                    ``(A) in psychology; general, geriatric, child or 
                adolescent psychiatry; social work; marriage and family 
                therapy; professional mental health or substance abuse 
                counseling; or addiction medicine; or
                    ``(B) another mental and behavioral health 
                specialty, as deemed appropriate by the Secretary.
    ``(g) Authorization of Appropriations.--To carry out this section, 
there is authorized to be appropriated $60,000,000 for each of fiscal 
years 2011 through 2015. Of the amounts appropriated to carry out this 
section for a fiscal year, not less than 15 percent shall be used for 
training programs in psychology.''.

SEC. 2523. REAUTHORIZATION OF TELEHEALTH AND TELEMEDICINE GRANT 
              PROGRAMS.

    (a) Telehealth Network and Telehealth Resource Centers Grant 
Programs.--Section 330I (42 U.S.C. 254c-14) is amended--
            (1) in subsection (a)--
                    (A) by striking paragraph (3) (relating to frontier 
                communities); and
                    (B) by inserting after paragraph (2) the following:
            ``(3) Health disparities.--The term `health disparities' 
        has the meaning given such term in section 3171.'';
            (2) in subsection (d)(1)--
                    (A) in subparagraph (B), by striking ``and'' at the 
                end;
                    (B) in subparagraph (C), by striking the period at 
                the end and inserting ``; and''; and
                    (C) by adding at the end the following:
                    ``(D) reduce health disparities.'';
            (3) in subsection (f)(1)(B)(iii)--
                    (A) in subclause (VII), by inserting ``, including 
                skilled nursing facilities'' before the period at the 
                end;
                    (B) in subclause (IX), by inserting ``, including 
                county mental health and public mental health 
                facilities'' before the period at the end; and
                    (C) by adding at the end the following:
                                    ``(XIII) Renal dialysis 
                                facilities.'';
            (4) by amending subsection (i) to read as follows:
    ``(i) Preferences.--
            ``(1) Telehealth networks.--In awarding grants under 
        subsection (d)(1) for projects involving telehealth networks, 
        the Secretary shall give preference to eligible entities 
        meeting at least one of the following:
                    ``(A) Network.--The eligible entity is a health 
                care provider in, or proposing to form, a health care 
                network that furnishes services in a medically 
                underserved area or a health professional shortage 
                area.
                    ``(B) Broad geographic coverage.--The eligible 
                entity demonstrates broad geographic coverage in the 
                rural or medically underserved areas of the State or 
                States in which the entity is located.
                    ``(C) Health disparities.--The eligible entity 
                demonstrates how the project to be funded through the 
                grant will address health disparities.
                    ``(D) Linkages.--The eligible entity agrees to use 
                the grant to establish or develop plans for telehealth 
                systems that will link rural hospitals and rural health 
                care providers to other hospitals, health care 
                providers, and patients.
                    ``(E) Efficiency.--The eligible entity agrees to 
                use the grant to promote greater efficiency in the use 
                of health care resources.
                    ``(F) Viability.--The eligible entity demonstrates 
                the long-term viability of projects through--
                            ``(i) availability of non-Federal funding 
                        sources; or
                            ``(ii) institutional and community support 
                        for the telehealth network.
                    ``(G) Services.--The eligible entity provides a 
                plan for coordinating system use by eligible entities 
                and prioritizes use of grant funds for health care 
                services over nonclinical uses.
            ``(2) Telehealth resource centers.--In awarding grants 
        under subsection (d)(2) for projects involving telehealth 
        resource centers, the Secretary shall give preference to 
        eligible entities meeting at least one of the following:
                    ``(A) Provision of a broad range of services.--The 
                eligible entity has a record of success in the 
                provision of a broad range of telehealth services to 
                medically underserved areas or populations.
                    ``(B) Provision of telehealth technical 
                assistance.--The eligible entity has a record of 
                success in the provision of technical assistance to 
                providers serving medically underserved communities or 
                populations in the establishment and implementation of 
                telehealth services.
                    ``(C) Collaboration and sharing of expertise.--The 
                eligible entity has a demonstrated record of 
                collaborating and sharing expertise with providers of 
                telehealth services at the national, regional, State, 
                and local levels.'';
            (5) in subsection (j)(2)(B), by striking ``such projects 
        for fiscal year 2001'' and all that follows through the period 
        and inserting ``such projects for fiscal year 2010.'';
            (6) in subsection (k)(1)--
                    (A) in subparagraph (E)(i), by striking 
                ``transmission of medical data'' and inserting 
                ``transmission and electronic archival of medical 
                data''; and
                    (B) by amending subparagraph (F) to read as 
                follows:
                    ``(F) developing projects to use telehealth 
                technology to--
                            ``(i) facilitate collaboration between 
                        health care providers;
                            ``(ii) promote telenursing services; or
                            ``(iii) promote patient understanding and 
                        adherence to national guidelines for chronic 
                        disease and self-management of such 
                        conditions;'';
            (7) in subsection (q), by striking ``Not later than 
        September 30, 2005'' and inserting ``Not later than 1 year 
        after the date of the enactment of the Affordable Health Care 
        for America Act, and annually thereafter'';
            (8) by striking subsection (r);
            (9) by redesignating subsection (s) as subsection (r); and
            (10) in subsection (r) (as so redesignated)--
                    (A) in paragraph (1)--
                            (i) by striking ``and'' before ``such 
                        sums''; and
                            (ii) by inserting ``, $10,000,000 for 
                        fiscal year 2011, and such sums as may be 
                        necessary for each of fiscal years 2012 through 
                        2015'' before the semicolon; and
                    (B) in paragraph (2)--
                            (i) by striking ``and'' before ``such 
                        sums''; and
                            (ii) by inserting ``, $10,000,000 for 
                        fiscal year 2011, and such sums as may be 
                        necessary for each of fiscal years 2012 through 
                        2015'' before the period.
    (b) Telemedicine; Incentive Grants Regarding Coordination Among 
States.--Subsection (b) of section 330L (42 U.S.C. 254c-18) is amended 
by inserting ``, $10,000,000 for fiscal year 2011, and such sums as may 
be necessary for each of fiscal years 2012 through 2015'' before the 
period at the end.

SEC. 2524. NO CHILD LEFT UNIMMUNIZED AGAINST INFLUENZA: DEMONSTRATION 
              PROGRAM USING ELEMENTARY AND SECONDARY SCHOOLS AS 
              INFLUENZA VACCINATION CENTERS.

    (a) Purpose.--The Secretary of Health and Human Services in 
consultation with the Secretary of Education, shall award grants to 
eligible partnerships to carry out demonstration programs designed to 
test the feasibility of using the Nation's elementary schools and 
secondary schools as influenza vaccination centers.
    (b) In General.--The Secretary shall coordinate with the Secretary 
of Labor, the Secretary of Education, State Medicaid agencies, State 
insurance agencies, and private insurers to carry out a program 
consisting of awarding grants under subsection (c) to ensure that 
children have coverage for all reasonable and customary expenses 
related to influenza vaccinations, including the costs of purchasing 
and administering the vaccine incurred when influenza vaccine is 
administered outside of the physician's office in a school or other 
related setting.
    (c) Program Description.--
            (1) Grants.--From amounts appropriated pursuant to 
        subsection (l), the Secretary shall award grants to eligible 
        partnerships to be used to provide influenza vaccinations to 
        children in elementary and secondary schools, in coordination 
        with school nurses, school health care programs, community 
        health care providers, State insurance agencies, or private 
        insurers.
            (2) ACIP recommendations.--The program under this section 
        shall be designed to administer vaccines consistent with the 
        recommendations of the Centers for Disease Control and 
        Prevention's Advisory Committee on Immunization Practices 
        (ACIP) for the annual vaccination of all children 5 through 19 
        years of age.
            (3) Participation voluntary.--Participation by a school or 
        an individual shall be voluntary.
    (d) Use of Funds.--Eligible partnerships receiving a grant under 
this section shall ensure the maximum number of children access 
influenza vaccinations as follows:
            (1) Covered children.--To the extent to which payment of 
        the costs of purchasing or administering the influenza vaccine 
        for children is not covered through other federally funded 
        programs or through private insurance, eligible partnerships 
        receiving a grant shall use funds to purchase and administer 
        influenza vaccinations.
            (2) Children covered by other federal programs.--For 
        children who are eligible under other federally funded programs 
        for payment of the costs of purchasing or administering the 
        influenza vaccine, eligible partnerships receiving a grant 
        shall not use funds provided under this section for such costs.
            (3) Children covered by private health insurance.--For 
        children who have private insurance, eligible partnerships 
        receiving a grant shall offer assistance in accessing coverage 
        for vaccinations administered through the program under this 
        section.
    (e) Privacy.--The Secretary shall ensure that the program under 
this section adheres to confidentiality and privacy requirements of 
section 264 of the Health Insurance Portability and Accountability Act 
of 1996 (42 U.S.C. 1320d-2 note) and section 444 of the General 
Education Provisions Act (20 U.S.C. 1232g; commonly referred to as the 
``Family Educational Rights and Privacy Act of 1974'').
    (f) Application.--An eligible partnership desiring a grant under 
this section shall submit an application to the Secretary at such time, 
in such manner, and containing such information as the Secretary may 
require.
    (g) Duration.--Eligible partnerships receiving a grant shall 
administer a demonstration program funded through this section over a 
period of 2 consecutive school years.
    (h) Choice of Vaccine.--The program under this section shall not 
restrict the discretion of a health care provider to administer any 
influenza vaccine approved by the Food and Drug Administration for use 
in pediatric populations.
    (i) Awards.--The Secretary shall award--
            (1) a minimum of 10 grants in 10 different States to 
        eligible partnerships that each include one or more public 
        schools serving primarily low-income students; and
            (2) a minimum of 5 grants in 5 different States to eligible 
        partnerships that each include one or more public schools 
        located in a rural local educational agency.
    (j) Report.--Not later than 90 days following the completion of the 
program under this section, the Secretary shall submit to the 
Committees on Education and Labor, Energy and Commerce, and 
Appropriations of the House of Representatives and to the Committees on 
Health, Education, Labor, and Pensions and Appropriations of the Senate 
a report on the results of the program. The report shall include--
            (1) an assessment of the influenza vaccination rates of 
        school-age children in localities where the program is 
        implemented, compared to the national average influenza 
        vaccination rates for school-aged children, including whether 
        school-based vaccination assists in achieving the 
        recommendations of the Advisory Committee on Immunization 
        Practices;
            (2) an assessment of the utility of employing elementary 
        schools and secondary schools as a part of a multistate, 
        community-based pandemic response program that is consistent 
        with existing Federal and State pandemic response plans;
            (3) an assessment of the feasibility of using existing 
        Federal and private insurance funding in establishing a 
        multistate, school-based vaccination program for seasonal 
        influenza vaccination;
            (4) an assessment of the number of education days gained by 
        students as a result of seasonal vaccinations based on 
        absenteeism rates;
            (5) a determination of whether the program under this 
        section--
                    (A) increased vaccination rates in the 
                participating localities; and
                    (B) was implemented for sufficient time for 
                gathering enough valid data; and
            (6) a recommendation on whether the program should be 
        continued, expanded, or terminated.
    (k) Definitions.--In this section:
            (1) Eligible partnership.--The term ``eligible 
        partnership'' means a local public health department, or 
        another health organization defined by the Secretary as 
        eligible to submit an application, and one or more elementary 
        and secondary schools.
            (2) Elementary school.--The terms ``elementary school'' and 
        ``secondary school'' have the meanings given such terms in 
        section 9101 of the Elementary and Secondary Education Act of 
        1965 (20 U.S.C. 7801).
            (3) Low-income.--The term ``low-income'' means a student, 
        age 5 through 19, eligible for free or reduced-price lunch 
        under the National School Lunch Act (42 U.S.C. 1751 et seq.).
            (4) Rural local educational agency.--The term ``rural local 
        educational agency'' means an eligible local educational agency 
        described in section 6211(b)(1) of the Elementary and Secondary 
        Education Act of 1965 (20 U.S.C. 7345(b)(1)).
            (5) Secretary.--Except as otherwise specified, the term 
        ``Secretary'' means the Secretary of Health and Human Services.
    (l) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.

SEC. 2525. EXTENSION OF WISEWOMAN PROGRAM.

    Section 1509 of the Public Health Service Act (42 U.S.C. 300n-4a) 
is amended--
            (1) in subsection (a)--
                    (A) by striking the heading and inserting ``In 
                General.--''; and
                    (B) in the matter preceding paragraph (1), by 
                striking ``may make grants'' and all that follows 
                through ``purpose'' and inserting the following: ``may 
                make grants to such States for the purpose''; and
            (2) in subsection (d)(1), by striking ``there are 
        authorized'' and all that follows through the period and 
        inserting ``there are authorized to be appropriated $70,000,000 
        for fiscal year 2011, $73,500,000 for fiscal year 2012, 
        $77,000,000 for fiscal year 2013, $81,000,000 for fiscal year 
        2014, and $85,000,000 for fiscal year 2015.''.

SEC. 2526. HEALTHY TEEN INITIATIVE TO PREVENT TEEN PREGNANCY.

    Part B of title III (42 U.S.C. 243 et seq.) is amended by inserting 
after section 317T the following:

``SEC. 317U. HEALTHY TEEN INITIATIVE TO PREVENT TEEN PREGNANCY.

    ``(a) Program.--To the extent and in the amount of appropriations 
made in advance in appropriations Acts, the Secretary, acting through 
the Director of the Centers for Disease Control and Prevention, shall 
establish a program consisting of making grants, in amounts determined 
under subsection (c), to each State that submits an application in 
accordance with subsection (d) for an evidence-based education program 
described in subsection (b).
    ``(b) Use of Funds.--Amounts received by a State under this section 
shall be used to conduct or support evidence-based education programs 
(directly or through grants or contracts to public or private nonprofit 
entities, including schools and community-based and faith-based 
organizations) to reduce teen pregnancy or sexually transmitted 
diseases.
    ``(c) Distribution of Funds.--The Director shall, for fiscal year 
2011 and each subsequent fiscal year, make a grant to each State 
described in subsection (a) in an amount equal to the product of--
            ``(1) the amount appropriated to carry out this section for 
        the fiscal year; and
            ``(2) the percentage determined for the State under section 
        502(c)(1)(B)(ii) of the Social Security Act.
    ``(d) Application.--To seek a grant under this section, a State 
shall submit an application at such time, in such manner, and 
containing such information and assurance of compliance with this 
section as the Secretary may require. At a minimum, an application 
shall to the satisfaction of the Secretary--
            ``(1) describe how the State's proposal will address the 
        needs of at-risk teens in the State;
            ``(2) identify the evidence-based education program or 
        programs selected from the registry developed under subsection 
        (g) that will be used to address risks in priority populations;
            ``(3) describe how the program or programs will be 
        implemented and any adaptations to the evidence-based model 
        that will be made;
            ``(4) list any private and public entities with whom the 
        State proposes to work, including schools and community-based 
        and faith-based organizations, and demonstrate their capacity 
        to implement the proposed program or programs; and
            ``(5) identify an independent entity that will evaluate the 
        impact of the program or programs.
    ``(e) Evaluation.--
            ``(1) Requirement.--As a condition on receipt of a grant 
        under this section, a State shall agree--
                    ``(A) to arrange for an independent evaluation of 
                the impact of the programs to be conducted or supported 
                through the grant; and
                    ``(B) submit reports to the Secretary on such 
                programs and the results of evaluation of such 
                programs.
            ``(2) Funding limitation.--Of the amounts made available to 
        a State through a grant under this section for any fiscal year, 
        not more than 10 percent may be used for such evaluation.
    ``(f) Rule of Construction.--This section shall not be construed to 
preempt or limit any State law regarding parental involvement and 
decisionmaking in children's education.
    ``(g) Registry of Eligible Programs.--The Secretary shall develop 
not later than 180 days after the date of the enactment of the 
Affordable Health Care for America Act, and periodically update 
thereafter, a publicly available registry of programs described in 
subsection (b) that, as determined by the Secretary--
            ``(1) meet the definition of the term `evidence-based' in 
        subsection (i);
            ``(2) are medically and scientifically accurate; and
            ``(3) provide age-appropriate information.
    ``(h) Matching Funds.--The Secretary may award a grant to a State 
under this section for a fiscal year only if the State agrees to 
provide, from non-Federal sources, an amount equal to $1 (in cash or in 
kind) for each $4 provided through the grant to carry out the 
activities supported by the grant.
    ``(i) Definition.--In this section, the term `evidence-based' means 
based on a model that has been found, in methodologically sound 
research--
            ``(1) to delay initiation of sex;
            ``(2) to decrease number of partners;
            ``(3) to reduce teen pregnancy;
            ``(4) to reduce sexually transmitted infection rates; or
            ``(5) to improve rates of contraceptive use.
    ``(j) Authorization of Appropriations.--To carry out this section, 
there is authorized to be appropriated $50,000,000 for each of fiscal 
years 2011 through 2015.''.

SEC. 2527. NATIONAL TRAINING INITIATIVES ON AUTISM SPECTRUM DISORDERS.

    Title I of the Developmental Disabilities Assistance and Bill of 
Rights Act of 2000 (42 U.S.C. 15001 et seq.) is amended by adding at 
the end the following:

``Subtitle F--National Training Initiative on Autism Spectrum Disorders

``SEC. 171. NATIONAL TRAINING INITIATIVE.

    ``(a) Grants and Technical Assistance.--
            ``(1) Grants.--
                    ``(A) In general.--The Secretary, in consultation 
                with the Interagency Autism Coordinating Committee, 
                shall award multiyear grants to eligible entities to 
                provide individuals (including parents and health, 
                allied health, vocational, and educational 
                professionals) with interdisciplinary training, 
                continuing education, technical assistance, and 
                information for the purpose of improving services 
                rendered to children and adults with autism, and their 
                families, to address unmet needs related to autism.
                    ``(B) Eligible entity.--To be eligible to receive a 
                grant under this subsection, an entity shall be--
                            ``(i) a University Center for Excellence in 
                        Developmental Disabilities Education, Research, 
                        and Service; or
                            ``(ii) a comparable interdisciplinary 
                        education, research, and service entity.
                    ``(C) Application requirements.--An entity that 
                desires to receive a grant for a program under this 
                paragraph shall submit to the Secretary an 
                application--
                            ``(i) demonstrating that the entity has 
                        capacity to--
                                    ``(I) provide training and 
                                technical assistance in evidence-based 
                                practices to evaluate, and provide 
                                effective interventions, services, 
                                treatments, and supports to, children 
                                and adults with autism and their 
                                families;
                                    ``(II) include individuals with 
                                autism and their families as part of 
                                the program to ensure that an 
                                individual- and family-centered 
                                approach is used;
                                    ``(III) share and disseminate 
                                materials and practices that are 
                                developed for, and evaluated to be 
                                effective in, the provision of training 
                                and technical assistance; and
                                    ``(IV) provide training, technical 
                                assistance, interventions, services, 
                                treatments, and supports under this 
                                subsection statewide.
                            ``(ii) providing assurances that the entity 
                        will--
                                    ``(I) provide trainees under this 
                                subsection with an appropriate balance 
                                of interdisciplinary academic and 
                                community-based experiences; and
                                    ``(II) provide to the Secretary, in 
                                the manner prescribed by the Secretary, 
                                data regarding the number of 
                                individuals who have benefitted from, 
                                and outcomes of, the provision of 
                                training and technical assistance under 
                                this subsection;
                            ``(iii) providing assurances that training, 
                        technical assistance, dissemination of 
                        information, and services under this subsection 
                        will be--
                                    ``(I) consistent with the goals of 
                                this Act, the Americans with 
                                Disabilities Act of 1990, the 
                                Individuals with Disabilities Education 
                                Act, and the Elementary and Secondary 
                                Education Act of 1965; and
                                    ``(II) conducted in coordination 
                                with relevant State agencies, 
                                institutions of higher education, and 
                                service providers; and
                            ``(iv) containing such other information 
                        and assurances as the Secretary may require.
                    ``(D) Use of funds.--A grant received under this 
                subsection shall be used to provide individuals 
                (including parents and health, allied health, 
                vocational, and educational professionals) with 
                interdisciplinary training, continuing education, 
                technical assistance, and information for the purpose 
                of improving services rendered to children and adults 
                with autism, and their families, to address unmet needs 
                related to autism. Such training, education, 
                assistance, and information shall include each of the 
                following:
                            ``(i) Training health, allied health, 
                        vocational, and educational professionals to 
                        identify, evaluate the needs of, and develop 
                        interventions, services, treatments, and 
                        supports for, children and adults with autism.
                            ``(ii) Developing model services and 
                        supports that demonstrate evidence-based 
                        practices.
                            ``(iii) Developing systems and products 
                        that allow for the interventions, services, 
                        treatments, and supports to be evaluated for 
                        fidelity of implementation.
                            ``(iv) Working to expand the availability 
                        of evidence-based, lifelong interventions; 
                        educational, employment, and transition 
                        services; and community supports.
                            ``(v) Providing statewide technical 
                        assistance in collaboration with relevant State 
                        agencies, institutions of higher education, 
                        autism advocacy groups, and community-based 
                        service providers.
                            ``(vi) Working to develop comprehensive 
                        systems of supports and services for 
                        individuals with autism and their families, 
                        including seamless transitions between 
                        education and health systems across the 
                        lifespan.
                            ``(vii) Promoting training, technical 
                        assistance, dissemination of information, 
                        supports, and services.
                            ``(viii) Developing mechanisms to provide 
                        training and technical assistance, including 
                        for-credit courses, intensive summer 
                        institutes, continuing education programs, 
                        distance based programs, and Web-based 
                        information dissemination strategies.
                            ``(ix) Promoting activities that support 
                        community-based family and individual services 
                        and enable individuals with autism and related 
                        developmental disabilities to fully participate 
                        in society and achieve good quality-of-life 
                        outcomes.
                            ``(x) Collecting data on the outcomes of 
                        training and technical assistance programs to 
                        meet statewide needs for the expansion of 
                        services to children and adults with autism.
                    ``(E) Amount of grants.--The amount of a grant to 
                any entity for a fiscal year under this section shall 
                be not less than $250,000.
            ``(2) Technical assistance.--The Secretary shall reserve 2 
        percent of the amount appropriated to carry out this subsection 
        for a fiscal year to make a grant to a national organization 
        with demonstrated capacity for providing training and technical 
        assistance to--
                    ``(A) assist in national dissemination of specific 
                information, including evidence-based best practices, 
                from interdisciplinary training programs, and when 
                appropriate, other entities whose findings would inform 
                the work performed by entities awarded grants;
                    ``(B) compile and disseminate strategies and 
                materials that prove to be effective in the provision 
                of training and technical assistance so that the entire 
                network can benefit from the models, materials, and 
                practices developed in individual centers;
                    ``(C) assist in the coordination of activities of 
                grantees under this subsection;
                    ``(D) develop a Web portal that will provide 
                linkages to each of the individual training initiatives 
                and provide access to training modules, promising 
                training, and technical assistance practices and other 
                materials developed by grantees;
                    ``(E) serve as a research-based resource for 
                Federal and State policymakers on information 
                concerning the provision of training and technical 
                assistance for the assessment, and provision of 
                supports and services for, children and adults with 
                autism;
                    ``(F) convene experts from multiple 
                interdisciplinary training programs, individuals with 
                autism, and the families of such individuals to discuss 
                and make recommendations with regard to training issues 
                related to assessment, interventions, services, 
                treatment, and supports for children and adults with 
                autism; and
                    ``(H) undertake any other functions that the 
                Secretary determines to be appropriate.
            ``(3) Authorization of appropriations.--To carry out this 
        subsection, there are authorized to be appropriated $17,000,000 
        for fiscal year 2011 and such sums as may be necessary for each 
        of fiscal years 2012 through 2015.
    ``(b) Expansion of the Number of University Centers for Excellence 
in Developmental Disabilities Education, Research, and Service.--
            ``(1) Grants.--To provide for the establishment of up to 4 
        new University Centers for Excellence in Developmental 
        Disabilities Education, Research, and Service, the Secretary 
        shall award up to 4 grants to institutions of higher education.
            ``(2) Applicable provisions.--Except for subsection (a)(3), 
        the provisions of subsection (a) shall apply with respect to 
        grants under this subsection to the same extent and in the same 
        manner as such provisions apply with respect to grants under 
        subsection (a).
            ``(3) Priority.--In awarding grants under this subsection, 
        the Secretary shall give priority to applicants that--
                    ``(A) are minority institutions that have 
                demonstrated capacity to meet the requirements of this 
                section and provide services to individuals with autism 
                and their families; or
                    ``(B) are located in a State with one or more 
                underserved populations.
            ``(4) Authorization of appropriations.--To carry out this 
        subsection, there is authorized to be appropriated $2,000,000 
        for each of fiscal years 2011 through 2015.
    ``(c) Definitions.--In this section:
            ``(1) The term `autism' means an autism spectrum disorder 
        or a related developmental disability.
            ``(2) The term `interventions' means educational methods 
        and positive behavioral support strategies designed to improve 
        or ameliorate symptoms associated with autism.
            ``(3) The term `minority institution' has the meaning given 
        to such term in section 365 of the Higher Education Act of 
        1965.
            ``(4) The term `services' means services to assist 
        individuals with autism to live more independently in their 
        communities.
            ``(5) The term `treatments' means health services, 
        including mental health services, designed to improve or 
        ameliorate symptoms associated with autism.
            ``(6) The term `University Center for Excellence in 
        Developmental Disabilities Education, Research, and Service' 
        means a University Center for Excellence in Development 
        Disabilities Education, Research, and Service that has been or 
        is funded through subtitle D or subsection (b).''.

SEC. 2528. IMPLEMENTATION OF MEDICATION MANAGEMENT SERVICES IN 
              TREATMENT OF CHRONIC DISEASES.

    (a) In General.--The Secretary of Health and Human Services 
(referred to in this section as the ``Secretary''), acting through the 
Director of the Agency for Health Care Research and Quality, shall 
establish a program to provide grants to eligible entities to implement 
medication management services (referred to in this section as ``MTM 
services'') provided by licensed pharmacists, as a part of a 
collaborative, multidisciplinary, interprofessional approach to the 
treatment of chronic diseases for targeted individuals, to improve the 
quality of care and reduce overall cost in the treatment of such 
diseases. The Secretary shall commence the grant program not later than 
May 1, 2011.
    (b) Eligible Entities.--To be eligible to receive a grant under 
subsection (a), an entity shall--
            (1) provide a setting appropriate for MTM services, as 
        recommended by the experts described in subsection (e);
            (2) submit to the Secretary a plan for achieving long-term 
        financial sustainability;
            (3) where applicable, submit a plan for coordinating MTM 
        services with other local providers and where applicable, 
        through or in collaboration with the Medicare Medical Home 
        Pilot program as established by section 1866F of the Social 
        Security Act, as added by section 1302(a) of this Act;
            (4) submit a plan for meeting the requirements under 
        subsection (c); and
            (5) submit to the Secretary such other information as the 
        Secretary may require.
    (c) MTM Services to Targeted Individuals.--The MTM services 
provided with the assistance of a grant awarded under subsection (a) 
shall, as allowed by State law (including applicable collaborative 
pharmacy practice agreements), include--
            (1) performing or obtaining necessary assessments of the 
        health and functional status of each patient receiving such MTM 
        services;
            (2) formulating a medication treatment plan according to 
        therapeutic goals agreed upon by the prescriber and the patient 
        or caregiver or authorized representative of the patient;
            (3) selecting, initiating, modifying, recommending changes 
        to, or administering medication therapy;
            (4) monitoring, which may include access to, ordering, or 
        performing laboratory assessments, and evaluating the response 
        of the patient to therapy, including safety and effectiveness;
            (5) performing an initial comprehensive medication review 
        to identify, resolve, and prevent medication-related problems, 
        including adverse drug events, quarterly targeted medication 
        reviews for ongoing monitoring, and additional followup 
        interventions on a schedule developed collaboratively with the 
        prescriber;
            (6) documenting the care delivered and communicating 
        essential information about such care (including a summary of 
        the medication review) and the recommendations of the 
        pharmacist to other appropriate health care providers of the 
        patient in a timely fashion;
            (7) providing education and training designed to enhance 
        the understanding and appropriate use of the medications by the 
        patient, caregiver, and other authorized representative;
            (8) providing information, support services, and resources 
        and strategies designed to enhance patient adherence with 
        therapeutic regimens;
            (9) coordinating and integrating MTM services within the 
        broader health care management services provided to the 
        patient; and
            (10) such other patient care services as are allowed under 
        the scopes of practice for pharmacists for purposes of other 
        Federal programs.
    (d) Targeted Individuals.--MTM services provided by licensed 
pharmacists under a grant awarded under subsection (a) shall be offered 
to targeted individuals who--
            (1) take 4 or more prescribed medications (including over-
        the-counter and dietary supplements);
            (2) take any high-risk medications;
            (3) have 2 or more chronic diseases, as identified by the 
        Secretary; or
            (4) have undergone a transition of care, or other factors, 
        as determined by the Secretary, that are likely to create a 
        high risk of medication-related problems.
    (e) Consultation With Experts.--In designing and implementing MTM 
services provided under grants awarded under subsection (a), the 
Secretary shall consult with Federal, State, private, public-private, 
and academic entities, pharmacy and pharmacist organizations, health 
care organizations, consumer advocates, chronic disease groups, and 
other stakeholders involved with the research, dissemination, and 
implementation of pharmacist-delivered MTM services, as the Secretary 
determines appropriate. The Secretary, in collaboration with this 
group, shall determine whether it is possible to incorporate rapid 
cycle process improvement concepts in use in other Federal programs 
that have implemented MTM services.
    (f) Reporting to the Secretary.--An entity that receives a grant 
under subsection (a) shall submit to the Secretary a report that 
describes and evaluates, as requested by the Secretary, the activities 
carried out under subsection (c), including quality measures, as 
determined by the Secretary.
    (g) Evaluation and Report.--The Secretary shall submit to the 
relevant committees of Congress a report which shall--
            (1) assess the clinical effectiveness of pharmacist-
        provided services under the MTM services program, as compared 
        to usual care, including an evaluation of whether enrollees 
        maintained better health with fewer hospitalizations and 
        emergency room visits than similar patients not enrolled in the 
        program;
            (2) assess changes in overall health care resource of 
        targeted individuals;
            (3) assess patient and prescriber satisfaction with MTM 
        services;
            (4) assess the impact of patient-cost-sharing requirements 
        on medication adherence and recommendations for modifications;
            (5) identify and evaluate other factors that may impact 
        clinical and economic outcomes, including demographic 
        characteristics, clinical characteristics, and health services 
        use of the patient, as well as characteristics of the regimen, 
        pharmacy benefit, and MTM services provided; and
            (6) evaluate the extent to which participating pharmacists 
        who maintain a dispensing role have a conflict of interest in 
        the provision of MTM services, and if such conflict is found, 
        provide recommendations on how such a conflict might be 
        appropriately addressed.
    (h) Grant To Fund Development of Performance Measures.--The 
Secretary may award grants or contracts to eligible entities for the 
purpose of funding the development of performance measures that assess 
the use and effectiveness of medication therapy management services.

SEC. 2529. POSTPARTUM DEPRESSION.

    (a) Expansion and Intensification of Activities.--
            (1) Continuation of activities.--The Secretary is 
        encouraged to expand and intensify activities on postpartum 
        conditions.
            (2) Programs for postpartum conditions.--In carrying out 
        paragraph (1), the Secretary is encouraged to continue research 
        to expand the understanding of the causes of, and treatments 
        for, postpartum conditions, including conducting and supporting 
        the following:
                    (A) Basic research concerning the etiology and 
                causes of the conditions.
                    (B) Epidemiological studies to address the 
                frequency and natural history of the conditions and the 
                differences among racial and ethnic groups with respect 
                to the conditions.
                    (C) The development of improved screening and 
                diagnostic techniques.
                    (D) Clinical research for the development and 
                evaluation of new treatments.
                    (E) Information and education programs for health 
                professionals and the public, which may include a 
                coordinated national campaign that--
                            (i) is designed to increase the awareness 
                        and knowledge of postpartum conditions;
                            (ii) may include public service 
                        announcements through television, radio, and 
                        other means; and
                            (iii) may focus on--
                                    (I) raising awareness about 
                                screening;
                                    (II) educating new mothers and 
                                their families about postpartum 
                                conditions to promote earlier diagnosis 
                                and treatment; and
                                    (III) ensuring that such education 
                                includes complete information 
                                concerning postpartum conditions, 
                                including its symptoms, methods of 
                                coping with the illness, and treatment 
                                resources.
    (b) Report by the Secretary.--
            (1) Study.--The Secretary shall conduct a study on the 
        benefits of screening for postpartum conditions.
            (2) Report.--Not later than 2 years after the date of the 
        enactment of this Act, the Secretary shall complete the study 
        required by paragraph (1) and submit a report to the Congress 
        on the results of such study.
    (c) Sense of Congress Regarding Longitudinal Study of Relative 
Mental Health Consequences for Women of Resolving a Pregnancy.--
            (1) Sense of congress.--It is the sense of the Congress 
        that the Director of the National Institute of Mental Health 
        may conduct a nationally representative longitudinal study 
        (during the period of fiscal years 2011 through 2020) on the 
        relative mental health consequences for women of resolving a 
        pregnancy (intended and unintended) in various ways, including 
        carrying the pregnancy to term and parenting the child, 
        carrying the pregnancy to term and placing the child for 
        adoption, miscarriage, and having an abortion. This study may 
        assess the incidence, timing, magnitude, and duration of the 
        immediate and long-term mental health consequences (positive or 
        negative) of these pregnancy outcomes.
            (2) Report.--Beginning not later than 3 years after the 
        date of the enactment of this Act, and periodically thereafter 
        for the duration of the study, such Director may prepare and 
        submit to the Congress reports on the findings of the study.
    (d) Definitions.--In this section:
            (1) The term ``postpartum condition'' means postpartum 
        depression or postpartum psychosis.
            (2) The term ``Secretary'' means the Secretary of Health 
        and Human Services.
    (e) Authorization of Appropriations.--For the purpose of carrying 
out this section, in addition to any other amounts authorized to be 
appropriated for such purpose, there are authorized to be appropriated 
such sums as may be necessary for each of fiscal years 2011 through 
2013.

SEC. 2530. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND OUTCOMES.

    Part P of title III (42 U.S.C. 280g et seq.) is amended by adding 
at the end the following:

``SEC. 399V. GRANTS TO PROMOTE POSITIVE HEALTH BEHAVIORS AND OUTCOMES.

    ``(a) Grants Authorized.--The Secretary, in collaboration with the 
Director of the Centers for Disease Control and Prevention and other 
Federal officials determined appropriate by the Secretary, is 
authorized to award grants to eligible entities to promote positive 
health behaviors for populations in medically underserved communities 
through the use of community health workers.
    ``(b) Use of Funds.--Grants awarded under subsection (a) shall be 
used to support community health workers--
            ``(1) to educate, guide, and provide outreach in a 
        community setting regarding health problems prevalent in 
        medically underserved communities, especially racial and ethnic 
        minority populations;
            ``(2) to educate, guide, and provide experiential learning 
        opportunities that target behavioral risk factors including--
                    ``(A) poor nutrition;
                    ``(B) physical inactivity;
                    ``(C) being overweight or obese;
                    ``(D) tobacco use;
                    ``(E) alcohol and substance use;
                    ``(F) injury and violence;
                    ``(G) risky sexual behavior;
                    ``(H) untreated mental health problems;
                    ``(I) untreated dental and oral health problems; 
                and
                    ``(J) understanding informed consent;
            ``(3) to educate and provide guidance regarding effective 
        strategies to promote positive health behaviors within the 
        family;
            ``(4) to educate and provide outreach regarding enrollment 
        in health insurance including the State Children's Health 
        Insurance Program under title XXI of the Social Security Act, 
        Medicare under title XVIII of such Act, and Medicaid under 
        title XIX of such Act;
            ``(5) to educate and refer underserved populations to 
        appropriate health care agencies and community-based programs 
        and organizations in order to increase access to quality health 
        care services, including preventive health services, and to 
        eliminate duplicative care; or
            ``(6) to educate, guide, and provide home visitation 
        services regarding maternal health and prenatal care.
    ``(c) Application.--
            ``(1) In general.--Each eligible entity that desires to 
        receive a grant under subsection (a) shall submit an 
        application to the Secretary, at such time, in such manner, and 
        accompanied by such information as the Secretary may require.
            ``(2) Contents.--Each application submitted pursuant to 
        paragraph (1) shall--
                    ``(A) describe the activities for which assistance 
                is sought under this section;
                    ``(B) contain an assurance that, with respect to 
                each community health worker program receiving funds 
                under the grant, such program will provide training and 
                supervision to community health workers to enable such 
                workers to provide authorized program services;
                    ``(C) contain an assurance that the applicant will 
                evaluate the effectiveness of community health worker 
                programs receiving funds under the grant;
                    ``(D) contain an assurance that each community 
                health worker program receiving funds under the grant 
                will provide services in the cultural context most 
                appropriate for the individuals served by the program;
                    ``(E) contain a plan to document and disseminate 
                project descriptions and results to other States and 
                organizations as identified by the Secretary; and
                    ``(F) describe plans to enhance the capacity of 
                individuals to utilize health services and health-
                related social services under Federal, State, and local 
                programs by--
                            ``(i) assisting individuals in establishing 
                        eligibility under the programs and in receiving 
                        the services or other benefits of the programs; 
                        and
                            ``(ii) providing other services as the 
                        Secretary determines to be appropriate, that 
                        may include transportation and translation 
                        services.
    ``(d) Priority.--In awarding grants under subsection (a), the 
Secretary shall give priority to applicants that--
            ``(1) propose to target geographic areas--
                    ``(A) with a high percentage of residents who are 
                eligible for health insurance but are uninsured or 
                underinsured;
                    ``(B) with a high percentage of residents who 
                suffer from chronic diseases including pulmonary 
                conditions, hypertension, heart disease, mental 
                disorders, diabetes, and asthma; and
                    ``(C) with a high infant mortality rate;
            ``(2) have experience in providing health or health-related 
        social services to individuals who are underserved with respect 
        to such services; and
            ``(3) have documented community activity and experience 
        with community health workers.
    ``(e) Collaboration With Academic Institutions.--The Secretary 
shall encourage community health worker programs receiving funds under 
this section to collaborate with academic institutions, especially 
those that graduate a disproportionate number of health and health care 
students from underrepresented racial and ethnic minority backgrounds. 
Nothing in this section shall be construed to require such 
collaboration.
    ``(f) Evidence-Based Interventions.--The Secretary shall encourage 
community health worker programs receiving funding under this section 
to implement an outcome-based payment system that rewards community 
health workers for connecting underserved populations with the most 
appropriate services at the most appropriate time. Nothing in this 
section shall be construed to require such payment.
    ``(g) Quality Assurance and Cost Effectiveness.--The Secretary 
shall establish guidelines for assuring the quality of the training and 
supervision of community health workers under the programs funded under 
this section and for assuring the cost-effectiveness of such programs.
    ``(h) Monitoring.--The Secretary shall monitor community health 
worker programs identified in approved applications under this section 
and shall determine whether such programs are in compliance with the 
guidelines established under subsection (g).
    ``(i) Technical Assistance.--The Secretary may provide technical 
assistance to community health worker programs identified in approved 
applications under this section with respect to planning, developing, 
and operating programs under the grant.
    ``(j) Report to Congress.--
            ``(1) In general.--Not later than 4 years after the date on 
        which the Secretary first awards grants under subsection (a), 
        the Secretary shall submit to Congress a report regarding the 
        grant project.
            ``(2) Contents.--The report required under paragraph (1) 
        shall include the following:
                    ``(A) A description of the programs for which grant 
                funds were used.
                    ``(B) The number of individuals served under such 
                programs.
                    ``(C) An evaluation of--
                            ``(i) the effectiveness of such programs;
                            ``(ii) the cost of such programs; and
                            ``(iii) the impact of the programs on the 
                        health outcomes of the community residents.
                    ``(D) Recommendations for sustaining the community 
                health worker programs developed or assisted under this 
                section.
                    ``(E) Recommendations regarding training to enhance 
                career opportunities for community health workers.
    ``(k) Definitions.--In this section:
            ``(1) Community health worker.--The term `community health 
        worker' means an individual who promotes health or nutrition 
        within the community in which the individual resides--
                    ``(A) by serving as a liaison between communities 
                and health care agencies;
                    ``(B) by providing guidance and social assistance 
                to community residents;
                    ``(C) by enhancing community residents' ability to 
                effectively communicate with health care providers;
                    ``(D) by providing culturally and linguistically 
                appropriate health or nutrition education;
                    ``(E) by advocating for individual and community 
                health, including oral and mental, or nutrition needs; 
                and
                    ``(F) by providing referral and followup services 
                or otherwise coordinating care.
            ``(2) Community setting.--The term `community setting' 
        means a home or a community organization located in the 
        neighborhood in which a participant resides.
            ``(3) Medically underserved community.--The term `medically 
        underserved community' means a community identified by a State, 
        United States territory or possession, or federally recognized 
        Indian tribe--
                    ``(A) that has a substantial number of individuals 
                who are members of a medically underserved population, 
                as defined by section 330(b)(3); and
                    ``(B) a significant portion of which is a health 
                professional shortage area as designated under section 
                332.
            ``(4) Support.--The term `support' means the provision of 
        training, supervision, and materials needed to effectively 
        deliver the services described in subsection (b), reimbursement 
        for services, and other benefits.
            ``(5) Eligible entity.--The term `eligible entity' means a 
        public or private nonprofit entity (including a State or public 
        subdivision of a State, a public health department, or a 
        federally qualified health center), or a consortium of any of 
        such entities, located in the United States or territory 
        thereof.
    ``(l) Authorization of Appropriations.--There is authorized to be 
appropriated to carry out this section $30,000,000 for each of fiscal 
years 2011 through 2015.''.

SEC. 2531. MEDICAL LIABILITY ALTERNATIVES.

    (a) Incentive Payments for Medical Liability Reform.--
            (1) In general.--To the extent and in the amounts made 
        available in advance in appropriations Acts, the Secretary 
        shall make an incentive payment, in an amount determined by the 
        Secretary, to each State that has an alternative medical 
        liability law in compliance with this section.
            (2) Determination by secretary.--The Secretary shall 
        determine that a State has an alternative medical liability law 
        in compliance with this section if the Secretary is satisfied 
        that--
                    (A) the State enacted the law after the date of the 
                enactment of this Act and is implementing the law;
                    (B) the law is effective; and
                    (C) the contents of the law are in accordance with 
                paragraph (4).
            (3) Considerations for determining effectiveness.--In 
        determining whether an alternative medical liability law is 
        effective under paragraph (2)(B), the Secretary shall consider 
        whether the law--
                    (A) makes the medical liability system more 
                reliable through prevention of, or prompt and fair 
                resolution of, disputes;
                    (B) encourages the disclosure of health care 
                errors; and
                    (C) maintains access to affordable liability 
                insurance.
            (4) Contents of alternative medical liability law.--The 
        contents of an alternative liability law are in accordance with 
        this paragraph if--
                    (A) the litigation alternatives contained in the 
                law consist of certificate of merit, early offer, or 
                both; and
                    (B) the law does not limit attorneys' fees or 
                impose caps on damages.
    (b) Use of Incentive Payments.--Amounts received by a State as an 
incentive payment under this section shall be used to improve health 
care in that State.
    (c) Technical Assistance.--The Secretary may provide technical 
assistance to the States applying for or receiving an incentive payment 
under this section.
    (d) Reports.--Beginning not later than one year after the date of 
the enactment of this Act, the Secretary shall submit to the Congress 
an annual report on the progress States have made in enacting and 
implementing alternative medical liability laws in compliance with this 
section. Such reports shall contain sufficient documentation regarding 
the effectiveness of such laws to enable an objective comparative 
analysis of such laws.
    (e) Definition.--In this section--
            (1) the term ``Secretary'' means the Secretary of Health 
        and Human Services; and
            (2) the term ``State'' includes the several States, 
        District of Columbia, the Commonwealth of Puerto Rico, and each 
        other territory or possession of the United States.
    (f) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section such sums as may be necessary, 
to remain available until expended.

SEC. 2532. INFANT MORTALITY PILOT PROGRAMS.

    (a) In General.--The Secretary of Health and Human Services (in 
this section referred to as the ``Secretary''), acting through the 
Director, shall award grants to eligible entities to create, implement, 
and oversee infant mortality pilot programs.
    (b) Period of a Grant.--The period of a grant under this section 
shall be 5 consecutive fiscal years.
    (c) Preference.--In awarding grants under this section, the 
Secretary shall give preference to eligible entities proposing to serve 
any of the 15 counties or groups of counties with the highest rates of 
infant mortality in the United States in the past 3 years.
    (d) Use of Funds.--Any infant mortality pilot program funded under 
this section may--
            (1) include the development of a plan that identifies the 
        individual needs of each community to be served and strategies 
        to address those needs;
            (2) provide outreach to at-risk mothers through programs 
        deemed appropriate by the Director;
            (3) develop and implement standardized systems for improved 
        access, utilization, and quality of social, educational, and 
        clinical services to promote healthy pregnancies, full term 
        births, and healthy infancies delivered to women and their 
        infants, such as--
                    (A) counseling on infant care, feeding, and 
                parenting;
                    (B) postpartum care;
                    (C) prevention of premature delivery; and
                    (D) additional counseling for at-risk mothers, 
                including smoking cessation programs, drug treatment 
                programs, alcohol treatment programs, nutrition and 
                physical activity programs, postpartum depression and 
                domestic violence programs, social and psychological 
                services, dental care, and parenting programs;
            (4) establish a rural outreach program to provide care to 
        at-risk mothers in rural areas;
            (5) establish a regional public education campaign, 
        including a campaign to--
                    (A) prevent preterm births; and
                    (B) educate the public about infant mortality; and
            (6) provide for any other activities, programs, or 
        strategies as identified by the community plan.
    (e) Limitation.--Of the funds received through a grant under this 
section for a fiscal year, an eligible entity shall not use more than 
10 percent for program evaluation.
    (f) Reports on Pilot Programs.--
            (1) In general.--Not later than 1 year after receiving a 
        grant, and annually thereafter for the duration of the grant 
        period, each entity that receives a grant under subsection (a) 
        shall submit a report to the Secretary detailing its infant 
        mortality pilot program.
            (2) Contents of report.--The reports required under 
        paragraph (1) shall include information such as the methodology 
        of, and outcomes and statistics from, the grantee's infant 
        mortality pilot program.
            (3) Evaluation.--The Secretary shall use the reports 
        required under paragraph (1) to evaluate, and conduct 
        statistical research on, infant mortality pilot programs funded 
        through this section.
    (g) Definitions.--For the purposes of this section:
            (1) Director.--The term ``Director'' means the Director of 
        the Centers for Disease Control and Prevention.
            (2) Eligible entity.--The term ``eligible entity'' means a 
        State, county, city, territorial, or tribal health department 
        that has submitted a proposal to the Secretary that the 
        Secretary deems likely to reduce infant mortality rates within 
        the standard metropolitan statistical area involved.
            (3) Tribal.--The term ``tribal'' refers to an Indian tribe, 
        a Tribal organization, or an Urban Indian organization, as such 
        terms are defined in section 4 of the Indian Health Care 
        Improvement Act.
    (h) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated $10,000,000 for each of fiscal 
years 2011 through 2015.

SEC. 2533. SECONDARY SCHOOL HEALTH SCIENCES TRAINING PROGRAM.

     (a) Program.--The Secretary of Health and Human Services, acting 
through the Administrator of the Health Resources and Services 
Administration, and in consultation with the Secretary of Education, 
may establish a health sciences training program consisting of awarding 
grants and contracts under subsection (b) to prepare secondary school 
students for careers in health professions.
    (b) Development and Implementation of Health Sciences Curricula.--
The Secretary may make grants to, or enter into contracts with, 
eligible entities--
            (1) to plan, develop, or implement secondary school health 
        sciences curricula, including curricula in biology, chemistry, 
        physiology, mathematics, nutrition, and other courses deemed 
        appropriate by the Secretary to prepare students for 
        associate's or bachelor's degree programs in health professions 
        or bachelor's degree programs in health professions-related 
        majors; and
            (2) to increase the interest of secondary school students 
        in applying to, and enrolling in, accredited associate's or 
        bachelor's degree programs in health professions or bachelor's 
        degree programs in health professions-related majors, including 
        through--
                    (A) work-study programs;
                    (B) programs to increase awareness of careers in 
                health professions; and
                    (C) other activities to increase such interest.
    (c) Eligibility.--To be eligible for a grant or contract under 
subsection (b), an entity shall--
            (1) be a local educational agency; and
            (2) provide assurances that activities under the grant or 
        contract will be carried out in partnership with an accredited 
        health professions school or program, public or private 
        nonprofit hospital, or public or private nonprofit entity.
    (d) Preference.--In awarding grants and contracts under subsection 
(b), the Secretary shall give preference to entities that have a 
demonstrated record of at least one of the following:
            (1) Graduating a high or significantly improved percentage 
        of students who have exhibited mastery in secondary school 
        State science standards.
            (2) Graduating students from disadvantaged backgrounds, 
        including racial and ethnic minorities who are underrepresented 
        in--
                    (A) associate's or bachelor's degree programs in 
                health professions or bachelor's degree programs in 
                health professions-related majors; or
                    (B) health professions.
    (e) Report.--The Secretary shall submit to the Congress an annual 
report on the program carried out under this section.
    (f) Definitions.--In this section:
            (1) The term ``health profession'' means the profession of 
        any member of the health workforce, as defined in section 
        764(i) of the Public Health Service Act, as added by section 
        2261.
            (2) The term ``local educational agency'' has the meaning 
        given to the term in section 9101 of the Elementary and 
        Secondary Education Act of 1965 (20 U.S.C. 7801).
            (3) The term ``secondary school''--
                    (A) means a secondary school, as defined in section 
                9101 of the Elementary and Secondary Education Act of 
                1965 (20 U.S.C. 7801); and
                    (B) includes any such school that is a middle 
                school.
            (4) The term ``Secretary'' means the Secretary of Health 
        and Human Services except as otherwise specified.
    (g) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.

SEC. 2534. COMMUNITY-BASED COLLABORATIVE CARE NETWORKS.

    (a) Purpose.--The purpose of this subtitle is to establish and 
provide assistance to community-based collaborative care networks--
            (1) to develop or strengthen coordination of services to 
        allow all individuals, including the uninsured and low-income, 
        to receive efficient and higher quality care and to gain entry 
        into and receive services from a comprehensive system of care;
            (2) to develop efficient and sustainable infrastructure for 
        a health care delivery system characterized by effective 
        collaboration, information sharing, and clinical and financial 
        coordination among providers of care in the community;
            (3) to develop or strengthen activities related to 
        providing coordinated care for individuals with chronic 
        conditions; and
            (4) to reduce the use of emergency departments, inpatient 
        and other expensive resources of hospitals and other providers.
    (b) Creation of the Community-Based Collaborative Care Network 
Program.--Part D of title III (42 U.S.C. 254b et seq.), as amended, is 
further amended by inserting after subpart XII the following new 
subpart:

   ``Subpart XIII--Community-Based Collaborative Care Network Program

``SEC. 340O. COMMUNITY-BASED COLLABORATIVE CARE NETWORK PROGRAM.

    ``(a) In General.--The Secretary may award grants to eligible 
entities for the purpose of establishing model projects to accomplish 
the following goals:
            ``(1) To reduce unnecessary use of items and services 
        furnished in emergency departments of hospitals (especially to 
        ensure that individuals without health insurance coverage or 
        with inadequate health insurance coverage do not use the 
        services of such department instead of the services of a 
        primary care provider) through methods such as--
                    ``(A) screening individuals who seek emergency 
                department services for possible eligibility under 
                relevant governmental health programs or for subsidies 
                under such programs; and
                    ``(B) providing such individuals referrals for 
                followup care and chronic condition care.
            ``(2) To manage chronic conditions to reduce their 
        severity, negative health outcomes, and expense.
            ``(3) To encourage health care providers to coordinate 
        their efforts so that the most vulnerable patient populations 
        seek and obtain primary care.
            ``(4) To provide more comprehensive and coordinated care to 
        vulnerable low-income individuals and individuals without 
        health insurance coverage or with inadequate coverage.
            ``(5) To provide mechanisms for improving both quality and 
        efficiency of care for low-income individuals and families, 
        with an emphasis on those most likely to remain uninsured 
        despite the existence of government programs to make health 
        insurance more affordable.
            ``(6) To increase preventive services, including screening 
        and counseling, to those who would otherwise not receive such 
        screening, in order to improve health status and reduce long-
        term complications and costs.
            ``(7) To ensure the availability of community-wide safety 
        net services, including emergency and trauma care.
    ``(b) Eligibility and Grantee Selection.--
            ``(1) Application.--A community-based collaborative care 
        network described in subsection (d) shall submit to the 
        Secretary an application in such form and manner and containing 
        such information as specified by the Secretary. Such 
        information shall at least--
                    ``(A) identify the health care providers 
                participating in the community-based collaborative care 
                network proposed by the applicant and, if a provider 
                designated in paragraph (d)(1)(B) is not included, the 
                reason such provider is not so included;
                    ``(B) include a description of how the providers 
                plan to collaborate to provide comprehensive and 
                integrated care for low-income individuals, including 
                uninsured and underinsured individuals;
                    ``(C) include a description of the organizational 
                and joint governance structure of the community-based 
                collaborative care network in a manner so that it is 
                clear how decisions will be made, and how the 
                decisionmaking process of the network will include 
                appropriate representation of the participating 
                entities;
                    ``(D) define the geographic areas and populations 
                that the network intends to serve;
                    ``(E) define the scope of services that the network 
                intends to provide and identify any reasons why such 
                services would not include a suggested core service 
                identified by the Secretary under paragraph (3);
                    ``(F) demonstrate the network's ability to meet the 
                requirements of this section; and
                    ``(G) provide assurances that grant funds received 
                shall be used to support the entire community-based 
                collaborative care network.
            ``(2) Selection of grantees.--
                    ``(A) In general.--The Secretary shall select 
                community-based collaborative care networks to receive 
                grants from applications submitted under paragraph (1) 
                on the basis of quality of the proposal involved, 
                geographic diversity (including different States and 
                regions served and urban and rural diversity), and the 
                number of low-income and uninsured individuals that the 
                proposal intends to serve.
                    ``(B) Priority.--The Secretary shall give priority 
                to proposals from community-based collaborative care 
                networks that--
                            ``(i) include the capability to provide the 
                        broadest range of services to low-income 
                        individuals; and
                            ``(ii) include providers that currently 
                        serve a high volume of low-income individuals.
                    ``(C) Renewal.--In subsequent years, based on the 
                performance of grantees, the Secretary may provide 
                renewal grants to prior year grant recipients.
            ``(3) Suggested core services.--For purposes of paragraph 
        (1)(E), the Secretary shall develop a list of suggested core 
        patient and core network services to be provided by a 
        community-based collaborative care network. The Secretary may 
        select a community-based collaborative care network under 
        paragraph (2), the application of which does not include all 
        such services, if such application provides a reasonable 
        explanation why such services are not proposed to be included, 
        and the Secretary determines that the application is otherwise 
        high quality.
            ``(4) Termination authority.--The Secretary may terminate 
        selection of a community-based collaborative care network under 
        this section for good cause. Such good cause shall include a 
        determination that the network--
                    ``(A) has failed to provide a comprehensive range 
                of coordinated and integrated health care services as 
                required under subsection (d)(2);
                    ``(B) has failed to meet reasonable quality 
                standards;
                    ``(C) has misappropriated funds provided under this 
                section; or
                    ``(D) has failed to make progress toward 
                accomplishing goals set out in subsection (a).
    ``(c) Use of Funds.--
            ``(1) Use by grantees.--Grant funds are provided to 
        community-based collaborative care networks to carry out the 
        following activities:
                    ``(A) Assist low-income individuals without 
                adequate health care coverage to--
                            ``(i) access and appropriately use health 
                        services;
                            ``(ii) enroll in applicable public or 
                        private health insurance programs;
                            ``(iii) obtain referrals to and see a 
                        primary care provider in case such an 
                        individual does not have a primary care 
                        provider; and
                            ``(iv) obtain appropriate care for chronic 
                        conditions.
                    ``(B) Improve heath care by providing case 
                management, application assistance, and appropriate 
                referrals such as through methods to--
                            ``(i) create and meaningfully use a health 
                        information technology network to track 
                        patients across collaborative providers;
                            ``(ii) perform health outreach, such as by 
                        using neighborhood health workers who may 
                        inform individuals about the availability of 
                        safety net and primary care providers available 
                        through the community-based collaborative care 
                        network;
                            ``(iii) provide for followup outreach to 
                        remind patients of appointments or follow-up 
                        care instructions;
                            ``(iv) provide transportation to 
                        individuals to and from the site of care;
                            ``(v) expand the capacity to provide care 
                        at any provider participating in the community-
                        based collaborative care network, including 
                        telehealth, hiring new clinical or 
                        administrative staff, providing access to 
                        services after-hours, on weekends, or otherwise 
                        providing an urgent care alternative to an 
                        emergency department; and
                            ``(vi) provide a primary care provider or 
                        medical home for each network patient.
                    ``(C) Provide direct patient care services as 
                described in their application and approved by the 
                Secretary.
            ``(2) Grant funds to hrsa grantees.--The Secretary may 
        limit the percent of grant funding that may be spent on direct 
        care services provided by grantees of programs administered by 
        the Health Resources and Services Administration (in this 
        section referred to as `HRSA') or impose other requirements on 
        HRSA grantees participating in a community-based collaborative 
        care network as may be necessary for consistency with the 
        requirements of such programs.
            ``(3) Reservation of funds for national program purposes.--
        The Secretary may use not more than 7 percent of funds 
        appropriated to carry out this section for providing technical 
        assistance to grantees, obtaining assistance of experts and 
        consultants, holding meetings, developing of tools, 
        disseminating of information, and evaluation.
    ``(d) Community-Based Collaborative Care Networks.--
            ``(1) In general.--
                    ``(A) Description.--A community-based collaborative 
                care network described in this subsection is a 
                consortium of health care providers with a joint 
                governance structure that provides a comprehensive 
                range of coordinated and integrated health care 
                services for low-income patient populations or 
                medically underserved communities (whether or not such 
                individuals receive benefits under title XVIII, XIX, or 
                XXI of the Social Security Act, private or other health 
                insurance or are uninsured or underinsured) and that 
                complies with any applicable minimum eligibility 
                requirements that the Secretary may determine 
                appropriate.
                    ``(B) Required inclusion.--Each such network shall 
                include the following providers that serve the 
                community (unless such provider does not exist within 
                the community, declines or refuses to participate, or 
                places unreasonable conditions on their 
                participation)--
                            ``(i) A safety net hospital that provides 
                        services to a high volume of low-income 
                        patients, as demonstrated by meeting the 
                        criteria in section 1923(b)(1) of the Social 
                        Security Act, or other similar criteria 
                        determined by the Secretary; and
                            ``(ii) All Federally qualified health 
                        centers (as defined in section 1861(aa) of the 
                        Social Security Act (42 U.S.C. 1395x(aa))) 
                        located in the geographic area served by the 
                        Coordinated Care Network;
                    ``(C) Additional inclusions.--Each such network may 
                include any of the following additional providers:
                            ``(i) A hospital, including a critical 
                        access hospital (as defined in section 
                        1820(c)(2) of the Social Security Act (42 
                        U.S.C. 1395i-4(c)(2))).
                            ``(ii) A county or municipal department of 
                        health.
                            ``(iii) A rural health clinic or a rural 
                        health network (as defined in sections 1861(aa) 
                        and 1820(d) of the Social Security Act, 
                        respectively (42 U.S.C. 1395x(aa), 1395i-
                        4(d))).
                            ``(iv) A community clinic, including a 
                        mental health clinic, substance abuse clinic, 
                        or a reproductive health clinic.
                            ``(v) A health center controlled network as 
                        defined by section 330(e)(1)(C) of the Public 
                        Health Service Act
                            ``(vi) A private practice physician or 
                        group practice.
                            ``(vii) A nurse or physician assistant or 
                        group practice.
                            ``(viii) An adult day care center.
                            ``(ix) A home health provider.
                            ``(x) Any other type of provider specified 
                        by the Secretary, which has a desire to serve 
                        low-income and uninsured patients.
                    ``(D) Construction.--
                            ``(i) Nothing in this section shall 
                        prohibit a single entity from qualifying as 
                        community-based collaborative care network so 
                        long as such single entity meets the criteria 
                        of a community-based collaborative care 
                        network. If the network does not include the 
                        providers referenced in clauses (i) and (ii) of 
                        subparagraph (B) of this paragraph, the 
                        application must explain the reason pursuant to 
                        subsection (b)(1)(A).
                            ``(ii) Participation in a community-based 
                        collaborative care network shall not affect 
                        Federally qualified health centers' obligation 
                        to comply with the governance requirements 
                        under section 330 of the Public Health Service 
                        Act (42 U.S.C. 254b).
                            ``(iii) Federally qualified health centers 
                        participating in a community-based 
                        collaborative care network may not be required 
                        to provide services beyond their Federal Health 
                        Center scope of project approved by HRSA.
                            ``(iv) Nothing in this section shall be 
                        construed to expand medical malpractice 
                        liability protection under the Federal Tort 
                        Claims Act for Section 330-funded Federally 
                        qualified health centers.
            ``(2) Comprehensive range of coordinated and integrated 
        health care services.--The Secretary shall define criteria for 
        evaluating whether the services offered by a community-based 
        collaborative care network qualify as a comprehensive range of 
        coordinated and integrated health care services. Such criteria 
        may vary based on the needs of the geographic areas and 
        populations to be served by the network and may include the 
        following:
                    ``(A) Requiring community-based collaborative care 
                networks to include at least the suggested core 
                services identified under subsection (b)(3), or 
                whichever subset of the suggested core services is 
                applicable to a particular network.
                    ``(B) Requiring such networks to assign each 
                patient of the network to a primary care provider 
                responsible for managing that patient's care.
                    ``(C) Requiring the services provided by a 
                community-based collaborative care network to include 
                support services appropriate to meet the health needs 
                of low-income populations in the network's community, 
                which may include chronic care management, nutritional 
                counseling, transportation, language services, 
                enrollment counselors, social services and other 
                services as proposed by the network.
                    ``(D) Providing that the services provided by a 
                community-based collaborative care network may also 
                include long-term care services and other services not 
                specified in this subsection.
                    ``(E) Providing for the approval by the Secretary 
                of a scope of community-based collaborative care 
                network services for each network that addresses an 
                appropriate minimum scope of work consistent with the 
                setting of the network and the health professionals 
                available in the community the network serves.
            ``(3) Clarification.--Participation in a community-based 
        collaborative care network shall not disqualify a health care 
        provider from reimbursement under title XVIII, XIX, or XXI of 
        the Social Security Act with respect to services otherwise 
        reimbursable under such title. Nothing in this section shall 
        prevent a community-based collaborative care network that is 
        otherwise eligible to contract with Medicare, a private health 
        insurer, or any other appropriate entity to provide care under 
        Medicare, under health insurance coverage offered by the 
        insurer, or otherwise.
    ``(e) Evaluations.--
            ``(1) Grantee reports.--Beginning in the third year 
        following an initial grant, each community-based collaborative 
        care network shall submit to the Secretary, with respect to 
        each year the grantee has received a grant, an evaluation on 
        the activities carried out by the community-based collaborative 
        care network under the community-based collaborative care 
        network program and shall include--
                    ``(A) the number of people served;
                    ``(B) the most common health problems treated;
                    ``(C) any reductions in emergency department use;
                    ``(D) any improvements in access to primary care;
                    ``(E) an accounting of how amounts received were 
                used, including identification of amounts used for 
                patient care services as may be required for HRSA 
                grantees; and
                    ``(F) to the extent requested by the Secretary, any 
                quality measures or any other measures specified by the 
                Secretary.
            ``(2) Program reports.--The Secretary shall submit to 
        Congress an annual evaluation (beginning not later than 6 
        months after the first reports under paragraph (1) are 
        submitted) on the extent to which emergency department use was 
        reduced as a result of the activities carried out by the 
        community-based collaborative care network under the program. 
        Each such evaluation shall also include information on--
                    ``(A) the prevalence of certain chronic conditions 
                in various populations, including a comparison of such 
                prevalence in the general population versus in the 
                population of individuals with inadequate health 
                insurance coverage;
                    ``(B) demographic characteristics of the population 
                of uninsured and underinsured individuals served by the 
                community-based collaborative care network involved; 
                and
                    ``(C) the conditions of such individuals for whom 
                services were requested at such emergency departments 
                of participating hospitals.
            ``(3) Audit authority.--The Secretary may conduct periodic 
        audits and request periodic spending reports of community-based 
        collaborative care networks under the community-based 
        collaborative care network program.
    ``(f) Clarification.--Nothing in this section requires a provider 
to report individually identifiable information of an individual to 
government agencies, unless the individual consents, consistent with 
HIPAA privacy and security law, as defined in section 3009(a)(2).
    ``(g) Authorization of Appropriations.--There are authorized to be 
appropriated to carry out this section such sums as may be necessary 
for each of fiscal years 2011 through 2015.''.

SEC. 2535. COMMUNITY-BASED OVERWEIGHT AND OBESITY PREVENTION PROGRAM.

    Part Q of title III (42 U.S.C. 280h et seq.) is amended by 
inserting after section 399W the following:

``SEC. 399W-1. COMMUNITY-BASED OVERWEIGHT AND OBESITY PREVENTION 
              PROGRAM.

    ``(a) Program.--The Secretary shall establish a community-based 
overweight and obesity prevention program consisting of awarding grants 
and contracts under subsection (b).
    ``(b) Grants.--The Secretary shall award grants to, or enter into 
contracts with, eligible entities--
            ``(1) to plan evidence-based programs for the prevention of 
        overweight and obesity among children and their families 
        through improved nutrition and increased physical activity; or
            ``(2) to implement such programs.
    ``(c) Eligibility.--To be eligible for a grant or contract under 
subsection (b), an entity shall be a community partnership that 
demonstrates community support and includes--
            ``(1) a broad cross section of stakeholders, such as--
                    ``(A) hospitals, health care systems, community 
                health centers, or other health care providers;
                    ``(B) universities, local educational agencies, or 
                childcare providers;
                    ``(C) State, local, and tribal health departments;
                    ``(D) State, local, and tribal park and recreation 
                departments;
                    ``(E) employers; and
                    ``(F) health insurance companies;
            ``(2) residents of the community; and
            ``(3) representatives of public and private entities that 
        have a history of working within and serving the community.
    ``(d) Period of Awards.--
            ``(1) In general.--The period of a grant or contract under 
        this section shall be 5 years, subject to renewal under 
        paragraph (2).
            ``(2) Renewal.--At the end of each fiscal year, the 
        Secretary may renew a grant or contract award under this 
        section only if the grant or contract recipient demonstrates to 
        the Secretary's satisfaction that the recipient has made 
        appropriate, measurable progress in preventing overweight and 
        obesity.
    ``(e) Requirements.--
            ``(1) In general.--The Secretary may award a grant or 
        contract under this section to an entity only if the entity 
        demonstrates to the Secretary's satisfaction that--
                    ``(A) not later than 90 days after receiving the 
                grant or contract, the entity will establish a steering 
                committee to provide input on the assessment of, and 
                recommendations on improvements to, the entity's 
                program funded through the grant or contract; and
                    ``(B) the entity has conducted or will conduct an 
                assessment of the overweight and obesity problem in its 
                community, including the extent of the problem and 
                factors contributing to the problem.
            ``(2) Matching requirement.--The Secretary may award a 
        grant or contract to an eligible entity under this section only 
        if the entity agrees to provide, from non-Federal sources, an 
        amount equal to $1 (in cash or in kind) for each $9 provided 
        through the grant or contract to carry out the activities 
        supported by the grant or contract.
            ``(3) Payor of last resort.--The Secretary may award a 
        grant or contract under this section to an entity only if the 
        entity demonstrates to the satisfaction of the Secretary that 
        funds received through the grant or contract will not be 
        expended for any activity to the extent that payment has been 
        made, or can reasonably be expected to be made--
                    ``(A) under any insurance policy;
                    ``(B) under any Federal or State health benefits 
                program (including titles XIX and XXI of the Social 
                Security Act); or
                    ``(C) by an entity which provides health services 
                on a prepaid basis.
            ``(4) Maintenance of effort.--The Secretary may award a 
        grant or contract under this section to an entity only if the 
        entity demonstrates to the satisfaction of the Secretary that--
                    ``(A) funds received through the grant or contract 
                will be expended only to supplement, and not supplant, 
                non-Federal and Federal funds otherwise available to 
                the entity for the activities to be funded through the 
                grant or contract; and
                    ``(B) with respect to such activities, the entity 
                will maintain expenditures of non-Federal amounts for 
                such activities at a level not less than the lesser of 
                such expenditures maintained by the entity for the 
                fiscal year preceding the fiscal year for which the 
                entity receives the grant or contract.
    ``(f) Preferences.--In awarding grants and contracts under this 
section, the Secretary shall give preference to eligible entities 
that--
            ``(1) will serve communities with high levels of overweight 
        and obesity and related chronic diseases; or
            ``(2) will plan or implement activities for the prevention 
        of overweight and obesity in school or workplace settings.
    ``(g) Report.--The Secretary shall submit to the Congress an annual 
report on the program of grants and contracts awarded under this 
section.
    ``(h) Definitions.--In this section:
            ``(1) The term `evidence-based' means that methodologically 
        sound research has demonstrated a beneficial health effect in 
        the judgment of the Secretary and includes the Ways to Enhance 
        Children's Activity and Nutrition (We Can) program and 
        curriculum of the National Institutes of Health.
            ``(2) The term `local educational agency' has the meaning 
        given to the term in section 9101 of the Elementary and 
        Secondary Education Act of 1965.
    ``(i) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated $10,000,000 for fiscal year 
2011 and such sums as may be necessary for each of fiscal years 2012 
through 2015.''.

SEC. 2536. REDUCING STUDENT-TO-SCHOOL NURSE RATIOS.

    (a) Demonstration Grants.--
            (1) In general.--The Secretary of Education, in 
        consultation with the Secretary of Health and Human Services 
        and the Director of the Centers for Disease Control and 
        Prevention, may make demonstration grants to eligible local 
        educational agencies for the purpose of reducing the student-
        to-school nurse ratio in public elementary and secondary 
        schools.
            (2) Special consideration.--In awarding grants under this 
        section, the Secretary of Education shall give special 
        consideration to applications submitted by high-need local 
        educational agencies that demonstrate the greatest need for new 
        or additional nursing services among children in the public 
        elementary and secondary schools served by the agency, in part 
        by providing information on current ratios of students to 
        school nurses.
            (3) Matching funds.--The Secretary of Education may require 
        recipients of grants under this subsection to provide matching 
        funds from non-Federal sources, and shall permit the recipients 
        to match funds in whole or in part with in-kind contributions.
    (b) Report.--Not later than 24 months after the date on which 
assistance is first made available to local educational agencies under 
this section, the Secretary of Education shall submit to the Congress a 
report on the results of the demonstration grant program carried out 
under this section, including an evaluation of the effectiveness of the 
program in improving the student-to-school nurse ratios described in 
subsection (a) and an evaluation of the impact of any resulting 
enhanced health of students on learning.
    (c) Definitions.--For purposes of this section:
            (1) The terms ``elementary school'', ``local educational 
        agency'', and ``secondary school'' have the meanings given to 
        those terms in section 9101 of the Elementary and Secondary 
        Education Act of 1965 (20 U.S.C. 7801).
            (2) The term ``eligible local educational agency'' means a 
        local educational agency in which the student-to-school nurse 
        ratio in the public elementary and secondary schools served by 
        the agency is 750 or more students to every school nurse.
            (3) The term ``high-need local educational agency'' means a 
        local educational agency--
                    (A) that serves not fewer than 10,000 children from 
                families with incomes below the poverty line; or
                    (B) for which not less than 20 percent of the 
                children served by the agency are from families with 
                incomes below the poverty line.
            (4) The term ``nurse'' means a licensed nurse, as defined 
        under State law.
    (d) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.

SEC. 2537. MEDICAL-LEGAL PARTNERSHIPS.

    (a) In General.--The Secretary shall establish a nationwide 
demonstration project consisting of--
            (1) awarding grants to, and entering into contracts with, 
        medical-legal partnerships to assist patients and their 
        families to navigate health-related programs and activities; 
        and
            (2) evaluating the effectiveness of such partnerships.
    (b) Use of Funds.--Amounts received as a grant or contract under 
this section shall be used to assist patients and their families to 
navigate health care-related programs and activities and thereby 
achieve one or more of the following goals:
            (1) Enhancing access to health care services.
            (2) Improving health outcomes for low-income individuals.
            (3) Reducing health disparities.
            (4) Enhancing wellness and prevention of chronic 
        conditions.
    (c) Prohibition.--No funds under this section may be used--
            (1) for any medical malpractice or other civil action or 
        proceeding; or
            (2) to assist individuals who are not lawfully present in 
        the United States.
    (d) Report.--Not later than 5 years after the date of the enactment 
of this Act, the Secretary shall submit a report to the Congress on the 
results of the demonstration project under this section. Such report 
shall include the following:
            (1) A description of the extent to which medical-legal 
        partnerships funded through this section achieved the goals 
        described in subsection (b).
            (2) Recommendations on the possibility of extending or 
        expanding the demonstration project.
    (e) Definitions.--In this section:
            (1) The term ``health disparities'' has the meaning given 
        to the term in section 3171 of the Public Health Service Act, 
        as added by section 2301.
            (2) The term ``medical-legal partnership'' means an 
        entity--
                    (A) that is a collaboration between--
                            (i) a community health center, public 
                        hospital, children's hospital, or other 
                        provider of health care services to a 
                        significant number of low-income beneficiaries; 
                        and
                            (ii) one or more attorneys; and
                    (B) whose primary mission is to assist patients and 
                their families navigate health care-related programs 
                and activities.
            (3) The term ``Secretary'' means the Secretary of Health 
        and Human Services.
    (f) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.

                PART 3--EMERGENCY CARE-RELATED PROGRAMS

SEC. 2551. TRAUMA CARE CENTERS.

    (a) Grants for Trauma Care Centers.--Section 1241 (42 U.S.C. 300d-
41) is amended to read as follows:

``SEC. 1241. GRANTS FOR CERTAIN TRAUMA CENTERS.

    ``(a) In General.--The Secretary shall establish a trauma center 
program consisting of awarding grants under section (b).
    ``(b) Grants.--The Secretary shall award grants as follows:
            ``(1) Existing centers.--Grants to public, private 
        nonprofit, Indian Health Service, Indian tribal, and urban 
        Indian trauma centers--
                    ``(A) to further the core missions of such centers; 
                or
                    ``(B) to provide emergency relief to ensure the 
                continued and future availability of trauma services by 
                trauma centers--
                            ``(i) at risk of closing or operating in an 
                        area where a closing has occurred within their 
                        primary service area; or
                            ``(ii) in need of financial assistance 
                        following a natural disaster or other 
                        catastrophic event, such as a terrorist attack.
            ``(2) New centers.--Grants to local governments and public 
        or private nonprofit entities to establish new trauma centers 
        in urban areas with a substantial degree of trauma resulting 
        from violent crimes.
    ``(c) Minimum Qualifications of Trauma Centers.--
            ``(1) Participation in trauma care system operating under 
        certain professional guidelines.--
                    ``(A) Limitation.--Subject to subparagraph (B), the 
                Secretary may not award a grant to an existing trauma 
                center under this section unless the center is a 
                participant in a trauma care system that substantially 
                complies with section 1213.
                    ``(B) Exemption.--Subparagraph (A) shall not apply 
                to trauma centers that are located in States with no 
                existing trauma care system.
            ``(2) Designation.--The Secretary may not award a grant 
        under this section to an existing trauma center unless the 
        center is--
                    ``(A) verified as a trauma center by the American 
                College of Surgeons; or
                    ``(B) designated as a trauma center by the 
                applicable State health or emergency medical services 
                authority.''.
    (b) Considerations in Making Grants.--Section 1242 (42 U.S.C. 300d-
42) is amended to read as follows:

``SEC. 1242. CONSIDERATIONS IN MAKING GRANTS.

    ``(a) Core Mission Awards.--
            ``(1) In general.--In awarding grants under section 
        1241(b)(1)(A), the Secretary shall--
                    ``(A) reserve a minimum of 25 percent of the amount 
                allocated for such grants for level III and level IV 
                trauma centers in rural or underserved areas;
                    ``(B) reserve a minimum of 25 percent of the amount 
                allocated for such grants for level I and level II 
                trauma centers in urban areas; and
                    ``(C) give preference to any application made by a 
                trauma center--
                            ``(i) in a geographic area where growth in 
                        demand for trauma services exceeds capacity;
                            ``(ii) that demonstrates the financial 
                        support of the State or political subdivision 
                        involved;
                            ``(iii) that has at least 1 graduate 
                        medical education fellowship in trauma or 
                        trauma-related specialties, including 
                        neurological surgery, surgical critical care, 
                        vascular surgery, and spinal cord injury, for 
                        which demand is exceeding supply; or
                            ``(iv) that demonstrates a substantial 
                        commitment to serving vulnerable populations.
            ``(2) Financial support.--For purposes of paragraph 
        (1)(C)(ii), financial support may be demonstrated by State or 
        political subdivision funding for the trauma center's capital 
        or operating expenses (including through State trauma regional 
        advisory coordination activities, Medicaid funding designated 
        for trauma services, or other governmental funding). State 
        funding derived from Federal support shall not constitute State 
        or local financial support for purposes of preferential 
        treatment under this subsection.
            ``(3) Use of funds.--The recipient of a grant under section 
        1241(b)(1)(A) shall carry out, consistent with furthering the 
        core missions of the center, one or more of the following 
        activities:
                    ``(A) Providing 24-hour-a-day, 7-day-a-week trauma 
                care availability.
                    ``(B) Reducing overcrowding related to throughput 
                of trauma patients.
                    ``(C) Enhancing trauma surge capacity.
                    ``(D) Ensuring physician and essential personnel 
                availability.
                    ``(E) Trauma education and outreach.
                    ``(F) Coordination with local and regional trauma 
                care systems.
                    ``(G) Such other activities as the Secretary may 
                deem appropriate.
    ``(b) Emergency Awards; New Centers.--In awarding grants under 
paragraphs (1)(B) and (2) of section 1241(b), the Secretary shall--
            ``(1) give preference to any application submitted by an 
        applicant that demonstrates the financial support (in 
        accordance with subsection (a)(2)) of the State or political 
        subdivision involved for the activities to be funded through 
        the grant for each fiscal year during which payments are made 
        to the center under the grant; and
            ``(2) give preference to any application submitted for a 
        trauma center that--
                    ``(A) is providing or will provide trauma care in a 
                geographic area in which the availability of trauma 
                care has either significantly decreased as a result of 
                a trauma center in the area permanently ceasing 
                participation in a system described in section 
                1241(c)(1) as of a date occurring during the 2-year 
                period preceding the fiscal year for which the trauma 
                center is applying to receive a grant, or in geographic 
                areas where growth in demand for trauma services 
                exceeds capacity;
                    ``(B) will, in providing trauma care during the 1-
                year period beginning on the date on which the 
                application for the grant is submitted, incur 
                substantial uncompensated care costs in an amount that 
                renders the center unable to continue participation in 
                such system and results in a significant decrease in 
                the availability of trauma care in the geographic area;
                    ``(C) operates or will operate in rural areas where 
                trauma care availability will significantly decrease if 
                the center is forced to close or downgrade service and 
                substantial costs are contributing to a likelihood of 
                such closure or downgradation;
                    ``(D) is in a geographic location substantially 
                affected by a natural disaster or other catastrophic 
                event such as a terrorist attack; or
                    ``(E) will establish a new trauma service in an 
                urban area with a substantial degree of trauma 
                resulting from violent crimes.
    ``(c) Designations of Levels of Trauma Centers in Certain States.--
In the case of a State which has not designated 4 levels of trauma 
centers, any reference in this section to--
            ``(1) a level I or level II trauma center is deemed to be a 
        reference to a trauma center within the highest 2 levels of 
        trauma centers designated under State guidelines; and
            ``(2) a level III or IV trauma center is deemed to be a 
        reference to a trauma center not within such highest 2 
        levels.''.
    (c) Certain Agreements.--Section 1243 (42 U.S.C. 300d-43) is 
amended to read as follows:

``SEC. 1243. CERTAIN AGREEMENTS.

    ``(a) Commitment Regarding Continued Participation in Trauma Care 
System.--The Secretary may not award a grant to an applicant under 
section 1241(b) unless the applicant agrees that--
            ``(1) the trauma center involved will continue 
        participation, or in the case of a new center will participate, 
        in the system described in section 1241(c)(1), except as 
        provided in section 1241(c)(1)(B), throughout the grant period 
        beginning on the date that the center first receives payments 
        under the grant; and
            ``(2) if the agreement made pursuant to paragraph (1) is 
        violated by the center, the center will be liable to the United 
        States for an amount equal to the sum of--
                    ``(A) the amount of assistance provided to the 
                center under section 1241; and
                    ``(B) an amount representing interest on the amount 
                specified in subparagraph (A).
    ``(b) Maintenance of Financial Support.--With respect to activities 
for which funds awarded through a grant under section 1241 are 
authorized to be expended, the Secretary may not award such a grant 
unless the applicant agrees that, during the period in which the trauma 
center involved is receiving payments under the grant, the center will 
maintain access to trauma services at levels not less than the levels 
for the prior year, taking into account--
            ``(1) reasonable volume fluctuation that is not caused by 
        intentional trauma boundary reduction;
            ``(2) downgrading of the level of services; and
            ``(3) whether such center diverts its incoming patients 
        away from such center 5 percent or more of the time during 
        which the center is in operation over the course of the year.
    ``(c) Trauma Care Registry.--The Secretary may not award a grant to 
a trauma center under section 1241(b)(1) unless the center agrees 
that--
            ``(1) not later than 6 months after the date on which the 
        center submits a grant application to the Secretary, the center 
        will establish and operate a registry of trauma cases in 
        accordance with guidelines developed by the American College of 
        Surgeons; and
            ``(2) in carrying out paragraph (1), the center will 
        maintain information on the number of trauma cases treated by 
        the center and, for each such case, the extent to which the 
        center incurs uncompensated costs in providing trauma care.''.
    (d) General Provisions.--Section 1244 (42 U.S.C. 300d-44) is 
amended to read as follows:

``SEC. 1244. GENERAL PROVISIONS.

    ``(a) Limitation on Duration of Support.--The period during which a 
trauma center receives payments under a grant under section 1241(b)(1) 
shall be for 3 fiscal years, except that the Secretary may waive such 
requirement for the center and authorize the center to receive such 
payments for 1 additional fiscal year.
    ``(b) Eligibility.--The acquisition of, or eligibility for, a grant 
under section 1241(b) shall not preclude a trauma center's eligibility 
for another grant described in such section.
    ``(c) Funding Distribution.--Of the total amount appropriated for a 
fiscal year under section 1245--
            ``(1) 90 percent shall be used for grants under paragraph 
        (1)(A) of section 1241(b); and
            ``(2) 10 percent shall be used for grants under paragraphs 
        (1)(B) and (2) of section 1241(b).
    ``(d) Report.--Beginning 2 years after the date of the enactment of 
the Affordable Health Care for America Act, and every 2 years 
thereafter, the Secretary shall biennially--
            ``(1) report to Congress on the status of the grants made 
        pursuant to section 1241;
            ``(2) evaluate and report to Congress on the overall 
        financial stability of trauma centers in the United States;
            ``(3) report on the populations using trauma care centers 
        and include aggregate patient data on income, race, ethnicity, 
        and geography; and
            ``(4) evaluate the effectiveness and efficiency of trauma 
        care center activities using standard public health measures 
        and evaluation methodologies.''.
    (e) Authorization of Appropriations.--Section 1245 (42 U.S.C. 300d-
45) is amended to read as follows:

``SEC. 1245. AUTHORIZATION OF APPROPRIATIONS.

    ``(a) In General.--For the purpose of carrying out this part, there 
are authorized to be appropriated $100,000,000 for fiscal year 2011, 
and such sums as may be necessary for each of fiscal years 2012 through 
2015. Such authorization of appropriations is in addition to any other 
authorization of appropriations or amounts that are available for such 
purpose.
    ``(b) Reallocation.--The Secretary shall reallocate for grants 
under section 1241(b)(1)(A) any funds appropriated for grants under 
paragraph (1)(B) or (2) of section 1241(b), but not obligated due to 
insufficient applications eligible for funding.''.

SEC. 2552. EMERGENCY CARE COORDINATION.

    (a) In General.--Subtitle B of title XXVIII (42 U.S.C. 300hh-10 et 
seq.) is amended by adding at the end the following:

``SEC. 2816. EMERGENCY CARE COORDINATION.

    ``(a) Emergency Care Coordination Center.--
            ``(1) Establishment.--The Secretary shall establish, within 
        the Office of the Assistant Secretary for Preparedness and 
        Response, an Emergency Care Coordination Center (in this 
        section referred to as the `Center'), to be headed by a 
        director.
            ``(2) Duties.--The Secretary, acting through the Director 
        of the Center, in coordination with the Federal Interagency 
        Committee on Emergency Medical Services, shall--
                    ``(A) promote and fund research in emergency 
                medicine and trauma health care;
                    ``(B) promote regional partnerships and more 
                effective emergency medical systems in order to enhance 
                appropriate triage, distribution, and care of routine 
                community patients; and
                    ``(C) promote local, regional, and State emergency 
                medical systems' preparedness for and response to 
                public health events.
    ``(b) Council of Emergency Care.--
            ``(1) Establishment.--The Secretary, acting through the 
        Director of the Center, shall establish a Council of Emergency 
        Care to provide advice and recommendations to the Director on 
        carrying out this section.
            ``(2) Composition.--The Council shall be comprised of 
        employees of the departments and agencies of the Federal 
        Government who are experts in emergency care and management.
    ``(c) Report.--
            ``(1) Submission.--Not later than 12 months after the date 
        of the enactment of the Affordable Health Care for America Act, 
        the Secretary shall submit to the Congress an annual report on 
        the activities carried out under this section.
            ``(2) Considerations.--In preparing a report under 
        paragraph (1), the Secretary shall consider factors including--
                    ``(A) emergency department crowding and boarding; 
                and
                    ``(B) delays in care following presentation.
    ``(d) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.''.
    (b) Functions, Personnel, Assets, Liabilities, and Administrative 
Actions.--All functions, personnel, assets, and liabilities of, and 
administrative actions applicable to, the Emergency Care Coordination 
Center, as in existence on the day before the date of the enactment of 
this Act, shall be transferred to the Emergency Care Coordination 
Center established under section 2816(a) of the Public Health Service 
Act, as added by subsection (a).

SEC. 2553. PILOT PROGRAMS TO IMPROVE EMERGENCY MEDICAL CARE.

    Part B of title III (42 U.S.C. 243 et seq.) is amended by inserting 
after section 314 the following:

``SEC. 315. REGIONALIZED COMMUNICATION SYSTEMS FOR EMERGENCY CARE 
              RESPONSE.

    ``(a) In General.--The Secretary, acting through the Assistant 
Secretary for Preparedness and Response, shall award not fewer than 4 
multiyear contracts or competitive grants to eligible entities to 
support demonstration programs that design, implement, and evaluate 
innovative models of regionalized, comprehensive, and accountable 
emergency care systems.
    ``(b) Eligible Entity; Region.--
            ``(1) Eligible entity.--In this section, the term `eligible 
        entity' means a State or a partnership of 1 or more States and 
        1 or more local governments.
            ``(2) Region.--In this section, the term `region' means an 
        area within a State, an area that lies within multiple States, 
        or a similar area (such as a multicounty area), as determined 
        by the Secretary.
    ``(c) Demonstration Program.--The Secretary shall award a contract 
or grant under subsection (a) to an eligible entity that proposes a 
demonstration program to design, implement, and evaluate an emergency 
medical system that--
            ``(1) coordinates with public safety services, public 
        health services, emergency medical services, medical 
        facilities, and other entities within a region;
            ``(2) coordinates an approach to emergency medical system 
        access throughout the region, including 9-1-1 public safety 
        answering points and emergency medical dispatch;
            ``(3) includes a mechanism, such as a regional medical 
        direction or transport communications system, that operates 
        throughout the region to ensure that the correct patient is 
        taken to the medically appropriate facility (whether an initial 
        facility or a higher level facility) in a timely fashion;
            ``(4) allows for the tracking of prehospital and hospital 
        resources, including inpatient bed capacity, emergency 
        department capacity, on-call specialist coverage, ambulance 
        diversion status, and the coordination of such tracking with 
        regional communications and hospital destination decisions; and
            ``(5) includes a consistent regionwide prehospital, 
        hospital, and interfacility data management system that--
                    ``(A) complies with the National EMS Information 
                System, the National Trauma Data Bank, and others;
                    ``(B) reports data to appropriate Federal and State 
                databanks and registries; and
                    ``(C) contains information sufficient to evaluate 
                key elements of prehospital care, hospital destination 
                decisions, including initial hospital and interfacility 
                decisions, and relevant outcomes of hospital care.
    ``(d) Application.--
            ``(1) In general.--An eligible entity that seeks a contract 
        or grant described in subsection (a) shall submit to the 
        Secretary an application at such time and in such manner as the 
        Secretary may require.
            ``(2) Application information.--Each application shall 
        include--
                    ``(A) an assurance from the eligible entity that 
                the proposed system--
                            ``(i) has been coordinated with the 
                        applicable State office of emergency medical 
                        services (or equivalent State office);
                            ``(ii) is compatible with the applicable 
                        State emergency medical services system;
                            ``(iii) includes consistent indirect and 
                        direct medical oversight of prehospital, 
                        hospital, and interfacility transport 
                        throughout the region;
                            ``(iv) coordinates prehospital treatment 
                        and triage, hospital destination, and 
                        interfacility transport throughout the region;
                            ``(v) includes a categorization or 
                        designation system for special medical 
                        facilities throughout the region that is--
                                    ``(I) consistent with State laws 
                                and regulations; and
                                    ``(II) integrated with the 
                                protocols for transport and destination 
                                throughout the region; and
                            ``(vi) includes a regional medical 
                        direction system, a patient tracking system, 
                        and a resource allocation system that--
                                    ``(I) support day-to-day emergency 
                                care system operation;
                                    ``(II) can manage surge capacity 
                                during a major event or disaster; and
                                    ``(III) are integrated with other 
                                components of the national and State 
                                emergency preparedness system;
                    ``(B) an agreement to make available non-Federal 
                contributions in accordance with subsection (e); and
                    ``(C) such other information as the Secretary may 
                require.
    ``(e) Matching Funds.--
            ``(1) In general.--With respect to the costs of the 
        activities to be carried out each year with a contract or grant 
        under subsection (a), a condition for the receipt of the 
        contract or grant is that the eligible entity involved agrees 
        to make available (directly or through donations from public or 
        private entities) non-Federal contributions toward such costs 
        in an amount that is not less than 25 percent of such costs.
            ``(2) Determination of amount contributed.--Non-Federal 
        contributions required in paragraph (1) may be in cash or in 
        kind, fairly evaluated, including plant, equipment, or 
        services. Amounts provided by the Federal Government, or 
        services assisted or subsidized to any significant extent by 
        the Federal Government, may not be included in determining the 
        amount of such non-Federal contributions.
    ``(f) Priority.--The Secretary shall give priority for the award of 
the contracts or grants described in subsection (a) to any eligible 
entity that serves a medically underserved population (as defined in 
section 330(b)(3)).
    ``(g) Report.--Not later than 90 days after the completion of a 
demonstration program under subsection (a), the recipient of such 
contract or grant described in such subsection shall submit to the 
Secretary a report containing the results of an evaluation of the 
program, including an identification of--
            ``(1) the impact of the regional, accountable emergency 
        care system on patient outcomes for various critical care 
        categories, such as trauma, stroke, cardiac emergencies, and 
        pediatric emergencies;
            ``(2) the system characteristics that contribute to the 
        effectiveness and efficiency of the program (or lack thereof);
            ``(3) methods of assuring the long-term financial 
        sustainability of the emergency care system;
            ``(4) the State and local legislation necessary to 
        implement and to maintain the system; and
            ``(5) the barriers to developing regionalized, accountable 
        emergency care systems, as well as the methods to overcome such 
        barriers.
    ``(h) Evaluation.--The Secretary, acting through the Assistant 
Secretary for Preparedness and Response, shall enter into a contract 
with an academic institution or other entity to conduct an independent 
evaluation of the demonstration programs funded under subsection (a), 
including an evaluation of--
            ``(1) the performance of the eligible entities receiving 
        the funds; and
            ``(2) the impact of the demonstration programs.
    ``(i) Dissemination of Findings.--The Secretary shall, as 
appropriate, disseminate to the public and to the appropriate 
committees of the Congress, the information contained in a report made 
under subsection (h).
    ``(j) Authorization of Appropriations.--
            ``(1) In general.--There is authorized to be appropriated 
        to carry out this section $12,000,000 for each of fiscal years 
        2011 through 2015.
            ``(2) Reservation.--Of the amount appropriated to carry out 
        this section for a fiscal year, the Secretary shall reserve 3 
        percent of such amount to carry out subsection (h) (relating to 
        an independent evaluation).''.

SEC. 2554. ASSISTING VETERANS WITH MILITARY EMERGENCY MEDICAL TRAINING 
              TO BECOME STATE-LICENSED OR CERTIFIED EMERGENCY MEDICAL 
              TECHNICIANS (EMTS).

    (a) In General.--Part B of title III (42 U.S.C. 243 et seq.), as 
amended, is amended by inserting after section 315 the following:

``SEC. 315A. ASSISTING VETERANS WITH MILITARY EMERGENCY MEDICAL 
              TRAINING TO BECOME STATE-LICENSED OR CERTIFIED EMERGENCY 
              MEDICAL TECHNICIANS (EMTS).

    ``(a) Program.--The Secretary shall establish a program consisting 
of awarding grants to States to assist veterans who received and 
completed military emergency medical training while serving in the 
Armed Forces of the United States to become, upon their discharge or 
release from active duty service, State-licensed or certified emergency 
medical technicians.
    ``(b) Use of Funds.--Amounts received as a grant under this section 
may be used to assist veterans described in subsection (a) to become 
State-licensed or certified emergency medical technicians as follows:
            ``(1) Providing training.
            ``(2) Providing reimbursement for costs associated with--
                    ``(A) training; or
                    ``(B) applying for licensure or certification.
            ``(3) Expediting the licensing or certification process.
    ``(c) Eligibility.--To be eligible for a grant under this section, 
a State shall demonstrate to the Secretary's satisfaction that the 
State has a shortage of emergency medical technicians.
    ``(d) Report.--The Secretary shall submit to the Congress an annual 
report on the program under this section.
    ``(e) Authorization of Appropriations.--To carry out this section, 
there are authorized to be appropriated such sums as may be necessary 
for each of fiscal years 2011 through 2015.''.
    (b) GAO Study and Report.--The Comptroller General of the United 
States shall--
            (1) conduct a study on the barriers experienced by veterans 
        who received training as medical personnel while serving in the 
        Armed Forces of the United States and, upon their discharge or 
        release from active duty service, seek to become licensed or 
        certified in a State as civilian health professionals; and
            (2) not later than 2 years after the date of the enactment 
        of this Act, submit to the Congress a report on the results of 
        such study, including recommendations on whether the program 
        established under section 315A of the Public Health Service 
        Act, as added by subsection (a), should be expanded to assist 
        veterans seeking to become licensed or certified in a State as 
        health providers other than emergency medical technicians.

SEC. 2555. DENTAL EMERGENCY RESPONDERS: PUBLIC HEALTH AND MEDICAL 
              RESPONSE.

    (a) National Health Security Strategy.--Section 2802(b)(3) (42 
U.S.C. 300hh-1(b)(3)) is amended--
            (1) in the matter preceding subparagraph (A), by inserting 
        ``dental and'' before ``mental health facilities''; and
            (2) in subparagraph (D), by inserting ``and dental'' after 
        ``medical''.
    (b) All-Hazards Public Health and Medical Response Curricula and 
Training.--Section 319F(a)(5)(B) (42 U.S.C. 247d-6(a)(5)(B)) is amended 
by striking ``public health or medical'' and inserting ``public health, 
medical, or dental''.

SEC. 2556. DENTAL EMERGENCY RESPONDERS: HOMELAND SECURITY.

    (a) National Response Framework.--Paragraph (6) of section 2 of the 
Homeland Security Act of 2002 (6 U.S.C. 101) is amended by inserting 
``and dental'' after ``emergency medical''.
    (b) National Preparedness System.--Subparagraph (B) of section 
653(b)(4) of the Post-Katrina Emergency Management Reform Act of 2006 
(6 U.S.C. 753(b)(4)) is amended by striking ``public health and 
medical'' and inserting ``public health, medical, and dental''.
    (c) Chief Medical Officer.--Paragraph (5) of section 516(c) of the 
Homeland Security Act of 2002 (6 U.S.C. 321e(c)) is amended by striking 
``medical community'' and inserting ``medical and dental communities''.

               PART 4--PAIN CARE AND MANAGEMENT PROGRAMS

SEC. 2561. INSTITUTE OF MEDICINE CONFERENCE ON PAIN.

    (a) Convening.--Not later than June 30, 2011, the Secretary of 
Health and Human Services shall seek to enter into an agreement with 
the Institute of Medicine of the National Academies to convene a 
Conference on Pain (in this section referred to as ``the Conference'').
    (b) Purposes.--The purposes of the Conference shall be to--
            (1) increase the recognition of pain as a significant 
        public health problem in the United States;
            (2) evaluate the adequacy of assessment, diagnosis, 
        treatment, and management of acute and chronic pain in the 
        general population, and in identified racial, ethnic, gender, 
        age, and other demographic groups that may be 
        disproportionately affected by inadequacies in the assessment, 
        diagnosis, treatment, and management of pain;
            (3) identify barriers to appropriate pain care, including--
                    (A) lack of understanding and education among 
                employers, patients, health care providers, regulators, 
                and third-party payors;
                    (B) barriers to access to care at the primary, 
                specialty, and tertiary care levels, including 
                barriers--
                            (i) specific to those populations that are 
                        disproportionately undertreated for pain;
                            (ii) related to physician concerns over 
                        regulatory and law enforcement policies 
                        applicable to some pain therapies; and
                            (iii) attributable to benefit, coverage, 
                        and payment policies in both the public and 
                        private sectors; and
                    (C) gaps in basic and clinical research on the 
                symptoms and causes of pain, and potential assessment 
                methods and new treatments to improve pain care; and
            (4) establish an agenda for action in both the public and 
        private sectors that will reduce such barriers and 
        significantly improve the state of pain care research, 
        education, and clinical care in the United States.
    (c) Other Appropriate Entity.--If the Institute of Medicine 
declines to enter into an agreement under subsection (a), the Secretary 
of Health and Human Services may enter into such agreement with another 
appropriate entity.
    (d) Report.--A report summarizing the Conference's findings and 
recommendations shall be submitted to the Congress not later than June 
30, 2012.
    (e) Authorization of Appropriations.--For the purpose of carrying 
out this section, there is authorized to be appropriated $500,000 for 
each of fiscal years 2011 and 2012.

SEC. 2562. PAIN RESEARCH AT NATIONAL INSTITUTES OF HEALTH.

    Part B of title IV (42 U.S.C. 284 et seq.) is amended by adding at 
the end the following:

``SEC. 409J. PAIN RESEARCH.

    ``(a) Research Initiatives.--
            ``(1) In general.--The Director of NIH is encouraged to 
        continue and expand, through the Pain Consortium, an aggressive 
        program of basic and clinical research on the causes of and 
        potential treatments for pain.
            ``(2) Annual recommendations.--Not less than annually, the 
        Pain Consortium, in consultation with the Division of Program 
        Coordination, Planning, and Strategic Initiatives, shall 
        develop and submit to the Director of NIH recommendations on 
        appropriate pain research initiatives that could be undertaken 
        with funds reserved under section 402A(c)(1) for the Common 
        Fund or otherwise available for such initiatives.
            ``(3) Definition.--In this subsection, the term `Pain 
        Consortium' means the Pain Consortium of the National 
        Institutes of Health or a similar trans-National Institutes of 
        Health coordinating entity designated by the Secretary for 
        purposes of this subsection.
    ``(b) Interagency Pain Research Coordinating Committee.--
            ``(1) Establishment.--The Secretary shall establish not 
        later than 1 year after the date of the enactment of this 
        section and as necessary maintain a committee, to be known as 
        the Interagency Pain Research Coordinating Committee (in this 
        section referred to as the `Committee'), to coordinate all 
        efforts within the Department of Health and Human Services and 
        other Federal agencies that relate to pain research.
            ``(2) Membership.--
                    ``(A) In general.--The Committee shall be composed 
                of the following voting members:
                            ``(i) Not more than 7 voting Federal 
                        representatives as follows:
                                    ``(I) The Director of the Centers 
                                for Disease Control and Prevention.
                                    ``(II) The Director of the National 
                                Institutes of Health and the directors 
                                of such national research institutes 
                                and national centers as the Secretary 
                                determines appropriate.
                                    ``(III) The heads of such other 
                                agencies of the Department of Health 
                                and Human Services as the Secretary 
                                determines appropriate.
                                    ``(IV) Representatives of other 
                                Federal agencies that conduct or 
                                support pain care research and 
                                treatment, including the Department of 
                                Defense and the Department of Veterans 
                                Affairs.
                            ``(ii) Twelve additional voting members 
                        appointed under subparagraph (B).
                    ``(B) Additional members.--The Committee shall 
                include additional voting members appointed by the 
                Secretary as follows:
                            ``(i) Six members shall be appointed from 
                        among scientists, physicians, and other health 
                        professionals, who--
                                    ``(I) are not officers or employees 
                                of the United States;
                                    ``(II) represent multiple 
                                disciplines, including clinical, basic, 
                                and public health sciences;
                                    ``(III) represent different 
                                geographical regions of the United 
                                States; and
                                    ``(IV) are from practice settings, 
                                academia, manufacturers, or other 
                                research settings.
                            ``(ii) Six members shall be appointed from 
                        members of the general public, who are 
                        representatives of leading research, advocacy, 
                        and service organizations for individuals with 
                        pain-related conditions.
                    ``(C) Nonvoting members.--The Committee shall 
                include such nonvoting members as the Secretary 
                determines to be appropriate.
            ``(3) Chairperson.--The voting members of the Committee 
        shall select a chairperson from among such members. The 
        selection of a chairperson shall be subject to the approval of 
        the Director of NIH.
            ``(4) Meetings.--The Committee shall meet at the call of 
        the chairperson of the Committee or upon the request of the 
        Director of NIH, but in no case less often than once each year.
            ``(5) Duties.--The Committee shall--
                    ``(A) develop a summary of advances in pain care 
                research supported or conducted by the Federal agencies 
                relevant to the diagnosis, prevention, and treatment of 
                pain and diseases and disorders associated with pain;
                    ``(B) identify critical gaps in basic and clinical 
                research on the symptoms and causes of pain;
                    ``(C) make recommendations to ensure that the 
                activities of the National Institutes of Health and 
                other Federal agencies, including the Department of 
                Defense and the Department of Veteran Affairs, are free 
                of unnecessary duplication of effort;
                    ``(D) make recommendations on how best to 
                disseminate information on pain care; and
                    ``(E) make recommendations on how to expand 
                partnerships between public entities, including Federal 
                agencies, and private entities to expand collaborative, 
                crosscutting research.
            ``(6) Review.--The Secretary shall review the necessity of 
        the Committee at least once every 2 years.''.

SEC. 2563. PUBLIC AWARENESS CAMPAIGN ON PAIN MANAGEMENT.

    Part B of title II (42 U.S.C. 238 et seq.) is amended by adding at 
the end the following:

``SEC. 249. NATIONAL EDUCATION OUTREACH AND AWARENESS CAMPAIGN ON PAIN 
              MANAGEMENT.

    ``(a) Establishment.--Not later than 12 months after the date of 
the enactment of this section, the Secretary shall establish and 
implement a national pain care education outreach and awareness 
campaign described in subsection (b).
    ``(b) Requirements.--The Secretary shall design the public 
awareness campaign under this section to educate consumers, patients, 
their families, and other caregivers with respect to--
            ``(1) the incidence and importance of pain as a national 
        public health problem;
            ``(2) the adverse physical, psychological, emotional, 
        societal, and financial consequences that can result if pain is 
        not appropriately assessed, diagnosed, treated, or managed;
            ``(3) the availability, benefits, and risks of all pain 
        treatment and management options;
            ``(4) having pain promptly assessed, appropriately 
        diagnosed, treated, and managed, and regularly reassessed with 
        treatment adjusted as needed;
            ``(5) the role of credentialed pain management specialists 
        and subspecialists, and of comprehensive interdisciplinary 
        centers of treatment expertise;
            ``(6) the availability in the public, nonprofit, and 
        private sectors of pain management-related information, 
        services, and resources for consumers, employers, third-party 
        payors, patients, their families, and caregivers, including 
        information on--
                    ``(A) appropriate assessment, diagnosis, treatment, 
                and management options for all types of pain and pain-
                related symptoms; and
                    ``(B) conditions for which no treatment options are 
                yet recognized; and
            ``(7) other issues the Secretary deems appropriate.
    ``(c) Consultation.--In designing and implementing the public 
awareness campaign required by this section, the Secretary shall 
consult with organizations representing patients in pain and other 
consumers, employers, physicians including physicians specializing in 
pain care, other pain management professionals, medical device 
manufacturers, and pharmaceutical companies.
    ``(d) Coordination.--
            ``(1) Lead official.--The Secretary shall designate one 
        official in the Department of Health and Human Services to 
        oversee the campaign established under this section.
            ``(2) Agency coordination.--The Secretary shall ensure the 
        involvement in the public awareness campaign under this section 
        of the Surgeon General of the Public Health Service, the 
        Director of the Centers for Disease Control and Prevention, and 
        such other representatives of offices and agencies of the 
        Department of Health and Human Services as the Secretary 
        determines appropriate.
    ``(e) Underserved Areas and Populations.--In designing the public 
awareness campaign under this section, the Secretary shall--
            ``(1) take into account the special needs of geographic 
        areas and racial, ethnic, gender, age, and other demographic 
        groups that are currently underserved; and
            ``(2) provide resources that will reduce disparities in 
        access to appropriate diagnosis, assessment, and treatment.
    ``(f) Grants and Contracts.--The Secretary may make awards of 
grants, cooperative agreements, and contracts to public agencies and 
private nonprofit organizations to assist with the development and 
implementation of the public awareness campaign under this section.
    ``(g) Evaluation and Report.--Not later than the end of fiscal year 
2012, the Secretary shall prepare and submit to the Congress a report 
evaluating the effectiveness of the public awareness campaign under 
this section in educating the general public with respect to the 
matters described in subsection (b).
    ``(h) Authorization of Appropriations.--For purposes of carrying 
out this section, there are authorized to be appropriated $2,000,000 
for fiscal year 2011 and $4,000,000 for each of fiscal years 2012 and 
2015.''.

                Subtitle C--Food and Drug Administration

                           PART 1--IN GENERAL

SEC. 2571. NATIONAL MEDICAL DEVICE REGISTRY.

    (a) Registry.--
            (1) In general.--Section 519 of the Federal Food, Drug, and 
        Cosmetic Act (21 U.S.C. 360i) is amended--
                    (A) by redesignating subsection (g) as subsection 
                (h); and
                    (B) by inserting after subsection (f) the 
                following:

                   ``National Medical Device Registry

    ``(g)(1)(A) The Secretary shall establish a national medical device 
registry (in this subsection referred to as the `registry') to 
facilitate analysis of postmarket safety and outcomes data on each 
covered device.
    ``(B) In this subsection, the term `covered device'--
            ``(i) shall include each class III device; and
            ``(ii) may include, as the Secretary determines appropriate 
        and specifies in regulation, a class II device that is life-
        supporting or life-sustaining.
    ``(C) Notwithstanding subparagraph (B)(i), the Secretary may by 
order exempt a class III device from the provisions of this subsection 
if the Secretary concludes that inclusion of information on the device 
in the registry will not provide useful information on safety or 
effectiveness.
    ``(2) In developing the registry, the Secretary shall, in 
consultation with the Commissioner of Food and Drugs, the Administrator 
of the Centers for Medicare & Medicaid Services, the Administrator of 
the Agency for Healthcare Research and Quality, the head of the Office 
of the National Coordinator for Health Information Technology, and the 
Secretary of Veterans Affairs, determine the best methods for--
            ``(A) including in the registry, in a manner consistent 
        with subsection (f), appropriate information to identify each 
        covered device by type, model, and serial number or other 
        unique identifier;
            ``(B) validating methods for analyzing patient safety and 
        outcomes data from multiple sources and for linking such data 
        with the information included in the registry as described in 
        subparagraph (A), including, to the extent feasible, use of--
                    ``(i) data provided to the Secretary under other 
                provisions of this chapter; and
                    ``(ii) information from public and private sources 
                identified under paragraph (3);
            ``(C) integrating the activities described in this 
        subsection (so as to avoid duplication) with--
                    ``(i) activities under paragraph (3) of section 
                505(k) (relating to active postmarket risk 
                identification);
                    ``(ii) activities under paragraph (4) of section 
                505(k) (relating to advanced analysis of drug safety 
                data);
                    ``(iii) other postmarket device surveillance 
                activities of the Secretary authorized by this chapter; 
                and
                    ``(iv) registries carried out by or for the Agency 
                for Healthcare Research and Quality; and
            ``(D) providing public access to the data and analysis 
        collected or developed through the registry in a manner and 
        form that protects patient privacy and proprietary information 
        and is comprehensive, useful, and not misleading to patients, 
        physicians, and scientists.
    ``(3)(A) To facilitate analyses of postmarket safety and patient 
outcomes for covered devices, the Secretary shall, in collaboration 
with public, academic, and private entities, develop methods to--
                    ``(i) obtain access to disparate sources of patient 
                safety and outcomes data, including--
                            ``(I) Federal health-related electronic 
                        data (such as data from the Medicare program 
                        under title XVIII of the Social Security Act or 
                        from the health systems of the Department of 
                        Veterans Affairs);
                            ``(II) private sector health-related 
                        electronic data (such as pharmaceutical 
                        purchase data and health insurance claims 
                        data); and
                            ``(III) other data as the Secretary deems 
                        necessary to permit postmarket assessment of 
                        device safety and effectiveness; and
                    ``(ii) link data obtained under clause (i) with 
                information in the registry.
    ``(B) In this paragraph, the term `data' refers to information 
respecting a covered device, including claims data, patient survey 
data, standardized analytic files that allow for the pooling and 
analysis of data from disparate data environments, electronic health 
records, and any other data deemed appropriate by the Secretary.
    ``(4) The Secretary shall promulgate regulations for establishment 
and operation of the registry under paragraph (1). Such regulations--
            ``(A)(i) in the case of covered devices that are sold on or 
        after the date of the enactment of this subsection, shall 
        require manufacturers of such devices to submit information to 
        the registry, including, for each such device, the type, model, 
        and serial number or, if required under subsection (f), other 
        unique device identifier; and
            ``(ii) in the case of covered devices that are sold before 
        such date, may require manufacturers of such devices to submit 
        such information to the registry, if deemed necessary by the 
        Secretary to protect the public health;
            ``(B) shall establish procedures--
                    ``(i) to permit linkage of information submitted 
                pursuant to subparagraph (A) with patient safety and 
                outcomes data obtained under paragraph (3); and
                    ``(ii) to permit analyses of linked data;
            ``(C) may require covered device manufacturers to submit 
        such other information as is necessary to facilitate postmarket 
        assessments of device safety and effectiveness and notification 
        of device risks;
            ``(D) shall establish requirements for regular and timely 
        reports to the Secretary, which shall be included in the 
        registry, concerning adverse event trends, adverse event 
        patterns, incidence and prevalence of adverse events, and other 
        information the Secretary determines appropriate, which may 
        include data on comparative safety and outcomes trends; and
            ``(E) shall establish procedures to permit public access to 
        the information in the registry in a manner and form that 
        protects patient privacy and proprietary information and is 
        comprehensive, useful, and not misleading to patients, 
        physicians, and scientists.
    ``(5)(A) The Secretary shall promulgate final regulations under 
paragraph (4) not later than 36 months after the date of the enactment 
of this subsection.
    ``(B) Before issuing the notice of proposed rulemaking preceding 
the final regulations described in subparagraph (A), the Secretary 
shall hold a public hearing before an advisory committee on the issue 
of which class II devices to include in the definition of covered 
devices.
    ``(C) The Secretary shall include in any regulation under this 
subsection an explanation demonstrating that the requirements of such 
regulation--
            ``(i) do not duplicate other Federal requirements; and
            ``(ii) do not impose an undue burden on device 
        manufacturers.
    ``(6) With respect to any entity that submits or is required to 
submit a safety report or other information in connection with the 
safety of a device under this section (and any release by the Secretary 
of that report or information), such report or information shall not be 
construed to reflect necessarily a conclusion by the entity or the 
Secretary that the report or information constitutes an admission that 
the product involved malfunctioned, caused or contributed to an adverse 
experience, or otherwise caused or contributed to a death, serious 
injury, or serious illness. Such an entity need not admit, and may 
deny, that the report or information submitted by the entity 
constitutes an admission that the product involved malfunctioned, 
caused or contributed to an adverse experience, or caused or 
contributed to a death, serious injury, or serious illness.
    ``(7) To carry out this subsection, there are authorized to be 
appropriated such sums as may be necessary for each of fiscal years 
2011 and 2012.''.
            (2) Effective date.--The Secretary of Health and Human 
        Services shall establish and begin implementation of the 
        registry under section 519(g) of the Federal Food, Drug, and 
        Cosmetic Act, as added by paragraph (1), by not later than the 
        date that is 36 months after the date of the enactment of this 
        Act, without regard to whether or not final regulations to 
        establish and operate the registry have been promulgated by 
        such date.
            (3) Conforming amendment.--Section 303(f)(1)(B)(ii) of the 
        Federal Food, Drug, and Cosmetic Act (21 U.S.C. 
        333(f)(1)(B)(ii)) is amended by striking ``519(g)'' and 
        inserting ``519(h)''.
    (b) Electronic Exchange and Use in Certified Electronic Health 
Records of Unique Device Identifiers.--
            (1) Recommendations.--The HIT Policy Committee established 
        under section 3002 of the Public Health Service Act (42 U.S.C. 
        300jj-12) shall recommend to the head of the Office of the 
        National Coordinator for Health Information Technology 
        standards, implementation specifications, and certification 
        criteria for the electronic exchange and use in certified 
        electronic health records of a unique device identifier for 
        each covered device (as defined under section 519(g)(1)(B) of 
        the Federal Food, Drug, and Cosmetic Act, as added by 
        subsection (a)).
            (2) Standards, implementation criteria, and certification 
        criteria.--The Secretary of Health and Human Services, acting 
        through the head of the Office of the National Coordinator for 
        Health Information Technology, shall adopt standards, 
        implementation specifications, and certification criteria for 
        the electronic exchange and use in certified electronic health 
        records of a unique device identifier for each covered device 
        referred to in paragraph (1), if such an identifier is required 
        by section 519(f) of the Federal Food, Drug, and Cosmetic Act 
        (21 U.S.C. 360i(f)) for the device.
    (c) Unique Device Identification System.--The Secretary of Health 
and Human Services, acting through the Commissioner of Food and Drugs, 
shall issue proposed regulations to implement section 519(f) of the 
Federal Food, Drug, and Cosmetic Act (21 U.S.C. 360i(f)) not later than 
6 months after the date of the enactment of this Act.

SEC. 2572. NUTRITION LABELING OF STANDARD MENU ITEMS AT CHAIN 
              RESTAURANTS AND OF ARTICLES OF FOOD SOLD FROM VENDING 
              MACHINES.

    (a) Technical Amendments.--Section 403(q)(5)(A) of the Federal 
Food, Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)(A)) is amended--
            (1) in subclause (i), by inserting ``except as provided in 
        clause (H)(ii)(III),'' after ``(i)'' ; and
            (2) in subclause (ii), by inserting ``except as provided in 
        clause (H)(ii)(III),'' after ``(ii)''.
    (b) Labeling Requirements.--Section 403(q)(5) of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 343(q)(5)) is amended by adding at 
the end the following:
    ``(H) Restaurants, Retail Food Establishments, and Vending 
Machines.--
            ``(i) General requirements for restaurants and similar 
        retail food establishments.--Except for food described in 
        subclause (vii), in the case of food that is a standard menu 
        item that is offered for sale in a restaurant or similar retail 
        food establishment that is part of a chain with 20 or more 
        locations doing business under the same name (regardless of the 
        type of ownership of the locations) and offering for sale 
        substantially the same menu items, the restaurant or similar 
        retail food establishment shall disclose the information 
        described in subclauses (ii) and (iii).
            ``(ii) Information required to be disclosed by restaurants 
        and retail food establishments.--Except as provided in 
        subclause (vii), the restaurant or similar retail food 
        establishment shall disclose in a clear and conspicuous 
        manner--
                    ``(I)(aa) in a nutrient content disclosure 
                statement adjacent to the name of the standard menu 
                item, so as to be clearly associated with the standard 
                menu item, on the menu listing the item for sale, the 
                number of calories contained in the standard menu item, 
                as usually prepared and offered for sale; and
                    ``(bb) a succinct statement concerning suggested 
                daily caloric intake, as specified by the Secretary by 
                regulation and posted prominently on the menu and 
                designed to enable the public to understand, in the 
                context of a total daily diet, the significance of the 
                caloric information that is provided on the menu;
                    ``(II)(aa) in a nutrient content disclosure 
                statement adjacent to the name of the standard menu 
                item, so as to be clearly associated with the standard 
                menu item, on the menu board, including a drive-through 
                menu board, the number of calories contained in the 
                standard menu item, as usually prepared and offered for 
                sale; and
                    ``(bb) a succinct statement concerning suggested 
                daily caloric intake, as specified by the Secretary by 
                regulation and posted prominently on the menu board, 
                designed to enable the public to understand, in the 
                context of a total daily diet, the significance of the 
                nutrition information that is provided on the menu 
                board;
                    ``(III) in a written form, available on the 
                premises of the restaurant or similar retail 
                establishment and to the consumer upon request, the 
                nutrition information required under clauses (C) and 
                (D) of subparagraph (1); and
                    ``(IV) on the menu or menu board, a prominent, 
                clear, and conspicuous statement regarding the 
                availability of the information described in item 
                (III).
            ``(iii) Self-service food and food on display.--Except as 
        provided in subclause (vii), in the case of food sold at a 
        salad bar, buffet line, cafeteria line, or similar self-service 
        facility, and for self-service beverages or food that is on 
        display and that is visible to customers, a restaurant or 
        similar retail food establishment shall place adjacent to each 
        food offered a sign that lists calories per displayed food item 
        or per serving.
            ``(iv) Reasonable basis.--For the purposes of this clause, 
        a restaurant or similar retail food establishment shall have a 
        reasonable basis for its nutrient content disclosures, 
        including nutrient databases, cookbooks, laboratory analyses, 
        and other reasonable means, as described in section 101.10 of 
        title 21, Code of Federal Regulations (or any successor 
        regulation) or in a related guidance of the Food and Drug 
        Administration.
            ``(v) Menu variability and combination meals.--The 
        Secretary shall establish by regulation standards for 
        determining and disclosing the nutrient content for standard 
        menu items that come in different flavors, varieties, or 
        combinations, but which are listed as a single menu item, such 
        as soft drinks, ice cream, pizza, doughnuts, or children's 
        combination meals, through means determined by the Secretary, 
        including ranges, averages, or other methods.
            ``(vi) Additional information.--If the Secretary determines 
        that a nutrient, other than a nutrient required under subclause 
        (ii)(III), should be disclosed for the purpose of providing 
        information to assist consumers in maintaining healthy dietary 
        practices, the Secretary may require, by regulation, disclosure 
        of such nutrient in the written form required under subclause 
        (ii)(III).
            ``(vii) Nonapplicability to certain food.--
                    ``(I) In general.--Subclauses (i) through (vi) do 
                not apply to--
                            ``(aa) items that are not listed on a menu 
                        or menu board (such as condiments and other 
                        items placed on the table or counter for 
                        general use);
                            ``(bb) daily specials, temporary menu items 
                        appearing on the menu for less than 60 days per 
                        calendar year, or custom orders; or
                            ``(cc) such other food that is part of a 
                        customary market test appearing on the menu for 
                        less than 90 days, under terms and conditions 
                        established by the Secretary.
                    ``(II) Written forms.--Clause (C) shall apply to 
                any regulations promulgated under subclauses (ii)(III) 
                and (vi).
            ``(viii) Vending machines.--In the case of an article of 
        food sold from a vending machine that--
                    ``(I) does not permit a prospective purchaser to 
                examine the Nutrition Facts Panel before purchasing the 
                article or does not otherwise provide visible nutrition 
                information at the point of purchase; and
                    ``(II) is operated by a person who is engaged in 
                the business of owning or operating 20 or more vending 
                machines,
        the vending machine operator shall provide a sign in close 
        proximity to each article of food or the selection button that 
        includes a clear and conspicuous statement disclosing the 
        number of calories contained in the article.
            ``(ix) Voluntary provision of nutrition information.--
                    ``(I) In general.--An authorized official of any 
                restaurant or similar retail food establishment or 
                vending machine operator not subject to the 
                requirements of this clause may elect to be subject to 
                the requirements of such clause, by registering 
                biannually the name and address of such restaurant or 
                similar retail food establishment or vending machine 
                operator with the Secretary, as specified by the 
                Secretary by regulation.
                    ``(II) Registration.--Within 120 days of the 
                enactment of this clause, the Secretary shall publish a 
                notice in the Federal Register specifying the terms and 
                conditions for implementation of item (I), pending 
                promulgation of regulations.
                    ``(III) Rule of construction.--Nothing in this 
                subclause shall be construed to authorize the Secretary 
                to require an application, review, or licensing process 
                for any entity to register with the Secretary, as 
                described in such item.
            ``(x) Regulations.--
                    ``(I) Proposed regulation.--Not later than 1 year 
                after the date of the enactment of this clause, the 
                Secretary shall promulgate proposed regulations to 
                carry out this clause.
                    ``(II) Contents.--In promulgating regulations, the 
                Secretary shall--
                            ``(aa) consider standardization of recipes 
                        and methods of preparation, reasonable 
                        variation in serving size and formulation of 
                        menu items, space on menus and menu boards, 
                        inadvertent human error, training of food 
                        service workers, variations in ingredients, and 
                        other factors, as the Secretary determines; and
                            ``(bb) specify the format and manner of the 
                        nutrient content disclosure requirements under 
                        this subclause.
                    ``(III) Reporting.--The Secretary shall submit to 
                the Committee on Health, Education, Labor, and Pensions 
                of the Senate and the Committee on Energy and Commerce 
                of the House of Representatives a quarterly report that 
                describes the Secretary's progress toward promulgating 
                final regulations under this subparagraph.
            ``(xi) Definition.--In this clause, the term `menu' or 
        `menu board' means the primary writing of the restaurant or 
        other similar retail food establishment from which a consumer 
        makes an order selection.''.
    (c) National Uniformity.--Section 403A(a)(4) of the Federal Food, 
Drug, and Cosmetic Act (21 U.S.C. 343-1(a)(4)) is amended by striking 
``except a requirement for nutrition labeling of food which is exempt 
under subclause (i) or (ii) of section 403(q)(5)(A)'' and inserting 
``except that this paragraph does not apply to food that is offered for 
sale in a restaurant or similar retail food establishment that is not 
part of a chain with 20 or more locations doing business under the same 
name (regardless of the type of ownership of the locations) and 
offering for sale substantially the same menu items unless such 
restaurant or similar retail food establishment complies with the 
voluntary provision of nutrition information requirements under section 
403(q)(5)(H)(ix)''.
    (d) Rule of Construction.--Nothing in the amendments made by this 
section shall be construed--
            (1) to preempt any provision of State or local law, unless 
        such provision establishes or continues into effect nutrient 
        content disclosures of the type required under section 
        403(q)(5)(H) of the Federal Food, Drug, and Cosmetic Act (as 
        added by subsection (b)) and is expressly preempted under 
        section 403A(a)(4) of such Act;
            (2) to apply to any State or local requirement respecting a 
        statement in the labeling of food that provides for a warning 
        concerning the safety of the food or component of the food; or
            (3) except as provided in section 403(q)(5)(H)(ix) of the 
        Federal Food, Drug, and Cosmetic Act (as added by subsection 
        (b)), to apply to any restaurant or similar retail food 
        establishment other than a restaurant or similar retail food 
        establishment described in section 403(q)(5)(H)(i) of such Act.

SEC. 2573. PROTECTING CONSUMER ACCESS TO GENERIC DRUGS.

    (a) Findings; Purpose.--
            (1) Findings.--The Congress finds the following:
                    (A) In 1984, the Drug Price Competition and Patent 
                Term Restoration Act (Pub. L. 98-417; in this 
                subsection referred to as the ``1984 Act'') was enacted 
                with the intent of facilitating the early entry of 
                generic drugs while preserving incentives for 
                innovation.
                    (B) Prescription drugs make up 10 percent of 
                national health care spending, but for the past decade 
                have been one of the fastest growing segments of health 
                care expenditures.
                    (C) Until recently, the 1984 Act was successful in 
                facilitating generic competition to the benefit of 
                consumers and health care payers--although 67 percent 
                of all prescriptions dispensed in the United States are 
                generic drugs, they account for only 20 percent of all 
                expenditures.
                    (D) In recent years, the intent of the 1984 Act has 
                been subverted by certain settlement agreements between 
                brand companies and their potential generic competitors 
                that make reverse payments, i.e., payments by the brand 
                company to the generic company.
                    (E) These settlement agreements have unduly delayed 
                the marketing of low-cost generic drugs contrary to 
                free competition and the interests of consumers.
                    (F) The state of antitrust law relating to such 
                settlement agreements is unsettled.
            (2) Purpose.--The purpose of this section is to provide an 
        additional means to effectuate the intent of the 1984 Act by 
        enhancing competition in the pharmaceutical market by stopping 
        agreements between brand name and generic drug manufacturers 
        that limit, delay, or otherwise prevent competition from 
        generic drugs.
    (b) In General.--Section 505 of the Federal Food, Drug, and 
Cosmetic Act (21 U.S.C. 355) is amended by adding at the end the 
following:
    ``(w) Protecting Consumer Access to Generic Drugs.--
            ``(1) Unfair and deceptive acts and practices related to 
        new drug applications.--
                    ``(A) Conduct prohibited.--It shall be unlawful for 
                any person to directly or indirectly be a party to any 
                agreement resolving or settling a patent infringement 
                claim in which--
                            ``(i) an ANDA filer receives anything of 
                        value; and
                            ``(ii) the ANDA filer agrees to limit or 
                        forego research, development, manufacturing, 
                        marketing, or sales, for any period of time, of 
                        the drug that is to be manufactured under the 
                        ANDA involved and is the subject of the patent 
                        infringement claim.
                    ``(B) Exceptions.--Notwithstanding subparagraph 
                (A)(i), subparagraph (A) does not prohibit a resolution 
                or settlement of a patent infringement claim in which 
                the value received by the ANDA filer includes no more 
                than--
                            ``(i) the right to market the drug that is 
                        to be manufactured under the ANDA involved and 
                        is the subject of the patent infringement 
                        claim, before the expiration of--
                                    ``(I) the patent that is the basis 
                                for the patent infringement claim; or
                                    ``(II) any other statutory 
                                exclusivity that would prevent the 
                                marketing of such drug; and
                            ``(ii) the waiver of a patent infringement 
                        claim for damages based on prior marketing of 
                        such drug.
                    ``(C) Enforcement.--
                            ``(i) In general.--A violation of 
                        subparagraph (A) shall be treated as an unfair 
                        and deceptive act or practice and an unfair 
                        method of competition in or affecting 
                        interstate commerce prohibited under section 5 
                        of the Federal Trade Commission Act and shall 
                        be enforced by the Federal Trade Commission in 
                        the same manner, by the same means, and with 
                        the same jurisdiction as though all applicable 
                        terms and provisions of the Federal Trade 
                        Commission Act were incorporated into and made 
                        a part of this subsection.
                            ``(ii) Inapplicability.--Subchapter A of 
                        chapter VII shall not apply with respect to 
                        this subsection.
                    ``(D) Definitions.--In this subsection:
                            ``(i) Agreement.--The term `agreement' 
                        means anything that would constitute an 
                        agreement under section 5 of the Federal Trade 
                        Commission Act.
                            ``(ii) Agreement resolving or settling.--
                        The term `agreement resolving or settling', in 
                        reference to a patent infringement claim, 
                        includes any agreement that is contingent upon, 
                        provides a contingent condition for, or is 
                        otherwise related to the resolution or 
                        settlement of the claim.
                            ``(iii) ANDA.--The term `ANDA' means an 
                        abbreviated new drug application for the 
                        approval of a new drug under section (j).
                            ``(iv) ANDA filer.--The term `ANDA filer' 
                        means a party that has filed an ANDA with the 
                        Food and Drug Administration.
                            ``(v) Patent infringement.--The term 
                        `patent infringement' means infringement of any 
                        patent or of any filed patent application, 
                        extension, reissuance, renewal, division, 
                        continuation, continuation in part, 
                        reexamination, patent term restoration, patent 
                        of addition, or extension thereof.
                            ``(vi) Patent infringement claim.--The term 
                        `patent infringement claim' means any 
                        allegation made to an ANDA filer, whether or 
                        not included in a complaint filed with a court 
                        of law, that its ANDA or drug to be 
                        manufactured under such ANDA may infringe any 
                        patent.
            ``(2) FTC rulemaking.--The Federal Trade Commission may, by 
        rule promulgated under section 553 of title 5, United States 
        Code, exempt certain agreements described in paragraph (1) from 
        the requirements of this subsection if the Commission finds 
        such agreements to be in furtherance of market competition and 
        for the benefit of consumers. Consistent with the authority of 
        the Commission, such rules may include interpretive rules and 
        general statements of policy with respect to the practices 
        prohibited under paragraph (1).''.
    (c) Notice and Certification of Agreements.--
            (1) Notice of all agreements.--Section 1112(c)(2) of the 
        Medicare Prescription Drug, Improvement, and Modernization Act 
        of 2003 (21 U.S.C. 3155 note) is amended by--
                    (A) striking ``the Commission the'' and inserting 
                the following: ``the Commission--
                    ``(A) the'';
                    (B) striking the period at the end and inserting 
                ``; and''; and
                    (C) adding at the end the following:
                    ``(B) any other agreement the parties enter into 
                within 30 days of entering into an agreement covered by 
                subsection (a) or (b).''.
            (2) Certification of agreements.--Section 1112 of such Act 
        is amended by adding at the end the following:
    ``(d) Certification.--The chief executive officer or the company 
official responsible for negotiating any agreement required to be filed 
under subsection (a), (b), or (c) shall execute and file with the 
Assistant Attorney General and the Commission a certification as 
follows: `I declare under penalty of perjury that the following is true 
and correct: The materials filed with the Federal Trade Commission and 
the Department of Justice under section 1112 of subtitle B of title XI 
of the Medicare Prescription Drug, Improvement, and Modernization Act 
of 2003, with respect to the agreement referenced in this 
certification: (1) represent the complete, final, and exclusive 
agreement between the parties; (2) include any ancillary agreements 
that are contingent upon, provide a contingent condition for, or are 
otherwise related to, the referenced agreement; and (3) include written 
descriptions of any oral agreements, representations, commitments, or 
promises between the parties that are responsive to subsection (a) or 
(b) of such section 1112 and have not been reduced to writing.'.''.
    (d) GAO Study.--
            (1) Study.--Beginning 2 years after the date of enactment 
        of this Act, and each year for a period of 4 years thereafter, 
        the Comptroller General shall conduct a study on the litigation 
        in United States courts during the period beginning 5 years 
        prior to the date of enactment of this Act relating to patent 
        infringement claims involving generic drugs, the number of 
        patent challenges initiated by manufacturers of generic drugs, 
        and the number of settlements of such litigation. The 
        Comptroller General shall transmit to Congress a report of the 
        findings of such a study and an analysis of the effect of the 
        amendments made by subsections (b) and (c) on such litigation, 
        whether such amendments have had an effect on the number and 
        frequency of claims settled, and whether such amendments 
        resulted in earlier or delayed entry of generic drugs to 
        market, including whether any harm or benefit to consumers has 
        resulted.
            (2) Disclosure of agreements.--Notwithstanding any other 
        law, agreements filed under section 1112 of the Medicare 
        Prescription Drug, Improvement, and Modernization Act of 2003 
        (21 U.S.C. 355 note), or unaggregated information from such 
        agreements, shall be disclosed to the Comptroller General for 
        purposes of the study under paragraph (1) within 30 days of a 
        request by the Comptroller General.

                          PART 2--BIOSIMILARS

SEC. 2575. LICENSURE PATHWAY FOR BIOSIMILAR BIOLOGICAL PRODUCTS.

    (a) Licensure of Biological Products as Biosimilar or 
Interchangeable.--Section 351 of the Public Health Service Act (42 
U.S.C. 262) is amended--
            (1) in subsection (a)(1)(A), by inserting ``under this 
        subsection or subsection (k)'' after ``biologics license''; and
            (2) by adding at the end the following:
    ``(k) Licensure of Biological Products as Biosimilar or 
Interchangeable.--
            ``(1) In general.--Any person may submit an application for 
        licensure of a biological product under this subsection.
            ``(2) Content.--
                    ``(A) In general.--
                            ``(i) Required information.--An application 
                        submitted under this subsection shall include 
                        information demonstrating that--
                                    ``(I) the biological product is 
                                biosimilar to a reference product based 
                                upon data derived from--
                                            ``(aa) analytical studies 
                                        that demonstrate that the 
                                        biological product is highly 
                                        similar to the reference 
                                        product notwithstanding minor 
                                        differences in clinically 
                                        inactive components;
                                            ``(bb) animal studies 
                                        (including the assessment of 
                                        toxicity); and
                                            ``(cc) a clinical study or 
                                        studies (including the 
                                        assessment of immunogenicity 
                                        and pharmacokinetics or 
                                        pharmacodynamics) that are 
                                        sufficient to demonstrate 
                                        safety, purity, and potency in 
                                        1 or more appropriate 
                                        conditions of use for which the 
                                        reference product is licensed 
                                        and intended to be used and for 
                                        which licensure is sought for 
                                        the biological product;
                                    ``(II) the biological product and 
                                reference product utilize the same 
                                mechanism or mechanisms of action for 
                                the condition or conditions of use 
                                prescribed, recommended, or suggested 
                                in the proposed labeling, but only to 
                                the extent the mechanism or mechanisms 
                                of action are known for the reference 
                                product;
                                    ``(III) the condition or conditions 
                                of use prescribed, recommended, or 
                                suggested in the labeling proposed for 
                                the biological product have been 
                                previously approved for the reference 
                                product;
                                    ``(IV) the route of administration, 
                                the dosage form, and the strength of 
                                the biological product are the same as 
                                those of the reference product; and
                                    ``(V) the facility in which the 
                                biological product is manufactured, 
                                processed, packed, or held meets 
                                standards designed to assure that the 
                                biological product continues to be 
                                safe, pure, and potent.
                            ``(ii) Determination by secretary.--The 
                        Secretary may determine, in the Secretary's 
                        discretion, that an element described in clause 
                        (i)(I) is unnecessary in an application 
                        submitted under this subsection.
                            ``(iii) Additional information.--An 
                        application submitted under this subsection--
                                    ``(I) shall include publicly 
                                available information regarding the 
                                Secretary's previous determination that 
                                the reference product is safe, pure, 
                                and potent; and
                                    ``(II) may include any additional 
                                information in support of the 
                                application, including publicly 
                                available information with respect to 
                                the reference product or another 
                                biological product.
                    ``(B) Interchangeability.--An application (or a 
                supplement to an application) submitted under this 
                subsection may include information demonstrating that 
                the biological product meets the standards described in 
                paragraph (4).
            ``(3) Evaluation by secretary.--Upon review of an 
        application (or a supplement to an application) submitted under 
        this subsection, the Secretary shall license the biological 
        product under this subsection if--
                    ``(A) the Secretary determines that the information 
                submitted in the application (or the supplement) is 
                sufficient to show that the biological product--
                            ``(i) is biosimilar to the reference 
                        product; or
                            ``(ii) meets the standards described in 
                        paragraph (4), and therefore is interchangeable 
                        with the reference product; and
                    ``(B) the applicant (or other appropriate person) 
                consents to the inspection of the facility that is the 
                subject of the application, in accordance with 
                subsection (c).
            ``(4) Safety standards for determining 
        interchangeability.--Upon review of an application submitted 
        under this subsection or any supplement to such application, 
        the Secretary shall determine the biological product to be 
        interchangeable with the reference product if the Secretary 
        determines that the information submitted in the application 
        (or a supplement to such application) is sufficient to show 
        that--
                    ``(A) the biological product--
                            ``(i) is biosimilar to the reference 
                        product; and
                            ``(ii) can be expected to produce the same 
                        clinical result as the reference product in any 
                        given patient; and
                    ``(B) for a biological product that is administered 
                more than once to an individual, the risk in terms of 
                safety or diminished efficacy of alternating or 
                switching between use of the biological product and the 
                reference product is not greater than the risk of using 
                the reference product without such alternation or 
                switch.
            ``(5) General rules.--
                    ``(A) One reference product per application.--A 
                biological product, in an application submitted under 
                this subsection, may not be evaluated against more than 
                1 reference product.
                    ``(B) Review.--An application submitted under this 
                subsection shall be reviewed by the division within the 
                Food and Drug Administration that is responsible for 
                the review and approval of the application under which 
                the reference product is licensed.
                    ``(C) Risk evaluation and mitigation strategies.--
                The authority of the Secretary with respect to risk 
                evaluation and mitigation strategies under the Federal 
                Food, Drug, and Cosmetic Act shall apply to biological 
                products licensed under this subsection in the same 
                manner as such authority applies to biological products 
                licensed under subsection (a).
                    ``(D) Restrictions on biological products 
                containing dangerous ingredients.--If information in an 
                application submitted under this subsection, in a 
                supplement to such an application, or otherwise 
                available to the Secretary shows that a biological 
                product--
                            ``(i) is, bears, or contains a select agent 
                        or toxin listed in section 73.3 or 73.4 of 
                        title 42, section 121.3 or 121.4 of title 9, or 
                        section 331.3 of title 7, Code of Federal 
                        Regulations (or any successor regulations); or
                            ``(ii) is, bears, or contains a controlled 
                        substance in schedule I or II of section 202 of 
                        the Controlled Substances Act, as listed in 
                        part 1308 of title 21, Code of Federal 
                        Regulations (or any successor regulations);
                the Secretary shall not license the biological product 
                under this subsection unless the Secretary determines, 
                after consultation with appropriate national security 
                and drug enforcement agencies, that there would be no 
                increased risk to the security or health of the public 
                from licensing such biological product under this 
                subsection.
            ``(6) Exclusivity for first interchangeable biological 
        product.--Upon review of an application submitted under this 
        subsection relying on the same reference product for which a 
        prior biological product has received a determination of 
        interchangeability for any condition of use, the Secretary 
        shall not make a determination under paragraph (4) that the 
        second or subsequent biological product is interchangeable for 
        any condition of use until the earlier of--
                    ``(A) 1 year after the first commercial marketing 
                of the first interchangeable biosimilar biological 
                product to be approved as interchangeable for that 
                reference product;
                    ``(B) 18 months after--
                            ``(i) a final court decision on all patents 
                        in suit in an action instituted under 
                        subsection (l)(5) against the applicant that 
                        submitted the application for the first 
                        approved interchangeable biosimilar biological 
                        product; or
                            ``(ii) the dismissal with or without 
                        prejudice of an action instituted under 
                        subsection (l)(5) against the applicant that 
                        submitted the application for the first 
                        approved interchangeable biosimilar biological 
                        product; or
                    ``(C)(i) 42 months after approval of the first 
                interchangeable biosimilar biological product if the 
                applicant that submitted such application has been sued 
                under subsection (l)(5) and such litigation is still 
                ongoing within such 42-month period; or
                    ``(ii) 18 months after approval of the first 
                interchangeable biosimilar biological product if the 
                applicant that submitted such application has not been 
                sued under subsection (l)(5).
        For purposes of this paragraph, the term `final court decision' 
        means a final decision of a court from which no appeal (other 
        than a petition to the United States Supreme Court for a writ 
        of certiorari) has been or can be taken.
            ``(7) Exclusivity for reference product.--
                    ``(A) Effective date of biosimilar application 
                approval.--Approval of an application under this 
                subsection may not be made effective by the Secretary 
                until the date that is 12 years after the date on which 
                the reference product was first licensed under 
                subsection (a).
                    ``(B) Filing period.--An application under this 
                subsection may not be submitted to the Secretary until 
                the date that is 4 years after the date on which the 
                reference product was first licensed under subsection 
                (a).
                    ``(C) First licensure.--Subparagraphs (A) and (B) 
                shall not apply to a license for or approval of--
                            ``(i) a supplement for the biological 
                        product that is the reference product; or
                            ``(ii) a subsequent application filed by 
                        the same sponsor or manufacturer of the 
                        biological product that is the reference 
                        product (or a licensor, predecessor in 
                        interest, or other related entity) for--
                                    ``(I) a change (not including a 
                                modification to the structure of the 
                                biological product) that results in a 
                                new indication, route of 
                                administration, dosing schedule, dosage 
                                form, delivery system, delivery device, 
                                or strength; or
                                    ``(II) a modification to the 
                                structure of the biological product 
                                that does not result in a change in 
                                safety, purity, or potency.
            ``(8) Pediatric studies.--
                    ``(A) Exclusivity.--If, before or after licensure 
                of the reference product under subsection (a) of this 
                section, the Secretary determines that information 
                relating to the use of such product in the pediatric 
                population may produce health benefits in that 
                population, the Secretary makes a written request for 
                pediatric studies (which shall include a timeframe for 
                completing such studies), the applicant or holder of 
                the approved application agrees to the request, such 
                studies are completed using appropriate formulations 
                for each age group for which the study is requested 
                within any such timeframe, and the reports thereof are 
                submitted and accepted in accordance with section 
                505A(d)(3) of the Federal Food, Drug, and Cosmetic Act 
                the period referred to in paragraph (7)(A) of this 
                subsection is deemed to be 12 years and 6 months rather 
                than 12 years.
                    ``(B) Exception.--The Secretary shall not extend 
                the period referred to in subparagraph (A) of this 
                paragraph if the determination under section 505A(d)(3) 
                of the Federal Food, Drug, and Cosmetic Act is made 
                later than 9 months prior to the expiration of such 
                period.
                    ``(C) Application of certain provisions.--The 
                provisions of subsections (a), (d), (e), (f), (h), (j), 
                (k), and (l) of section 505A of the Federal Food, Drug, 
                and Cosmetic Act shall apply with respect to the 
                extension of a period under subparagraph (A) of this 
                paragraph to the same extent and in the same manner as 
                such provisions apply with respect to the extension of 
                a period under subsection (b) or (c) of section 505A of 
                the Federal Food, Drug, and Cosmetic Act.
            ``(9) Guidance documents.--
                    ``(A) In general.--The Secretary may, after 
                opportunity for public comment, issue guidance in 
                accordance, except as provided in subparagraph (B)(i), 
                with section 701(h) of the Federal Food, Drug, and 
                Cosmetic Act with respect to the licensure of a 
                biological product under this subsection. Any such 
                guidance may be general or specific.
                    ``(B) Public comment.--
                            ``(i) In general.--The Secretary shall 
                        provide the public an opportunity to comment on 
                        any proposed guidance issued under subparagraph 
                        (A) before issuing final guidance.
                            ``(ii) Input regarding most valuable 
                        guidance.--The Secretary shall establish a 
                        process through which the public may provide 
                        the Secretary with input regarding priorities 
                        for issuing guidance.
                    ``(C) No requirement for application 
                consideration.--The issuance (or non-issuance) of 
                guidance under subparagraph (A) shall not preclude the 
                review of, or action on, an application submitted under 
                this subsection.
                    ``(D) Requirement for product class-specific 
                guidance.--If the Secretary issues product class-
                specific guidance under subparagraph (A), such guidance 
                shall include a description of--
                            ``(i) the criteria that the Secretary will 
                        use to determine whether a biological product 
                        is highly similar to a reference product in 
                        such product class; and
                            ``(ii) the criteria, if available, that the 
                        Secretary will use to determine whether a 
                        biological product meets the standards 
                        described in paragraph (4).
                    ``(E) Certain product classes.--
                            ``(i) Guidance.--The Secretary may indicate 
                        in a guidance document that the science and 
                        experience, as of the date of such guidance, 
                        with respect to a product or product class (not 
                        including any recombinant protein) does not 
                        allow approval of an application for a license 
                        as provided under this subsection for such 
                        product or product class.
                            ``(ii) Modification or reversal.--The 
                        Secretary may issue a subsequent guidance 
                        document under subparagraph (A) to modify or 
                        reverse a guidance document under clause (i).
                            ``(iii) No effect on ability to deny 
                        license.--Clause (i) shall not be construed to 
                        require the Secretary to approve a product with 
                        respect to which the Secretary has not 
                        indicated in a guidance document that the 
                        science and experience, as described in clause 
                        (i), does not allow approval of such an 
                        application.
            ``(10) Naming.--The Secretary shall ensure that the 
        labeling and packaging of each biological product licensed 
        under this subsection bears a name that uniquely identifies the 
        biological product and distinguishes it from the reference 
        product and any other biological products licensed under this 
        subsection following evaluation against such reference product.
    ``(l) Patent Notices; Relationship to Final Approval.--
            ``(1) Definitions.--For the purposes of this subsection, 
        the term--
                    ``(A) `biosimilar product' means the biological 
                product that is the subject of the application under 
                subsection (k);
                    ``(B) `relevant patent' means a patent that--
                            ``(i) expires after the date specified in 
                        subsection (k)(7)(A) that applies to the 
                        reference product; and
                            ``(ii) could reasonably be asserted against 
                        the applicant due to the unauthorized making, 
                        use, sale, or offer for sale within the United 
                        States, or the importation into the United 
                        States of the biosimilar product, or materials 
                        used in the manufacture of the biosimilar 
                        product, or due to a use of the biosimilar 
                        product in a method of treatment that is 
                        indicated in the application;
                    ``(C) `reference product sponsor' means the holder 
                of an approved application or license for the reference 
                product; and
                    ``(D) `interested third party' means a person other 
                than the reference product sponsor that owns a relevant 
                patent, or has the right to commence or participate in 
                an action for infringement of a relevant patent.
            ``(2) Handling of confidential information.--Any entity 
        receiving confidential information pursuant to this subsection 
        shall designate one or more individuals to receive such 
        information. Each individual so designated shall execute an 
        agreement in accordance with regulations promulgated by the 
        Secretary. The regulations shall require each such individual 
        to take reasonable steps to maintain the confidentiality of 
        information received pursuant to this subsection and use the 
        information solely for purposes authorized by this subsection. 
        The obligations imposed on an individual who has received 
        confidential information pursuant to this subsection shall 
        continue until the individual returns or destroys the 
        confidential information, a court imposes a protective order 
        that governs the use or handling of the confidential 
        information, or the party providing the confidential 
        information agrees to other terms or conditions regarding the 
        handling or use of the confidential information.
            ``(3) Public notice by secretary.--Within 30 days of 
        acceptance by the Secretary of an application filed under 
        subsection (k), the Secretary shall publish a notice 
        identifying--
                    ``(A) the reference product identified in the 
                application; and
                    ``(B) the name and address of an agent designated 
                by the applicant to receive notices pursuant to 
                paragraph (4)(B).
            ``(4) Exchanges concerning patents.--
                    ``(A) Exchanges with reference product sponsor.--
                            ``(i) Within 30 days of the date of 
                        acceptance of the application by the Secretary, 
                        the applicant shall provide the reference 
                        product sponsor with a copy of the application 
                        and information concerning the biosimilar 
                        product and its production. This information 
                        shall include a detailed description of the 
                        biosimilar product, its method of manufacture, 
                        and the materials used in the manufacture of 
                        the product.
                            ``(ii) Within 60 days of the date of 
                        receipt of the information required to be 
                        provided under clause (i), the reference 
                        product sponsor shall provide to the applicant 
                        a list of relevant patents owned by the 
                        reference product sponsor, or in respect of 
                        which the reference product sponsor has the 
                        right to commence an action of infringement or 
                        otherwise has an interest in the patent as such 
                        patent concerns the biosimilar product.
                            ``(iii) If the reference product sponsor is 
                        issued or acquires an interest in a relevant 
                        patent after the date on which the reference 
                        product sponsor provides the list required by 
                        clause (ii) to the applicant, the reference 
                        product sponsor shall identify that patent to 
                        the applicant within 30 days of the date of 
                        issue of the patent, or the date of acquisition 
                        of the interest in the patent, as applicable.
                    ``(B) Exchanges with interested third parties.--
                            ``(i) At any time after the date on which 
                        the Secretary publishes a notice for an 
                        application under paragraph (3), any interested 
                        third party may provide notice to the 
                        designated agent of the applicant that the 
                        interested third party owns or has rights under 
                        1 or more patents that may be relevant patents. 
                        The notice shall identify at least 1 patent and 
                        shall designate an individual who has executed 
                        an agreement in accordance with paragraph (2) 
                        to receive confidential information from the 
                        applicant.
                            ``(ii) Within 30 days of the date of 
                        receiving notice pursuant to clause (i), the 
                        applicant shall send to the individual 
                        designated by the interested third party the 
                        information specified in subparagraph (A)(i), 
                        unless the applicant and interested third party 
                        otherwise agree.
                            ``(iii) Within 90 days of the date of 
                        receiving information pursuant to clause (ii), 
                        the interested third party shall provide to the 
                        applicant a list of relevant patents which the 
                        interested third party owns, or in respect of 
                        which the interested third party has the right 
                        to commence or participate in an action for 
                        infringement.
                            ``(iv) If the interested third party is 
                        issued or acquires an interest in a relevant 
                        patent after the date on which the interested 
                        third party provides the list required by 
                        clause (iii), the interested third party shall 
                        identify that patent within 30 days of the date 
                        of issue of the patent, or the date of 
                        acquisition of the interest in the patent, as 
                        applicable.
                    ``(C) Identification of basis for infringement.--
                For any patent identified under clause (ii) or (iii) of 
                subparagraph (A) or under clause (iii) or (iv) of 
                subparagraph (B), the reference product sponsor or the 
                interested third party, as applicable--
                            ``(i) shall explain in writing why the 
                        sponsor or the interested third party believes 
                        the relevant patent would be infringed by the 
                        making, use, sale, or offer for sale within the 
                        United States, or importation into the United 
                        States, of the biosimilar product or by a use 
                        of the biosimilar product in treatment that is 
                        indicated in the application;
                            ``(ii) may specify whether the relevant 
                        patent is available for licensing; and
                            ``(iii) shall specify the number and date 
                        of expiration of the relevant patent.
                    ``(D) Certification by applicant concerning 
                identified relevant patents.--Not later than 45 days 
                after the date on which a patent is identified under 
                clause (ii) or (iii) of subparagraph (A) or under 
                clause (iii) or (iv) of subparagraph (B), the applicant 
                shall send a written statement regarding each 
                identified patent to the party that identified the 
                patent. Such statement shall either--
                            ``(i) state that the applicant will not 
                        commence marketing of the biosimilar product 
                        and has requested the Secretary to not grant 
                        final approval of the application before the 
                        date of expiration of the noticed patent; or
                            ``(ii) provide a detailed written 
                        explanation setting forth the reasons why the 
                        applicant believes--
                                    ``(I) the making, use, sale, or 
                                offer for sale within the United 
                                States, or the importation into the 
                                United States, of the biosimilar 
                                product, or the use of the biosimilar 
                                product in a treatment indicated in the 
                                application, would not infringe the 
                                patent; or
                                    ``(II) the patent is invalid or 
                                unenforceable.
            ``(5) Action for infringement involving reference product 
        sponsor.--If an action for infringement concerning a relevant 
        patent identified by the reference product sponsor under clause 
        (ii) or (iii) of paragraph (4)(A), or by an interested third 
        party under clause (iii) or (iv) of paragraph (4)(B), is 
        brought within 60 days of the date of receipt of a statement 
        under paragraph (4)(D)(ii), and the court in which such action 
        has been commenced determines the patent is infringed prior to 
        the date applicable under subsection (k)(7)(A) or (k)(8), the 
        Secretary shall make approval of the application effective on 
        the day after the date of expiration of the patent that has 
        been found to be infringed. If more than one such patent is 
        found to be infringed by the court, the approval of the 
        application shall be made effective on the day after the date 
        that the last such patent expires.
            ``(6) Notification of agreements.--
                    ``(A) Requirements.--
                            ``(i) Agreement between biosimilar product 
                        applicant and reference product sponsor.--If a 
                        biosimilar product applicant under subsection 
                        (k) and the reference product sponsor enter 
                        into an agreement described in subparagraph 
                        (B), the applicant and sponsor shall each file 
                        the agreement in accordance with subparagraph 
                        (C).
                            ``(ii) Agreement between biosimilar product 
                        applicants.--If 2 or more biosimilar product 
                        applicants submit an application under 
                        subsection (k) for biosimilar products with the 
                        same reference product and enter into an 
                        agreement described in subparagraph (B), the 
                        applicants shall each file the agreement in 
                        accordance with subparagraph (C).
                    ``(B) Subject matter of agreement.--An agreement 
                described in this subparagraph--
                            ``(i) is an agreement between the 
                        biosimilar product applicant under subsection 
                        (k) and the reference product sponsor or 
                        between 2 or more biosimilar product applicants 
                        under subsection (k) regarding the manufacture, 
                        marketing, or sale of--
                                    ``(I) the biosimilar product (or 
                                biosimilar products) for which an 
                                application was submitted; or
                                    ``(II) the reference product;
                            ``(ii) includes any agreement between the 
                        biosimilar product applicant under subsection 
                        (k) and the reference product sponsor or 
                        between 2 or more biosimilar product applicants 
                        under subsection (k) that is contingent upon, 
                        provides a contingent condition for, or 
                        otherwise relates to an agreement described in 
                        clause (i); and
                            ``(iii) excludes any agreement that solely 
                        concerns--
                                    ``(I) purchase orders for raw 
                                material supplies;
                                    ``(II) equipment and facility 
                                contracts;
                                    ``(III) employment or consulting 
                                contracts; or
                                    ``(IV) packaging and labeling 
                                contracts.
                    ``(C) Filing.--
                            ``(i) In general.--The text of an agreement 
                        required to be filed by subparagraph (A) shall 
                        be filed with the Assistant Attorney General 
                        and the Federal Trade Commission not later 
                        than--
                                    ``(I) 10 business days after the 
                                date on which the agreement is 
                                executed; and
                                    ``(II) prior to the date of the 
                                first commercial marketing of, for 
                                agreements described in subparagraph 
                                (A)(i), the biosimilar product that is 
                                the subject of the application or, for 
                                agreements described in subparagraph 
                                (A)(ii), any biosimilar product that is 
                                the subject of an application described 
                                in such subparagraph.
                            ``(ii) If agreement not reduced to text.--
                        If an agreement required to be filed by 
                        subparagraph (A) has not been reduced to text, 
                        the persons required to file the agreement 
                        shall each file written descriptions of the 
                        agreement that are sufficient to disclose all 
                        the terms and conditions of the agreement.
                            ``(iii) Certification.--The chief executive 
                        officer or the company official responsible for 
                        negotiating any agreement required to be filed 
                        by subparagraph (A) shall include in any filing 
                        under this paragraph a certification as 
                        follows: `I declare under penalty of perjury 
                        that the following is true and correct: The 
                        materials filed with the Federal Trade 
                        Commission and the Department of Justice under 
                        section 351(l)(6) of the Public Health Service 
                        Act, with respect to the agreement referenced 
                        in this certification: (1) represent the 
                        complete, final, and exclusive agreement 
                        between the parties; (2) include any ancillary 
                        agreements that are contingent upon, provide a 
                        contingent condition for, or are otherwise 
                        related to, the referenced agreement; and (3) 
                        include written descriptions of any oral 
                        agreements, representations, commitments, or 
                        promises between the parties that are 
                        responsive to such section and have not been 
                        reduced to writing.'.
                    ``(D) Disclosure exemption.--Any information or 
                documentary material filed with the Assistant Attorney 
                General or the Federal Trade Commission pursuant to 
                this paragraph shall be exempt from disclosure under 
                section 552 of title 5, United States Code, and no such 
                information or documentary material may be made public, 
                except as may be relevant to any administrative or 
                judicial action or proceeding. Nothing in this 
                subparagraph prevents disclosure of information or 
                documentary material to either body of the Congress or 
                to any duly authorized committee or subcommittee of the 
                Congress.
                    ``(E) Enforcement.--
                            ``(i) Civil penalty.--Any person that 
                        violates a provision of this paragraph shall be 
                        liable for a civil penalty of not more than 
                        $11,000 for each day on which the violation 
                        occurs. Such penalty may be recovered in a 
                        civil action--
                                    ``(I) brought by the United States; 
                                or
                                    ``(II) brought by the Federal Trade 
                                Commission in accordance with the 
                                procedures established in section 
                                16(a)(1) of the Federal Trade 
                                Commission Act.
                            ``(ii) Compliance and equitable relief.--If 
                        any person violates any provision of this 
                        paragraph, the United States district court may 
                        order compliance, and may grant such other 
                        equitable relief as the court in its discretion 
                        determines necessary or appropriate, upon 
                        application of the Assistant Attorney General 
                        or the Federal Trade Commission.
                    ``(F) Rulemaking.--The Federal Trade Commission, 
                with the concurrence of the Assistant Attorney General 
                and by rule in accordance with section 553 of title 5, 
                United States Code, consistent with the purposes of 
                this paragraph--
                            ``(i) may define the terms used in this 
                        paragraph;
                            ``(ii) may exempt classes of persons or 
                        agreements from the requirements of this 
                        paragraph; and
                            ``(iii) may prescribe such other rules as 
                        may be necessary and appropriate to carry out 
                        the purposes of this paragraph.
                    ``(G) Savings clause.--Any action taken by the 
                Assistant Attorney General or the Federal Trade 
                Commission, or any failure of the Assistant Attorney 
                General or the Commission to take action, under this 
                paragraph shall not at any time bar any proceeding or 
                any action with respect to any agreement between a 
                biosimilar product applicant under subsection (k) and 
                the reference product sponsor, or any agreement between 
                biosimilar product applicants under subsection (k), 
                under any other provision of law, nor shall any filing 
                under this paragraph constitute or create a presumption 
                of any violation of any competition laws.''.
    (b) Definitions.--Section 351(i) of the Public Health Service Act 
(42 U.S.C. 262(i)) is amended--
            (1) by striking ``In this section, the term `biological 
        product' means'' and inserting the following: ``In this 
        section:
            ``(1) The term `biological product' means'';
            (2) in paragraph (1), as so designated, by inserting 
        ``protein (except any chemically synthesized polypeptide),'' 
        after ``allergenic product,''; and
            (3) by adding at the end the following:
            ``(2) The term `biosimilar' or `biosimilarity', in 
        reference to a biological product that is the subject of an 
        application under subsection (k), means--
                    ``(A) that the biological product is highly similar 
                to the reference product notwithstanding minor 
                differences in clinically inactive components; and
                    ``(B) there are no clinically meaningful 
                differences between the biological product and the 
                reference product in terms of the safety, purity, and 
                potency of the product.
            ``(3) The term `interchangeable' or `interchangeability', 
        in reference to a biological product that is shown to meet the 
        standards described in subsection (k)(4), means that the 
        biological product may be substituted for the reference product 
        without the intervention of the health care provider who 
        prescribed the reference product.
            ``(4) The term `reference product' means the single 
        biological product licensed under subsection (a) against which 
        a biological product is evaluated in an application submitted 
        under subsection (k).''.
    (c) Products Previously Approved Under Section 505.--
            (1) Requirement to follow section 351.--Except as provided 
        in paragraph (2), an application for a biological product shall 
        be submitted under section 351 of the Public Health Service Act 
        (42 U.S.C. 262) (as amended by this Act).
            (2) Exception.--An application for a biological product may 
        be submitted under section 505 of the Federal Food, Drug, and 
        Cosmetic Act (21 U.S.C. 355) if--
                    (A) such biological product is in a product class 
                for which a biological product in such product class is 
                the subject of an application approved under such 
                section 505 not later than the date of enactment of 
                this Act; and
                    (B) such application--
                            (i) has been submitted to the Secretary of 
                        Health and Human Services (referred to in this 
                        Act as the ``Secretary'') before the date of 
                        enactment of this Act; or
                            (ii) is submitted to the Secretary not 
                        later than the date that is 10 years after the 
                        date of enactment of this Act.
            (3) Limitation.--Notwithstanding paragraph (2), an 
        application for a biological product may not be submitted under 
        section 505 of the Federal Food, Drug, and Cosmetic Act (21 
        U.S.C. 355) if there is another biological product approved 
        under subsection (a) of section 351 of the Public Health 
        Service Act that could be a reference product with respect to 
        such application (within the meaning of such section 351) if 
        such application were submitted under subsection (k) of such 
        section 351.
            (4) Deemed approved under section 351.--An approved 
        application for a biological product under section 505 of the 
        Federal Food, Drug, and Cosmetic Act (21 U.S.C. 355) shall be 
        deemed to be a license for the biological product under such 
        section 351 on the date that is 10 years after the date of 
        enactment of this Act.
            (5) Definitions.--For purposes of this subsection, the term 
        ``biological product'' has the meaning given such term under 
        section 351 of the Public Health Service Act (42 U.S.C. 262) 
        (as amended by this Act).

SEC. 2576. FEES RELATING TO BIOSIMILAR BIOLOGICAL PRODUCTS.

    Subparagraph (B) of section 735(1) of the Federal Food, Drug, and 
Cosmetic Act (21 U.S.C. 379g(1)) is amended by inserting ``, including 
licensure of a biological product under section 351(k) of such Act'' 
before the period at the end.

SEC. 2577. AMENDMENTS TO CERTAIN PATENT PROVISIONS.

    (a) Section 271(e)(2) of title 35, United States Code is amended--
            (1) in subparagraph (A), by striking ``or'' after 
        ``patent,'';
            (2) in subparagraph (B), by adding ``or'' after the comma 
        at the end;
            (3) by inserting the following after subparagraph (B):
                    ``(C) a statement under section 351(l)(4)(D)(ii) of 
                the Public Health Service Act,''; and
            (4) in the matter following subparagraph (C) (as added by 
        paragraph (3)), by inserting before the period the following: 
        ``, or if the statement described in subparagraph (C) is 
        provided in connection with an application to obtain a license 
        to engage in the commercial manufacture, use, or sale of a 
        biological product claimed in a patent or the use of which is 
        claimed in a patent before the expiration of such patent''.
    (b) Section 271(e)(4) of title 35, United States Code, is amended 
by striking ``in paragraph (2)'' in both places it appears and 
inserting ``in paragraph (2)(A) or (2)(B)''.

     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).

    (a) Establishment of CLASS Program.--The Public Health Service Act 
(42 U.S.C. 201 et seq.), as amended by section 2301, is amended by 
adding at the end the following:

    ``TITLE XXXII--COMMUNITY LIVING ASSISTANCE SERVICES AND SUPPORTS

``SEC. 3201. PURPOSE.

    ``The purpose of this title is to establish a national voluntary 
insurance program for purchasing community living assistance services 
and supports in order to--
            ``(1) provide individuals with functional limitations with 
        tools that will allow them to maintain their personal and 
        financial independence and live in the community through a new 
        financing strategy for community living assistance services and 
        supports;
            ``(2) establish an infrastructure that will help address 
        the Nation's community living assistance services and supports 
        needs;
            ``(3) alleviate burdens on family caregivers; and
            ``(4) address institutional bias by providing a financing 
        mechanism that supports personal choice and independence to 
        live in the community.

``SEC. 3202. DEFINITIONS.

    ``In this title:
            ``(1) Active enrollee.--The term `active enrollee' means an 
        individual who is enrolled in the CLASS program in accordance 
        with section 3204 and who has paid any premiums due to maintain 
        such enrollment.
            ``(2) Actively employed.--The term `actively employed' 
        means an individual who--
                    ``(A) is reporting for work at the individual's 
                usual place of employment or at another location to 
                which the individual is required to travel because of 
                the individual's employment (or in the case of an 
                individual who is a member of the uniformed services, 
                is on active duty and is physically able to perform the 
                duties of the individual's position); and
                    ``(B) is able to perform all the usual and 
                customary duties of the individual's employment on the 
                individual's regular work schedule.
            ``(3) Activities of daily living.--The term `activities of 
        daily living' has the meaning given the term in section 
        7702B(c)(2)(B) of the Internal Revenue Code of 1986.
            ``(4) CLASS program.--The term `CLASS program' means the 
        program established under this title.
            ``(5) Eligibility assessment system.--The term `Eligibility 
        Assessment System' means the entity designated by the Secretary 
        under section 3205(a)(2)(A)(i).
            ``(6) Eligible beneficiary.--
                    ``(A) In general.--The term `eligible beneficiary' 
                means any individual who is an active enrollee in the 
                CLASS program and, as of the date described in 
                subparagraph (B)--
                            ``(i) has paid premiums for enrollment in 
                        such program for at least 60 months;
                            ``(ii) has earned, for each calendar year 
                        that occurs during the first 60 months for 
                        which the individual has paid premiums for 
                        enrollment in the program, at least an amount 
                        equal to the amount of wages and self-
                        employment income which an individual must have 
                        in order to be credited with a quarter of 
                        coverage under section 213(d) of the Social 
                        Security Act for that year; and
                            ``(iii) has paid premiums for enrollment in 
                        such program for at least 24 consecutive 
                        months, if a lapse in premium payments of more 
                        than 3 months has occurred during the period 
                        that begins on the date of the individual's 
                        enrollment and ends on the date of such 
                        determination.
                    ``(B) Date described.--For purposes of subparagraph 
                (A), the date described in this subparagraph is the 
                date on which the individual is determined to have a 
                functional limitation described in section 
                3203(a)(1)(C) that is expected to last for a continuous 
                period of more than 90 days.
                    ``(C) Regulations.--The Secretary shall promulgate 
                regulations specifying exceptions to the minimum 
                earnings requirements under subparagraph (A)(ii) for 
                purposes of being considered an eligible beneficiary 
                for certain populations.
            ``(7) Hospital; nursing facility; intermediate care 
        facility for the mentally retarded; institution for mental 
        diseases.--The terms `hospital', `nursing facility', 
        `intermediate care facility for the mentally retarded', and 
        `institution for mental diseases' have the meanings given such 
        terms for purposes of Medicaid.
            ``(8) CLASS independence advisory council.--The term `CLASS 
        Independence Advisory Council' or `Council' means the Advisory 
        Council established under section 3207 to advise the Secretary.
            ``(9) CLASS independence benefit plan.--The term `CLASS 
        Independence Benefit Plan' means the benefit plan developed and 
        designated by the Secretary in accordance with section 3203.
            ``(10) CLASS independence fund.--The term `CLASS 
        Independence Fund' or `Fund' means the fund established under 
        section 3206.
            ``(11) Medicaid.--The term `Medicaid' means the program 
        established under title XIX of the Social Security Act.
            ``(12) Protection and advocacy system.--The term 
        `Protection and Advocacy System' means the system for each 
        State established under section 143 of the Developmental 
        Disabilities Assistance and Bill of Rights Act of 2000.

``SEC. 3203. CLASS INDEPENDENCE BENEFIT PLAN.

    ``(a) Process for Development.--
            ``(1) In general.--The Secretary, in consultation with 
        appropriate actuaries and other experts, shall develop at least 
        3 actuarially sound benefit plans as alternatives for 
        consideration for designation by the Secretary as the CLASS 
        Independence Benefit Plan under which eligible beneficiaries 
        shall receive benefits under this title. Each of the plan 
        alternatives developed shall be designed to provide eligible 
        beneficiaries with the benefits described in section 3205 
        consistent with the following requirements:
                    ``(A) Premiums.--Beginning with the first year of 
                the CLASS program, and for each year thereafter, the 
                Secretary shall establish all premiums to be paid by 
                enrollees for the year based on an actuarial analysis 
                of the 75-year costs of the program that ensures 
                solvency throughout such 75-year period.
                    ``(B) Vesting period.--A 5-year vesting period for 
                eligibility for benefits.
                    ``(C) Benefit triggers.--A benefit trigger for 
                provision of benefits that requires a determination 
                that an individual has a functional limitation, as 
                certified by a licensed health care practitioner, 
                described in any of the following clauses that is 
                expected to last for a continuous period of more than 
                90 days:
                            ``(i) The individual is determined to be 
                        unable to perform at least the minimum number 
                        (which may be 2 or 3) of activities of daily 
                        living as are required under the plan for the 
                        provision of benefits without substantial 
                        assistance (as defined by the Secretary) from 
                        another individual.
                            ``(ii) The individual requires substantial 
                        supervision to protect the individual from 
                        threats to health and safety due to substantial 
                        cognitive impairment.
                            ``(iii) The individual has a level of 
                        functional limitation similar (as determined 
                        under regulations prescribed by the Secretary) 
                        to the level of functional limitation described 
                        in clause (i) or (ii).
                    ``(D) Cash benefit.--Payment of a cash benefit that 
                satisfies the following requirements:
                            ``(i) Minimum required amount.--The benefit 
                        amount provides an eligible beneficiary with 
                        not less than an average of $50 per day (as 
                        determined based on the reasonably expected 
                        distribution of beneficiaries receiving 
                        benefits at various benefit levels).
                            ``(ii) Amount scaled to functional 
                        ability.--The benefit amount is varied based on 
                        a scale of functional ability, with not less 
                        than 2, and not more than 6, benefit level 
                        amounts.
                            ``(iii) Daily or weekly.--The benefit is 
                        paid on a daily or weekly basis.
                            ``(iv) No lifetime or aggregate limit.--The 
                        benefit is not subject to any lifetime or 
                        aggregate limit.
            ``(2) Review and recommendation by the class independence 
        advisory council.--The CLASS Independence Advisory Council 
        shall--
                    ``(A) evaluate the alternative benefit plans 
                developed under paragraph (1); and
                    ``(B) recommend for designation as the CLASS 
                Independence Benefit Plan for offering to the public 
                the plan that the Council determines best balances 
                price and benefits to meet enrollees' needs in an 
                actuarially sound manner, while optimizing the 
                probability of the long-term sustainability of the 
                CLASS program.
            ``(3) Designation by the secretary.--Not later than October 
        1, 2012, the Secretary, taking into consideration the 
        recommendation of the CLASS Independence Advisory Council under 
        paragraph (2)(B), shall designate a benefit plan as the CLASS 
        Independence Benefit Plan. The Secretary shall publish such 
        designation, along with details of the plan and the reasons for 
        the selection by the Secretary, in a final rule that allows for 
        a period of public comment.
    ``(b) Additional Premium Requirements.--
            ``(1) Adjustment of premiums.--
                    ``(A) In general.--Except as provided in 
                subparagraphs (B), (C), (D), and (E), the amount of the 
                monthly premium determined for an individual upon such 
                individual's enrollment in the CLASS program shall 
                remain the same for as long as the individual is an 
                active enrollee in the program.
                    ``(B) Recalculated premium if required for program 
                solvency.--
                            ``(i) In general.--Subject to clause (ii), 
                        if the Secretary determines, based on the most 
                        recent report of the Board of Trustees of the 
                        CLASS Independence Fund, the advice of the 
                        CLASS Independence Advisory Council, and the 
                        annual report of the Inspector General of the 
                        Department of Health and Human Services, and 
                        waste, fraud, and abuse, or such other 
                        information as the Secretary determines 
                        appropriate, that the monthly premiums and 
                        income to the CLASS Independence Fund for a 
                        year are projected to be insufficient with 
                        respect to the 20-year period that begins with 
                        that year, the Secretary shall adjust the 
                        monthly premiums for individuals enrolled in 
                        the CLASS program as necessary.
                            ``(ii) Exemption from increase.--Any 
                        increase in a monthly premium imposed as result 
                        of a determination described in clause (i) 
                        shall not apply with respect to the monthly 
                        premium of any active enrollee who--
                                    ``(I) has attained age 65;
                                    ``(II) has paid premiums for 
                                enrollment in the program for at least 
                                20 years; and
                                    ``(III) is not actively employed.
                    ``(C) Recalculated premium if reenrollment after 
                more than a 3-month lapse.--
                            ``(i) In general.--The reenrollment of an 
                        individual after a 90-day period during which 
                        the individual failed to pay the monthly 
                        premium required to maintain the individual's 
                        enrollment in the CLASS program shall be 
                        treated as an initial enrollment for purposes 
                        of age-adjusting the premium for enrollment in 
                        the program.
                            ``(ii) Credit for prior months if 
                        reenrolled within 5 years.--An individual who 
                        reenrolls in the CLASS program after such a 90-
                        day period and before the end of the 5-year 
                        period that begins with the first month for 
                        which the individual failed to pay the monthly 
                        premium required to maintain the individual's 
                        enrollment in the program shall be--
                                    ``(I) credited with any months of 
                                paid premiums that accrued prior to the 
                                individual's lapse in enrollment; and
                                    ``(II) notwithstanding the total 
                                amount of any such credited months, 
                                required to satisfy section 
                                3202(6)(A)(ii) before being eligible to 
                                receive benefits.
                    ``(D) Penalty for reenrollment after 5-year 
                lapse.--In the case of an individual who reenrolls in 
                the CLASS program after the end of the 5-year period 
                described in subparagraph (C)(ii), the monthly premium 
                required for the individual shall be the age-adjusted 
                premium that would be applicable to an initially 
                enrolling individual who is the same age as the 
                reenrolling individual, increased by the greater of--
                            ``(i) an amount that the Secretary 
                        determines is actuarially sound for each month 
                        that occurs during the period that begins with 
                        the first month for which the individual failed 
                        to pay the monthly premium required to maintain 
                        the individual's enrollment in the CLASS 
                        program and ends with the month preceding the 
                        month in which the reenrollment is effective; 
                        or
                            ``(ii) 1 percent of the applicable age-
                        adjusted premium for each such month occurring 
                        in such period.
            ``(2) Administrative expenses.--In determining the monthly 
        premiums for the CLASS program, the Secretary may factor in 
        costs for administering the program, not to exceed--
                    ``(A) in the case of the first 5 years in which the 
                program is in effect under this title, an amount equal 
                to 3 percent of all premiums paid during each such 
                year; and
                    ``(B) in the case of subsequent years, an amount 
                equal to 5 percent of the total amount of all 
                expenditures (including benefits paid) under this title 
                with respect to that year.
            ``(3) No underwriting requirements.--No underwriting (other 
        than on the basis of age in accordance with paragraph (2)) 
        shall be used to--
                    ``(A) determine the monthly premium for enrollment 
                in the CLASS program; or
                    ``(B) prevent an individual from enrolling in the 
                program.

``SEC. 3204. ENROLLMENT AND DISENROLLMENT REQUIREMENTS.

    ``(a) Automatic Enrollment.--
            ``(1) In general.--Subject to paragraph (2), the Secretary 
        shall establish procedures under which each individual 
        described in subsection (c) shall be automatically enrolled in 
        the CLASS program by an employer of such individual under rules 
        similar to the rules of sections 401(k)(13) and 414(w) of the 
        Internal Revenue Code of 1986.
            ``(2) Alternative enrollment procedures.--The procedures 
        established under paragraph (1) shall provide for an 
        alternative enrollment process for an individual described in 
        subsection (c) in the case of such an individual--
                    ``(A) who is self-employed;
                    ``(B) who has more than 1 employer;
                    ``(C) whose employer does not elect to participate 
                in the automatic enrollment process established by the 
                Secretary; or
                    ``(D) who is a spouse described in subsection 
                (c)(2) of who is not subject to automatic enrollment.
            ``(3) Administration.--
                    ``(A) In general.--The Secretary shall, by 
                regulation, establish procedures to--
                            ``(i) ensure that an individual is not 
                        automatically enrolled in the CLASS program by 
                        more than 1 employer; and
                            ``(ii) allow for an individual's employer 
                        to deduct a premium for a spouse described in 
                        subsection (c)(1)(B) who is not subject to 
                        automatic enrollment.
                    ``(B) Form.--Enrollment in the CLASS program shall 
                be made in such manner as the Secretary may prescribe 
                in order to ensure ease of administration.
    ``(b) Election To Opt-Out.--An individual described in subsection 
(c) may elect to waive enrollment in the CLASS program at any time in 
such form and manner as the Secretary shall prescribe.
    ``(c) Individual Described.--For purposes of enrolling in the CLASS 
program, an individual described in this paragraph is--
            ``(1) an individual--
                    ``(A) who has attained age 18;
                    ``(B) who receives wages on which there is imposed 
                a tax under section 3101(a) or 3201(a) of the Internal 
                Revenue Code of 1986;
                    ``(C) who is actively employed; and
                    ``(D) who is not--
                            ``(i) a patient in a hospital or nursing 
                        facility, an intermediate care facility for the 
                        mentally retarded, or an institution for mental 
                        diseases and receiving medical assistance under 
                        Medicaid; or
                            ``(ii) confined in a jail, prison, other 
                        penal institution or correctional facility, or 
                        by court order pursuant to conviction of a 
                        criminal offense or in connection with a 
                        verdict or finding described in section 
                        202(x)(1)(A)(ii) of the Social Security Act; or
            ``(2) the spouse of an individual described in paragraph 
        (1) and who would be an individual so described but for 
        subparagraph (B) or (C) of that paragraph.
    ``(d) Rule of Construction.--Nothing in this title shall be 
construed as requiring an active enrollee to continue to satisfy 
subparagraph (B) or (C) of subsection (c)(1) in order to maintain 
enrollment in the CLASS program.
    ``(e) Payment.--
            ``(1) Payroll deduction.--An amount equal to the monthly 
        premium for the enrollment in the CLASS program of an 
        individual shall be deducted from the wages of such individual 
        in accordance with such procedures as the Secretary shall 
        establish for employers who elect to deduct and withhold such 
        premiums on behalf of enrolled employees.
            ``(2) Alternative payment mechanism.--The Secretary shall 
        establish alternative procedures for the payment of monthly 
        premiums by an individual enrolled in the CLASS program who 
        does not have an employer who elects to deduct and withhold 
        premiums in accordance with subparagraph (A).
    ``(f) Transfer of Premiums Collected.--
            ``(1) In general.--During each calendar year the Secretary 
        of the Treasury shall deposit into the CLASS Independence Fund 
        a total amount equal, in the aggregate, to 100 percent of the 
        premiums collected during that year.
            ``(2) Transfers based on estimates.--The amount deposited 
        pursuant to paragraph (1) shall be transferred in at least 
        monthly payments to the CLASS Independence Fund on the basis of 
        estimates by the Secretary and certified to the Secretary of 
        the Treasury of the amounts collected in accordance with this 
        section. Proper adjustments shall be made in amounts 
        subsequently transferred to the Fund to the extent prior 
        estimates were in excess of, or were less than, actual amounts 
        collected.
    ``(g) Other Enrollment and Disenrollment Opportunities.--The 
Secretary shall establish procedures under which--
            ``(1) an individual who, in the year of the individual's 
        initial eligibility to enroll in the CLASS program, has elected 
        to waive enrollment in the program, is eligible to elect to 
        enroll in the program, in such form and manner as the Secretary 
        shall establish, only during an open enrollment period 
        established by the Secretary that is specific to the individual 
        and that may not occur more frequently than biennially after 
        the date on which the individual first elected to waive 
        enrollment in the program; and
            ``(2) an individual shall only be permitted to disenroll 
        from the program during an annual disenrollment period 
        established by the Secretary and in such form and manner as the 
        Secretary shall establish.

``SEC. 3205. BENEFITS.

    ``(a) Determination of Eligibility.--
            ``(1) Application for receipt of benefits.--The Secretary 
        shall establish procedures under which an active enrollee shall 
        apply for receipt of benefits under the CLASS Independence 
        Benefit Plan.
            ``(2) Eligibility assessments.--
                    ``(A) In general.--Not later than January 1, 2012, 
                the Secretary shall--
                            ``(i) designate an entity (other than a 
                        service with which the Commissioner of Social 
                        Security has entered into an agreement, with 
                        respect to any State, to make disability 
                        determinations for purposes of title II or XVI 
                        of the Social Security Act) to serve as an 
                        Eligibility Assessment System by providing for 
                        eligibility assessments of active enrollees who 
                        apply for receipt of benefits;
                            ``(ii) enter into an agreement with the 
                        Protection and Advocacy System for each State 
                        to provide advocacy services in accordance with 
                        subsection (d); and
                            ``(iii) enter into an agreement with public 
                        and private entities to provide advice and 
                        assistance counseling in accordance with 
                        subsection (e).
                    ``(B) Regulations.--The Secretary shall promulgate 
                regulations to develop an expedited nationally 
                equitable eligibility determination process, as 
                certified by a licensed health care practitioner, an 
                appeals process, and a redetermination process, as 
                certified by a licensed health care practitioner, 
                including whether an applicant is eligible for a cash 
                benefit under the program and if so, the amount of the 
                cash benefit (in accordance the sliding scale 
                established under the plan).
                    ``(C) Presumptive eligibility for certain 
                institutionalized enrollees planning to discharge.--An 
                active enrollee shall be deemed presumptively eligible 
                if the enrollee--
                            ``(i) has applied for, and attests is 
                        eligible for, the maximum cash benefit 
                        available under the sliding scale established 
                        under the CLASS Independence Benefit Plan;
                            ``(ii) is a patient in a hospital (but only 
                        if the hospitalization is for long-term care), 
                        nursing facility, intermediate care facility 
                        for the mentally retarded, or an institution 
                        for mental diseases; and
                            ``(iii) is in the process of, or about to 
                        being the process of, planning to discharge 
                        from the hospital, facility, or institution, or 
                        within 60 days from the date of discharge from 
                        the hospital, facility, or institution.
                    ``(D) Appeals.--The Secretary shall establish 
                procedures under which an applicant for benefits under 
                the CLASS Independence Benefit Plan shall be guaranteed 
                the right to appeal an adverse determination.
    ``(b) Benefits.--An eligible beneficiary shall receive the 
following benefits under the CLASS Independence Benefit Plan:
            ``(1) Cash benefit.--A cash benefit established by the 
        Secretary in accordance with the requirements of section 
        3203(a)(1)(D) that--
                    ``(A) the first year in which beneficiaries receive 
                the benefits under the plan, is not less than the 
                average dollar amount specified in clause (i) of such 
                section; and
                    ``(B) for any subsequent year, is not less than the 
                average per day dollar limit applicable under this 
                subparagraph for the preceding year, increased by the 
                percentage increase in the consumer price index for all 
                urban consumers (U.S. city average) over the previous 
                year.
            ``(2) Advocacy services.--Advocacy services in accordance 
        with subsection (d).
            ``(3) Advice and assistance counseling.--Advice and 
        assistance counseling in accordance with subsection (e).
            ``(4) Administrative expenses.--Advocacy services and 
        advise and assistance counseling services under paragraphs (2) 
        and (3) of this subsection shall be included as administrative 
        expenses under section 3203(b)(2).
    ``(c) Payment of Benefits.--
            ``(1) Life independence account.--
                    ``(A) In general.--The Secretary shall establish 
                procedures for administering the provision of benefits 
                to eligible beneficiaries under the CLASS Independence 
                Benefit Plan, including the payment of the cash benefit 
                for the beneficiary into a Life Independence Account 
                established by the Secretary on behalf of each eligible 
                beneficiary.
                    ``(B) Use of cash benefits.--Cash benefits paid 
                into a Life Independence Account of an eligible 
                beneficiary shall be used to purchase nonmedical 
                services and supports that the beneficiary needs to 
                maintain his or her independence at home or in another 
                residential setting of their choice in the community, 
                including (but not limited to) home modifications, 
                assistive technology, accessible transportation, 
                homemaker services, respite care, personal assistance 
                services, home care aides, and nursing support. Nothing 
                in the preceding sentence shall prevent an eligible 
                beneficiary from using cash benefits paid into a Life 
                Independence Account for obtaining assistance with 
                decisionmaking concerning medical care, including the 
                right to accept or refuse medical or surgical treatment 
                and the right to formulate advance directives or other 
                written instructions recognized under State law, such 
                as a living will or durable power of attorney for 
                health care, in the case that an injury or illness 
                causes the individual to be unable to make health care 
                decisions.
                    ``(C) Electronic management of funds.--The 
                Secretary shall establish procedures for--
                            ``(i) crediting an account established on 
                        behalf of a beneficiary with the beneficiary's 
                        cash daily benefit;
                            ``(ii) allowing the beneficiary to access 
                        such account through debit cards; and
                            ``(iii) accounting for withdrawals by the 
                        beneficiary from such account.
                    ``(D) Primary payor rules for beneficiaries who are 
                enrolled in medicaid.--In the case of an eligible 
                beneficiary who is enrolled in Medicaid, the following 
                payment rules shall apply:
                            ``(i) Institutionalized beneficiary.--If 
                        the beneficiary is a patient in a hospital, 
                        nursing facility, intermediate care facility 
                        for the mentally retarded, or an institution 
                        for mental diseases, the beneficiary shall 
                        retain an amount equal to 5 percent of the 
                        beneficiary's daily or weekly cash benefit (as 
                        applicable) (which shall be in addition to the 
                        amount of the beneficiary's personal needs 
                        allowance provided under Medicaid), and the 
                        remainder of such benefit shall be applied 
                        toward the facility's cost of providing the 
                        beneficiary's care, and Medicaid shall provide 
                        secondary coverage for such care.
                            ``(ii) Beneficiaries receiving home and 
                        community-based services.--
                                    ``(I) 50 percent of benefit 
                                retained by beneficiary.--Subject to 
                                subclause (II), if a beneficiary is 
                                receiving medical assistance under 
                                Medicaid for home and community-based 
                                services, the beneficiary shall retain 
                                an amount equal to 50 percent of the 
                                beneficiary's daily or weekly cash 
                                benefit (as applicable), and the 
                                remainder of the daily or weekly cash 
                                benefit shall be applied toward the 
                                cost to the State of providing such 
                                assistance (and shall not be used to 
                                claim Federal matching funds under 
                                Medicaid), and Medicaid shall provide 
                                secondary coverage for the remainder of 
                                any costs incurred in providing such 
                                assistance.
                                    ``(II) Requirement for state 
                                offset.--A State shall be paid the 
                                remainder of a beneficiary's daily or 
                                weekly cash benefit under subclause (I) 
                                only if the State home and community-
                                based waiver under section 1115 of the 
                                Social Security Act or subsection (c) 
                                or (d) of section 1915 of such Act, or 
                                the State plan amendment under 
                                subsection (i) of such section does not 
                                include a waiver of the requirements of 
                                section 1902(a)(1) of the Social 
                                Security Act (relating to 
                                statewideness) or of section 
                                1902(a)(10)(B) of such Act (relating to 
                                comparability) and the State offers at 
                                a minimum case management services, 
                                personal care services, habilitation 
                                services, and respite care under such a 
                                waiver or State plan amendment.
                                    ``(III) Definition of home and 
                                community-based services.--In this 
                                clause, the term `home and community-
                                based services' means any services 
                                which may be offered under a home and 
                                community-based waiver authorized for a 
                                State under section 1115 of the Social 
                                Security Act or subsection (c) or (d) 
                                of section 1915 of such Act or under a 
                                State plan amendment under subsection 
                                (i) of such section.
                            ``(iii) Beneficiaries enrolled in programs 
                        of all-inclusive care for the elderly (pace).--
                                    ``(I) In general.--Subject to 
                                subclause (II), if a beneficiary is 
                                receiving medical assistance under 
                                Medicaid for PACE program services 
                                under section 1934 of the Social 
                                Security Act, the beneficiary shall 
                                retain an amount equal to 50 percent of 
                                the beneficiary's daily or weekly cash 
                                benefit (as applicable), and the 
                                remainder of the daily or weekly cash 
                                benefit shall be applied toward the 
                                cost to the State of providing such 
                                assistance (and shall not be used to 
                                claim Federal matching funds under 
                                Medicaid), and Medicaid shall provide 
                                secondary coverage for the remainder of 
                                any costs incurred in providing such 
                                assistance.
                                    ``(II) Institutionalized recipients 
                                of pace program services.--If a 
                                beneficiary receiving assistance under 
                                Medicaid for PACE program services is a 
                                patient in a hospital, nursing 
                                facility, intermediate care facility 
                                for the mentally retarded, or an 
                                institution for mental diseases, the 
                                beneficiary shall be treated as in 
                                institutionalized beneficiary under 
                                clause (i).
            ``(2) Authorized representatives.--
                    ``(A) In general.--The Secretary shall establish 
                procedures to allow access to a beneficiary's cash 
                benefits by an authorized representative of the 
                eligible beneficiary on whose behalf such benefits are 
                paid.
                    ``(B) Quality assurance and protection against 
                fraud and abuse.--The procedures established under 
                subparagraph (A) shall ensure that authorized 
                representatives of eligible beneficiaries comply with 
                standards of conduct established by the Secretary, 
                including standards requiring that such representatives 
                provide quality services on behalf of such 
                beneficiaries, do not have conflicts of interest, and 
                do not misuse benefits paid on behalf of such 
                beneficiaries or otherwise engage in fraud or abuse.
            ``(3) Commencement of benefits.--Benefits shall be paid to, 
        or on behalf of, an eligible beneficiary beginning with the 
        first month in which an application for such benefits is 
        approved.
            ``(4) Rollover option for lump-sum payment.--An eligible 
        beneficiary may elect to--
                    ``(A) defer payment of their daily or weekly 
                benefit and to rollover any such deferred benefits from 
                month-to-month, but not from year-to-year; and
                    ``(B) receive a lump-sum payment of such deferred 
                benefits in an amount that may not exceed the lesser 
                of--
                            ``(i) the total amount of the accrued 
                        deferred benefits; or
                            ``(ii) the applicable annual benefit.
            ``(5) Period for determination of annual benefits.--
                    ``(A) In general.--The applicable period for 
                determining with respect to an eligible beneficiary the 
                applicable annual benefit and the amount of any accrued 
                deferred benefits is the 12-month period that commences 
                with the first month in which the beneficiary began to 
                receive such benefits, and each 12-month period 
                thereafter.
                    ``(B) Inclusion of increased benefits.--The 
                Secretary shall establish procedures under which cash 
                benefits paid to an eligible beneficiary that increase 
                or decrease as a result of a change in the functional 
                status of the beneficiary before the end of a 12-month 
                benefit period shall be included in the determination 
                of the applicable annual benefit paid to the eligible 
                beneficiary.
                    ``(C) Recoupment of unpaid, accrued benefits.--
                            ``(i) In general.--The Secretary, in 
                        coordination with the Secretary of the 
                        Treasury, shall recoup any accrued benefits in 
                        the event of--
                                    ``(I) the death of a beneficiary; 
                                or
                                    ``(II) the failure of a beneficiary 
                                to elect under paragraph (4)(B) to 
                                receive such benefits as a lump-sum 
                                payment before the end of the 12-month 
                                period in which such benefits accrued.
                            ``(ii) Payment into class independence 
                        fund.--Any benefits recouped in accordance with 
                        clause (i) shall be paid into the CLASS 
                        Independence Fund and used in accordance with 
                        section 3206.
            ``(6) Requirement to recertify eligibility for receipt of 
        benefits.--An eligible beneficiary shall periodically, as 
        determined by the Secretary--
                    ``(A) recertify by submission of medical evidence 
                the beneficiary's continued eligibility for receipt of 
                benefits; and
                    ``(B) submit records of expenditures attributable 
                to the aggregate cash benefit received by the 
                beneficiary during the preceding year.
            ``(7) Supplement, not supplant other health care 
        benefits.--Subject to the Medicaid payment rules under 
        paragraph (1)(D), benefits received by an eligible beneficiary 
        shall supplement, but not supplant, other health care benefits 
        for which the beneficiary is eligible under Medicaid or any 
        other Federally funded program that provides health care 
        benefits or assistance.
    ``(d) Advocacy Services.--An agreement entered into under 
subsection (a)(2)(A)(ii) shall require the Protection and Advocacy 
System for the State to--
            ``(1) assign, as needed, an advocacy counselor to each 
        eligible beneficiary that is covered by such agreement and who 
        shall provide an eligible beneficiary with--
                    ``(A) information regarding how to access the 
                appeals process established for the program;
                    ``(B) assistance with respect to the annual 
                recertification and notification required under 
                subsection (c)(6); and
                    ``(C) such other assistance with obtaining services 
                as the Secretary, by regulation, shall require; and
            ``(2) ensure that the System and such counselors comply 
        with the requirements of subsection (h).
    ``(e) Advice and Assistance Counseling.--An agreement entered into 
under subsection (a)(2)(A)(iii) shall require the entity to assign, as 
requested by an eligible beneficiary that is covered by such agreement, 
an advice and assistance counselor who shall provide an eligible 
beneficiary with information regarding--
            ``(1) accessing and coordinating long-term services and 
        supports in the most integrated setting;
            ``(2) possible eligibility for other benefits and services;
            ``(3) development of a service and support plan;
            ``(4) information about programs established under the 
        Assistive Technology Act of 1998 and the services offered under 
        such programs;
            ``(5) available assistance with decisionmaking concerning 
        medical care, including the right to accept or refuse medical 
        or surgical treatment and the right to formulate advance 
        directives or other written instructions recognized under State 
        law, such as a living will or durable power of attorney for 
        health care, in the case that an injury or illness causes the 
        individual to be unable to make health care decisions; and
            ``(6) such other services as the Secretary, by regulation, 
        may require.
    ``(f) No Effect on Eligibility for Other Benefits.--Benefits paid 
to an eligible beneficiary under the CLASS program shall be disregarded 
for purposes of determining or continuing the beneficiary's eligibility 
for receipt of benefits under any other Federal, State, or locally 
funded assistance program, including benefits paid under titles II, 
XVI, XVIII, XIX, or XXI of the Social Security Act, under the laws 
administered by the Secretary of Veterans Affairs, under low-income 
housing assistance programs, or under the supplemental nutrition 
assistance program established under the Food and Nutrition Act of 
2008.
    ``(g) Rule of Construction.--Nothing in this title shall be 
construed as prohibiting benefits paid under the CLASS Independence 
Benefit Plan from being used to compensate a family caregiver for 
providing community living assistance services and supports to an 
eligible beneficiary.
    ``(h) Protection Against Conflicts of Interest.--The Secretary 
shall establish procedures to ensure that the Eligibility Assessment 
System, the Protection and Advocacy System for a State, advocacy 
counselors for eligible beneficiaries, and any other entities that 
provide services to active enrollees and eligible beneficiaries under 
the CLASS program comply with the following:
            ``(1) If the entity provides counseling or planning 
        services, such services are provided in a manner that fosters 
        the best interests of the active enrollee or beneficiary.
            ``(2) The entity has established operating procedures that 
        are designed to avoid or minimize conflicts of interest between 
        the entity and an active enrollee or beneficiary.
            ``(3) The entity provides information about all services 
        and options available to the active enrollee or beneficiary, to 
        the best of its knowledge, including services available through 
        other entities or providers.
            ``(4) The entity assists the active enrollee or beneficiary 
        to access desired services, regardless of the provider.
            ``(5) The entity reports the number of active enrollees and 
        beneficiaries provided with assistance by age, disability, and 
        whether such enrollees and beneficiaries received services from 
        the entity or another entity.
            ``(6) If the entity provides counseling or planning 
        services, the entity ensures that an active enrollee or 
        beneficiary is informed of any financial interest that the 
        entity has in a service provider.
            ``(7) The entity provides an active enrollee or beneficiary 
        with a list of available service providers that can meet the 
        needs of the active enrollee or beneficiary.

``SEC. 3206. CLASS INDEPENDENCE FUND.

    ``(a) Establishment of CLASS Independence Fund.--There is 
established in the Treasury of the United States a trust fund to be 
known as the `CLASS Independence Fund'. The Secretary of the Treasury 
shall serve as Managing Trustee of such Fund. The Fund shall consist of 
all amounts derived from payments into the Fund under sections 3204(f) 
and 3205(c)(5)(C)(ii), and remaining after investment of such amounts 
under subsection (b), including additional amounts derived as income 
from such investments. The amounts held in the Fund are appropriated 
and shall remain available without fiscal year limitation--
            ``(1) to be held for investment on behalf of individuals 
        enrolled in the CLASS program;
            ``(2) to pay the administrative expenses related to the 
        Fund and to investment under subsection (b); and
            ``(3) to pay cash benefits to eligible beneficiaries under 
        the CLASS Independence Benefit Plan.
    ``(b) Investment of Fund Balance.--The Secretary of the Treasury 
shall invest and manage the CLASS Independence Fund in the same manner, 
and to the same extent, as the Federal Supplementary Medical Insurance 
Trust Fund may be invested and managed under subsections (c), (d), and 
(e) of section 1841(d) of the Social Security Act.
    ``(c) Board of Trustees.--
            ``(1) In general.--With respect to the CLASS Independence 
        Fund, there is hereby created a body to be known as the Board 
        of Trustees of the CLASS Independence Fund (hereinafter in this 
        section referred to as the `Board of Trustees') composed of the 
        Secretary of the Treasury, the Secretary of Labor, and the 
        Secretary of Health and Human Services, all ex officio, and of 
        two members of the public (both of whom may not be from the 
        same political party), who shall be nominated by the President 
        for a term of 4 years and subject to confirmation by the 
        Senate. A member of the Board of Trustees serving as a member 
        of the public and nominated and confirmed to fill a vacancy 
        occurring during a term shall be nominated and confirmed only 
        for the remainder of such term. An individual nominated and 
        confirmed as a member of the public may serve in such position 
        after the expiration of such member's term until the earlier of 
        the time at which the member's successor takes office or the 
        time at which a report of the Board is first issued under 
        paragraph (2) after the expiration of the member's term. The 
        Secretary of the Treasury shall be the Managing Trustee of the 
        Board of Trustees. The Board of Trustees shall meet not less 
        frequently than once each calendar year. A person serving on 
        the Board of Trustees shall not be considered to be a fiduciary 
        and shall not be personally liable for actions taken in such 
        capacity with respect to the Trust Fund.
            ``(2) Duties.--
                    ``(A) In general.--It shall be the duty of the 
                Board of Trustees to do the following:
                            ``(i) Hold the CLASS Independence Fund.
                            ``(ii) Report to the Congress not later 
                        than the first day of April of each year on the 
                        operation and status of the CLASS Independence 
                        Fund during the preceding fiscal year and on 
                        its expected operation and status during the 
                        current fiscal year and the next 2 fiscal 
                        years.
                            ``(iii) Report immediately to the Congress 
                        whenever the Board is of the opinion that the 
                        amount of the CLASS Independence Fund is not 
                        actuarially sound in regards to the projections 
                        under section 3203(b)(1)(B)(i).
                            ``(iv) Review the general policies followed 
                        in managing the CLASS Independence Fund, and 
                        recommend changes in such policies, including 
                        necessary changes in the provisions of law 
                        which govern the way in which the CLASS 
                        Independence Fund is to be managed.
                    ``(B) Report.--The report provided for in 
                subparagraph (A)(ii) shall--
                            ``(i) include--
                                    ``(I) a statement of the assets of, 
                                and the disbursements made from, the 
                                CLASS Independence Fund during the 
                                preceding fiscal year;
                                    ``(II) an estimate of the expected 
                                income to, and disbursements to be made 
                                from, the CLASS Independence Fund 
                                during the current fiscal year and each 
                                of the next 2 fiscal years;
                                    ``(III) a statement of the 
                                actuarial status of the CLASS 
                                Independence Fund for the current 
                                fiscal year, each of the next 2 fiscal 
                                years, and as projected over the 75-
                                year period beginning with the current 
                                fiscal year; and
                                    ``(IV) an actuarial opinion 
                                certifying that the techniques and 
                                methodologies used are generally 
                                accepted within the actuarial 
                                profession and that the assumptions and 
                                cost estimates used are reasonable; and
                            ``(ii) be printed as a House document of 
                        the session of the Congress to which the report 
                        is made.
                    ``(C) Recommendations.--If the Board of Trustees 
                determines that enrollment trends and expected future 
                benefit claims on the CLASS Independence Fund are not 
                actuarially sound in regards to the projections under 
                section 3203(b)(1)(B)(i) and are unlikely to be 
                resolved with reasonable premium increases or through 
                other means, the Board of Trustees shall include in the 
                report provided for in subparagraph (A)(ii) 
                recommendations for such legislative action as the 
                Board of Trustees determine to be appropriate, 
                including whether to adjust monthly premiums or impose 
                a temporary moratorium on new enrollments.

``SEC. 3207. CLASS INDEPENDENCE ADVISORY COUNCIL.

    ``(a) Establishment.--There is hereby created an Advisory Committee 
to be known as the `CLASS Independence Advisory Council'.
    ``(b) Membership.--
            ``(1) In general.--The CLASS Independence Advisory Council 
        shall be composed of not more than 15 individuals, not 
        otherwise in the employ of the United States--
                    ``(A) who shall be appointed by the President 
                without regard to the civil service laws and 
                regulations; and
                    ``(B) a majority of whom shall be representatives 
                of individuals who participate or are likely to 
                participate in the CLASS program, and shall include 
                representatives of older and younger workers, 
                individuals with disabilities, family caregivers of 
                individuals who require services and supports to 
                maintain their independence at home or in another 
                residential setting of their choice in the community, 
                individuals with expertise in long-term care or 
                disability insurance, actuarial science, economics, and 
                other relevant disciplines, as determined by the 
                Secretary.
            ``(2) Terms.--
                    ``(A) In general.--The members of the CLASS 
                Independence Advisory Council shall serve overlapping 
                terms of 3 years (unless appointed to fill a vacancy 
                occurring prior to the expiration of a term, in which 
                case the individual shall serve for the remainder of 
                the term).
                    ``(B) Limitation.--A member shall not be eligible 
                to serve for more than 2 consecutive terms.
            ``(3) Chair.--The President shall, from time to time, 
        appoint one of the members of the CLASS Independence Advisory 
        Council to serve as the Chair.
    ``(c) Duties.--The CLASS Independence Advisory Council shall advise 
the Secretary on matters of general policy in the administration of the 
CLASS program established under this title and in the formulation of 
regulations under this title including with respect to--
            ``(1) the development of the CLASS Independence Benefit 
        Plan under section 3203; and
            ``(2) the determination of monthly premiums under such 
        plan.
    ``(d) Application of FACA.--The Federal Advisory Committee Act, 
other than section 14 of that Act, shall apply to the CLASS 
Independence Advisory Council.
    ``(e) Authorization of Appropriations.--
            ``(1) In general.--There are authorized to be appropriated 
        to the CLASS Independence Advisory Council to carry out its 
        duties under this section, such sums as may be necessary for 
        fiscal year 2011 and for each fiscal year thereafter.
            ``(2) Availability.--Any sums appropriated under the 
        authorization contained in this section shall remain available, 
        without fiscal year limitation, until expended.

``SEC. 3208. REGULATIONS; ANNUAL REPORT.

    ``(a) Regulations.--The Secretary shall promulgate such regulations 
as are necessary to carry out the CLASS program in accordance with this 
title. Such regulations shall include provisions to prevent fraud and 
abuse under the program.
    ``(b) Annual Report.--Beginning January 1, 2014, the Secretary 
shall submit an annual report to Congress on the CLASS program. Each 
report shall include the following:
            ``(1) The total number of enrollees in the program.
            ``(2) The total number of eligible beneficiaries during the 
        fiscal year.
            ``(3) The total amount of cash benefits provided during the 
        fiscal year.
            ``(4) A description of instances of fraud or abuse 
        identified during the fiscal year.
            ``(5) Recommendations for such administrative or 
        legislative action as the Secretary determines is necessary to 
        improve the program or to prevent the occurrence of fraud or 
        abuse.

``SEC. 3209. INSPECTOR GENERAL'S REPORT.

    ``The Inspector General of the Department of Health and Human 
Services shall submit an annual report to the Secretary and Congress 
relating to the overall progress of the CLASS program and of the 
existence of waste, fraud, and abuse in the CLASS program. Each such 
report shall include findings in the following areas:
            ``(1) The eligibility determination process.
            ``(2) The provision of cash benefits.
            ``(3) Quality assurance and protection against waste, 
        fraud, and abuse.
            ``(4) Recouping of unpaid and accrued benefits.''.
    (b) Conforming Amendments to Medicaid.--For conforming provisions 
amending the Medicaid program, see section 1739.

                       Subtitle E--Miscellaneous

SEC. 2585. STATES FAILING TO ADHERE TO CERTAIN EMPLOYMENT OBLIGATIONS.

    A State is eligible for Federal funds under the provisions of the 
Public Health Service Act (42 U.S.C. 201 et seq.) only if the State--
            (1) agrees to be subject in its capacity as an employer to 
        each obligation under division A of this Act and the amendments 
        made by such division applicable to persons in their capacity 
        as an employer; and
            (2) assures that all political subdivisions in the State 
        will do the same.

SEC. 2586. HEALTH CENTERS UNDER PUBLIC HEALTH SERVICE ACT; LIABILITY 
              PROTECTIONS FOR VOLUNTEER PRACTITIONERS.

    (a) In General.--Section 224 (42 U.S.C. 233) is amended--
            (1) in subsection (g)(1)(A)--
                    (A) in the first sentence, by striking ``or 
                employee'' and inserting ``employee, or (subject to 
                subsection (k)(4)) volunteer practitioner''; and
                    (B) in the second sentence, by inserting ``and 
                subsection (k)(4)'' after ``subject to paragraph (5)''; 
                and
            (2) in each of subsections (g), (i), (j), (l), and (m), by 
        striking the term ``employee, or contractor'' each place such 
        term appears and inserting ``employee, volunteer practitioner, 
        or contractor'';
            (3) in subsection (g)(1)(H), by striking the term 
        ``employee, and contractor'' each place such term appears and 
        inserting ``employee, volunteer practitioner, and contractor'';
            (4) in subsection (l), by striking the term ``employee, or 
        any contractor'' and inserting ``employee, volunteer 
        practitioner, or contractor''; and
            (5) in subsections (h)(3) and (k), by striking the term 
        ``employees, or contractors'' each place such term appears and 
        inserting ``employees, volunteer practitioners, or 
        contractors''.
    (b) Applicability; Definition.--Section 224(k) (42 U.S.C. 233(k)) 
is amended by adding at the end the following paragraph:
    ``(4)(A) Subsections (g) through (m) apply with respect to 
volunteer practitioners beginning with the first fiscal year for which 
an appropriations Act provides that amounts in the fund under paragraph 
(2) are available with respect to such practitioners.
    ``(B) For purposes of subsections (g) through (m), the term 
`volunteer practitioner' means a practitioner who, with respect to an 
entity described in subsection (g)(4), meets the following conditions:
            ``(i) The practitioner is a licensed physician, a licensed 
        clinical psychologist, or other licensed or certified health 
        care practitioner.
            ``(ii) At the request of such entity, the practitioner 
        provides services to patients of the entity, at a site at which 
        the entity operates or at a site designated by the entity. The 
        weekly number of hours of services provided to the patients by 
        the practitioner is not a factor with respect to meeting 
        conditions under this subparagraph.
            ``(iii) The practitioner does not for the provision of such 
        services receive any compensation from such patients, from the 
        entity, or from third-party payors (including reimbursement 
        under any insurance policy or health plan, or under any Federal 
        or State health benefits program).''.

SEC. 2587. REPORT TO CONGRESS ON THE CURRENT STATE OF PARASITIC 
              DISEASES THAT HAVE BEEN OVERLOOKED AMONG THE POOREST 
              AMERICANS.

    Not later than 12 months after the date of the enactment of this 
Act, the Secretary of Health and Human Services shall report to 
Congress on the epidemiology of, impact of, and appropriate funding 
required to address neglected diseases of poverty, including neglected 
parasitic diseases identified as Chagas disease, cysticercosis, 
toxocariasis, toxoplasmosis, trichomoniasis, the soil-transmitted 
helminths, and others. The report should provide the information 
necessary to enhance health policy to accurately evaluate and address 
the threat of these diseases.

SEC. 2588. OFFICE OF WOMEN'S HEALTH.

    (a) Health and Human Services Office on Women's Health.--
            (1) Establishment.--Part A of title II (42 U.S.C. 202 et 
        seq.) is amended by adding at the end the following:

``SEC. 229. HEALTH AND HUMAN SERVICES OFFICE ON WOMEN'S HEALTH.

    ``(a) Establishment of Office.--There is established within the 
Office of the Secretary, an Office on Women's Health (referred to in 
this section as the `Office'). The Office shall be headed by a Deputy 
Assistant Secretary for Women's Health who may report to the Secretary.
    ``(b) Duties.--The Secretary, acting through the Office, with 
respect to the health concerns of women, shall--
            ``(1) establish short-range and long-range goals and 
        objectives within the Department of Health and Human Services 
        and, as relevant and appropriate, coordinate with other 
        appropriate offices on activities within the Department that 
        relate to disease prevention, health promotion, service 
        delivery, research, and public and health care professional 
        education, for issues of particular concern to women throughout 
        their lifespan;
            ``(2) provide expert advice and consultation to the 
        Secretary concerning scientific, legal, ethical, and policy 
        issues relating to women's health;
            ``(3) monitor the Department of Health and Human Services' 
        offices, agencies, and regional activities regarding women's 
        health and identify needs regarding the coordination of 
        activities, including intramural and extramural 
        multidisciplinary activities;
            ``(4) establish a Department of Health and Human Services 
        Coordinating Committee on Women's Health, which shall be 
        chaired by the Deputy Assistant Secretary for Women's Health 
        and composed of senior level representatives from each of the 
        agencies and offices of the Department of Health and Human 
        Services;
            ``(5) establish a National Women's Health Information 
        Center to--
                    ``(A) facilitate the exchange of information 
                regarding matters relating to health information, 
                health promotion, preventive health services, research 
                advances, and education in the appropriate use of 
                health care;
                    ``(B) facilitate access to such information;
                    ``(C) assist in the analysis of issues and problems 
                relating to the matters described in this paragraph; 
                and
                    ``(D) provide technical assistance with respect to 
                the exchange of information (including facilitating the 
                development of materials for such technical 
                assistance);
            ``(6) coordinate efforts to promote women's health programs 
        and policies with the private sector; and
            ``(7) through publications and any other means appropriate, 
        provide for the exchange of information between the Office and 
        recipients of grants, contracts, and agreements under 
        subsection (c), and between the Office and health professionals 
        and the general public.
    ``(c) Grants and Contracts Regarding Duties.--
            ``(1) Authority.--In carrying out subsection (b), the 
        Secretary may make grants to, and enter into cooperative 
        agreements, contracts, and interagency agreements with, public 
        and private entities, agencies, and organizations.
            ``(2) Evaluation and dissemination.--The Secretary shall 
        directly or through contracts with public and private entities, 
        agencies, and organizations, provide for evaluations of 
        projects carried out with financial assistance provided under 
        paragraph (1) and for the dissemination of information 
        developed as a result of such projects.
    ``(d) Reports.--Not later than 1 year after the date of enactment 
of this section, and every second year thereafter, the Secretary shall 
prepare and submit to the appropriate committees of Congress a report 
describing the activities carried out under this section during the 
period for which the report is being prepared.''.
            (2) Transfer of functions.--There are transferred to the 
        Office on Women's Health (established under section 229 of the 
        Public Health Service Act, as added by this section), all 
        functions exercised by the Office on Women's Health of the 
        Public Health Service prior to the date of enactment of this 
        section, including all personnel and compensation authority, 
        all delegation and assignment authority, and all remaining 
        appropriations. All orders, determinations, rules, regulations, 
        permits, agreements, grants, contracts, certificates, licenses, 
        registrations, privileges, and other administrative actions 
        that--
                    (A) have been issued, made, granted, or allowed to 
                become effective by the President, any Federal agency 
                or official thereof, or by a court of competent 
                jurisdiction, in the performance of functions 
                transferred under this paragraph; and
                    (B) are in effect at the time this section takes 
                effect, or were final before the date of enactment of 
                this section and are to become effective on or after 
                such date;
        shall continue in effect according to their terms until 
        modified, terminated, superseded, set aside, or revoked in 
        accordance with law by the President, the Secretary, or other 
        authorized official, a court of competent jurisdiction, or by 
        operation of law.
    (b) Centers for Disease Control and Prevention Office of Women's 
Health.--Part A of title III (42 U.S.C. 241 et seq.) is amended by 
adding at the end the following:

``SEC. 310A. CENTERS FOR DISEASE CONTROL AND PREVENTION OFFICE OF 
              WOMEN'S HEALTH.

    ``(a) Establishment.--There is established within the Office of the 
Director of the Centers for Disease Control and Prevention, an office 
to be known as the Office of Women's Health (referred to in this 
section as the `Office'). The Office shall be headed by a director who 
shall be appointed by the Director of such Centers.
    ``(b) Purpose.--The Director of the Office shall--
            ``(1) report to the Director of the Centers for Disease 
        Control and Prevention on the current level of the Centers' 
        activity regarding women's health conditions across, where 
        appropriate, age, biological, and sociocultural contexts, in 
        all aspects of the Centers' work, including prevention 
        programs, public and professional education, services, and 
        treatment;
            ``(2) establish short-range and long-range goals and 
        objectives within the Centers for women's health and, as 
        relevant and appropriate, coordinate with other appropriate 
        offices on activities within the Centers that relate to 
        prevention, research, education and training, service delivery, 
        and policy development, for issues of particular concern to 
        women;
            ``(3) identify projects in women's health that should be 
        conducted or supported by the Centers;
            ``(4) consult with health professionals, nongovernmental 
        organizations, consumer organizations, women's health 
        professionals, and other individuals and groups, as 
        appropriate, on the policy of the Centers with regard to women; 
        and
            ``(5) serve as a member of the Department of Health and 
        Human Services Coordinating Committee on Women's Health 
        (established under section 229(b)(4)).
    ``(c) Definition.--As used in this section, the term `women's 
health conditions', with respect to women of all age, ethnic, and 
racial groups, means diseases, disorders, and conditions--
            ``(1) unique to, significantly more serious for, or 
        significantly more prevalent in women; and
            ``(2) for which the factors of medical risk or type of 
        medical intervention are different for women, or for which 
        there is reasonable evidence that indicates that such factors 
        or types may be different for women.''.
    (c) Office of Women's Health Research.--Section 486(a) (42 U.S.C. 
287d(a)) is amended by inserting ``and who shall report directly to the 
Director'' before the period at the end thereof.
    (d) Substance Abuse and Mental Health Services Administration.--
Section 501(f) (42 U.S.C. 290aa(f)) is amended--
            (1) in paragraph (1), by inserting ``who shall report 
        directly to the Administrator'' before the period;
            (2) by redesignating paragraph (4) as paragraph (5); and
            (3) by inserting after paragraph (3), the following:
            ``(4) Office.--Nothing in this subsection shall be 
        construed to preclude the Secretary from establishing within 
        the Substance Abuse and Mental Health Administration an Office 
        of Women's Health.''.
    (e) Agency for Healthcare Research and Quality Activities Regarding 
Women's Health.--Part C of title IX (42 U.S.C. 299c et seq.) is 
amended--
            (1) by redesignating sections 927 and 928 as sections 928 
        and 929, respectively;
            (2) by inserting after section 926 the following:

``SEC. 927. ACTIVITIES REGARDING WOMEN'S HEALTH.

    ``(a) Establishment.--There is established within the Office of the 
Director, an Office of Women's Health and Gender-Based Research 
(referred to in this section as the `Office'). The Office shall be 
headed by a director who shall be appointed by the Director of 
Healthcare and Research Quality.
    ``(b) Purpose.--The official designated under subsection (a) 
shall--
            ``(1) report to the Director on the current Agency level of 
        activity regarding women's health, across, where appropriate, 
        age, biological, and sociocultural contexts, in all aspects of 
        Agency work, including the development of evidence reports and 
        clinical practice protocols and the conduct of research into 
        patient outcomes, delivery of health care services, quality of 
        care, and access to health care;
            ``(2) establish short-range and long-range goals and 
        objectives within the Agency for research important to women's 
        health and, as relevant and appropriate, coordinate with other 
        appropriate offices on activities within the Agency that relate 
        to health services and medical effectiveness research, for 
        issues of particular concern to women;
            ``(3) identify projects in women's health that should be 
        conducted or supported by the Agency;
            ``(4) consult with health professionals, nongovernmental 
        organizations, consumer organizations, women's health 
        professionals, and other individuals and groups, as 
        appropriate, on Agency policy with regard to women; and
            ``(5) serve as a member of the Department of Health and 
        Human Services Coordinating Committee on Women's Health 
        (established under section 229(b)(4)).''; and
            (3) by adding at the end of section 928 (as redesignated by 
        paragraph (1)) the following:
    ``(e) Women's Health.--For the purpose of carrying out section 927 
regarding women's health, there are authorized to be appropriated such 
sums as may be necessary for each of fiscal years 2011 through 2015.''.
    (f) Health Resources and Services Administration Office of Women's 
Health.--Title VII of the Social Security Act (42 U.S.C. 901 et seq.) 
is amended by adding at the end the following:

``SEC. 713. OFFICE OF WOMEN'S HEALTH.

    ``(a) Establishment.--The Secretary shall establish within the 
Office of the Administrator of the Health Resources and Services 
Administration, an office to be known as the Office of Women's Health. 
The Office shall be headed by a director who shall be appointed by the 
Administrator.
    ``(b) Purpose.--The Director of the Office shall--
            ``(1) report to the Administrator on the current 
        Administration level of activity regarding women's health 
        across, where appropriate, age, biological, and sociocultural 
        contexts;
            ``(2) establish short-range and long-range goals and 
        objectives within the Health Resources and Services 
        Administration for women's health and, as relevant and 
        appropriate, coordinate with other appropriate offices on 
        activities within the Administration that relate to health care 
        provider training, health service delivery, research, and 
        demonstration projects, for issues of particular concern to 
        women;
            ``(3) identify projects in women's health that should be 
        conducted or supported by the bureaus of the Administration;
            ``(4) consult with health professionals, nongovernmental 
        organizations, consumer organizations, women's health 
        professionals, and other individuals and groups, as 
        appropriate, on Administration policy with regard to women; and
            ``(5) serve as a member of the Department of Health and 
        Human Services Coordinating Committee on Women's Health 
        (established under section 229(b)(4) of the Public Health 
        Service Act).
    ``(c) Continued Administration of Existing Programs.--The Director 
of the Office shall assume the authority for the development, 
implementation, administration, and evaluation of any projects carried 
out through the Health Resources and Services Administration relating 
to women's health on the date of enactment of this section.
    ``(d) Definitions.--For purposes of this section:
            ``(1) Administration.--The term `Administration' means the 
        Health Resources and Services Administration.
            ``(2) Administrator.--The term `Administrator' means the 
        Administrator of the Health Resources and Services 
        Administration.
            ``(3) Office.--The term `Office' means the Office of 
        Women's Health established under this section in the 
        Administration.''.
    (g) Food and Drug Administration Office of Women's Health.--Chapter 
IX of the Federal Food, Drug, and Cosmetic Act (21 U.S.C. 391 et seq.) 
is amended by adding at the end the following:

``SEC. 911. OFFICE OF WOMEN'S HEALTH.

    ``(a) Establishment.--There is established within the Office of the 
Commissioner, an office to be known as the Office of Women's Health 
(referred to in this section as the `Office'). The Office shall be 
headed by a director who shall be appointed by the Commissioner of Food 
and Drugs.
    ``(b) Purpose.--The Director of the Office shall--
            ``(1) report to the Commissioner of Food and Drugs on 
        current Food and Drug Administration (referred to in this 
        section as the `Administration') levels of activity regarding 
        women's participation in clinical trials and the analysis of 
        data by sex in the testing of drugs, medical devices, and 
        biological products across, where appropriate, age, biological, 
        and sociocultural contexts;
            ``(2) establish short-range and long-range goals and 
        objectives within the Administration for issues of particular 
        concern to women's health within the jurisdiction of the 
        Administration, including, where relevant and appropriate, 
        adequate inclusion of women and analysis of data by sex in 
        Administration protocols and policies;
            ``(3) provide information to women and health care 
        providers on those areas in which differences between men and 
        women exist;
            ``(4) consult with pharmaceutical, biologics, and device 
        manufacturers, health professionals with expertise in women's 
        issues, consumer organizations, and women's health 
        professionals on Administration policy with regard to women;
            ``(5) make annual estimates of funds needed to monitor 
        clinical trials and analysis of data by sex in accordance with 
        needs that are identified; and
            ``(6) serve as a member of the Department of Health and 
        Human Services Coordinating Committee on Women's Health 
        (established under section 229(b)(4) of the Public Health 
        Service Act).''.
    (h) No New Regulatory Authority.--Nothing in this section and the 
amendments made by this section may be construed as establishing 
regulatory authority or modifying any existing regulatory authority.
    (i) Limitation on Termination.--Notwithstanding any other provision 
of law, a Federal office of women's health (including the Office of 
Research on Women's Health of the National Institutes of Health) or 
Federal appointive position with primary responsibility over women's 
health issues (including the Associate Administrator for Women's 
Services under the Substance Abuse and Mental Health Services 
Administration) that is in existence on the date of enactment of this 
section shall not be terminated, reorganized, or have any of its powers 
or duties transferred unless such termination, reorganization, or 
transfer is approved by an Act of Congress.
    (j) Rule of Construction.--Nothing in this section (or the 
amendments made by this section) shall be construed to limit the 
authority of the Secretary of Health and Human Services with respect to 
women's health, or with respect to activities carried out through the 
Department of Health and Human Services on the date of enactment of 
this section.

SEC. 2589. LONG-TERM CARE AND FAMILY CAREGIVER SUPPORT.

    (a) Amendments to the Older Americans Act of 1965.--
            (1) Promotion of direct care workforce.--Section 202(b)(1) 
        of the Older Americans Act of 1965 (42 U.S.C. 3012(b)(1)) is 
        amended by inserting before the semicolon the following: ``, 
        and, in carrying out the purposes of this paragraph, shall make 
        recommendations to other Federal entities regarding appropriate 
        and effective means of identifying, promoting, and implementing 
        investments in the direct care workforce necessary to meet the 
        growing demand for long-term health services and supports and 
        of assisting States in developing a comprehensive State 
        workforce development plan with respect to such workforce, 
        including assisting efforts to systematically assess, track, 
        and report on workforce adequacy and capacity''.
            (2) Personal care attendant workforce advisory panel.--
        Section 202 of such Act (42 U.S.C. 3012) is amended by adding 
        at the end the following:
    ``(g)(1) Not later than 90 days after the date of the enactment of 
this subsection, the Assistant Secretary shall establish a Personal 
Care Attendant Workforce Advisory Panel to examine and formulate 
recommendations on--
            ``(A) working conditions and training for workers providing 
        long-term services and supports, including home health aides, 
        certified nurse aides, and personal care attendants; and
            ``(B) other workforce issues related to such workers, 
        including with respect to the adequacy of the number of such 
        workers; the salaries, wages, and benefits of such workers; and 
        access to the services provided by such workers.
    ``(2) The Panel shall include representatives of--
            ``(A) relevant home- and community-based service providers, 
        health care agencies, and facilities (including personal or 
        home care agencies, home health care agencies, nursing homes, 
        assisted living facilities, and residential care facilities);
            ``(B) the disability community, including individuals with 
        disabilities and family caregivers;
            ``(C) the nursing community;
            ``(D) direct care workers (which may include unions and 
        national organizations);
            ``(E) older individuals, including senior individuals and 
        family caregivers;
            ``(F) State and Federal health care entities; and
            ``(G) experts in workforce development and adult learning.
    ``(3) Within one year after the establishment of the Panel, the 
Panel shall submit a report to the Assistant Secretary and the Congress 
on workforce issues related to providing long-term services and 
supports, including information on core competencies for eligible 
personal or home care aides necessary to successfully provide long-term 
services and supports to eligible consumers, as well as recommended 
training curricula and resources.
    ``(4) Within 180 days after receipt by the Assistant Secretary of 
the report under paragraph (3), the Assistant Secretary shall establish 
a 3-year demonstration program in 4 States to pilot and evaluate the 
effectiveness of the competencies articulated by the Panel and the 
training curricula and training methods recommended by the Panel.
    ``(5) Not later than 1 year after the completion of the 
demonstration program under paragraph (4), the Assistant Secretary 
shall submit to the Congress a report containing the results of the 
evaluations by the Assistant Secretary pursuant to paragraph (4), 
together with such recommendations for legislation or administrative 
action as the Assistant Secretary determines appropriate.''.
    (b) Authorization of Additional Appropriations for the Family 
Caregiver Support Program Under the Older Americans Act of 1965.--
Section 303(e)(2) of the Older Americans Act of 1965 (42 U.S.C. 
3023(e)(2)) is amended by striking ``, $173,000,000'' and all that 
follows through ``2011'', and inserting ``and $250,000,000 for each of 
fiscal years 2011, 2012, and 2013''.

SEC. 2590. WEB SITE ON HEALTH CARE LABOR MARKET AND RELATED EDUCATIONAL 
              AND TRAINING OPPORTUNITIES.

    (a) In General.--The Secretary of Labor, in consultation with the 
National Center for Health Workforce Analysis, shall establish and 
maintain a Web site to serve as a comprehensive source of information, 
searchable by workforce region, on the health care labor market and 
related educational and training opportunities.
    (b) Contents.--The Web site maintained under this section shall 
include the following:
            (1) Information on the types of jobs that are currently or 
        are projected to be in high demand in the health care field, 
        including--
                    (A) salary information; and
                    (B) training requirements, such as requirements for 
                educational credentials, licensure, or certification.
            (2) Information on training and educational opportunities 
        within each region for the type of jobs described in paragraph 
        (1), including by--
                    (A) type of provider or program (such as public, 
                private nonprofit, or private for-profit);
                    (B) duration;
                    (C) cost (such as tuition, fees, books, laboratory 
                expenses, and other mandatory costs);
                    (D) performance outcomes (such as graduation rates, 
                job placement, average salary, job retention, and wage 
                progression);
                    (E) Federal financial aid participation;
                    (F) average graduate loan debt;
                    (G) student loan default rates;
                    (H) average institutional grant aid provided;
                    (I) Federal and State accreditation information; 
                and
                    (J) other information determined by the Secretary.
            (3) A mechanism for searching and comparing training and 
        educational options for specific health care occupations to 
        facilitate informed career and education choices.
            (4) Financial aid information, including with respect to 
        loan forgiveness, loan cancellation, loan repayment, stipends, 
        scholarships, and grants or other assistance authorized by this 
        Act or other Federal or State programs.
    (c) Public Accessibility.--The Web site maintained under this 
section shall--
            (1) be publicly accessible;
            (2) be user friendly and convey information in a manner 
        that is easily understandable; and
            (3) be in English and the second most prevalent language 
        spoken based on the latest Census information.

SEC. 2591. ONLINE HEALTH WORKFORCE TRAINING PROGRAMS.

    Section 171 of the Workforce Investment Act of 1998 (29 U.S.C. 
2916) is amended by adding at the end the following:
    ``(f) Online Health Workforce Training Program.--
            ``(1) Grant program.--
                    ``(A) In general.--The Secretary in consultation 
                with the Secretary of Health and Human Services, shall 
                award National Health Workforce Online Training Grants 
                on a competitive basis to eligible entities to enable 
                such entities to carry out training for individuals to 
                attain or advance in health care occupations. An entity 
                may leverage such grant with other Federal, State, 
                local, and private resources, in order to expand the 
                participation of businesses, employees, and individuals 
                in such training programs.
                    ``(B) Eligibility.--In order to receive a grant 
                under the program established under this paragraph--
                            ``(i) an entity shall be an educational 
                        institution, community-based organization, 
                        nonprofit organization, workforce investment 
                        board, or local or county government; and
                            ``(ii) an entity shall provide online 
                        workforce training for individuals seeking to 
                        attain or advance in health care occupations, 
                        including nursing, nursing assistants, 
                        dentistry, pharmacy, health care management and 
                        administration, public health, health 
                        information systems analysis, medical 
                        assistants, and other health care practitioner 
                        and support occupations.
                    ``(C) Priority.--Priority in awarding grants under 
                this paragraph shall be given to entities that--
                            ``(i) have demonstrated experience in 
                        implementing and operating online worker skills 
                        training and education programs;
                            ``(ii) have demonstrated experience 
                        coordinating activities, where appropriate, 
                        with the workforce investment system; and
                            ``(iii) conduct training for occupations 
                        with national or local shortages.
                    ``(D) Data collection.--Grantees under this 
                paragraph shall collect and report information on--
                            ``(i) the number of participants;
                            ``(ii) the services received by the 
                        participants;
                            ``(iii) program completion rates;
                            ``(iv) factors determined as significantly 
                        interfering with program participation or 
                        completion;
                            ``(v) the rate of job placement; and
                            ``(vi) other information as determined as 
                        needed by the Secretary.
                    ``(E) Outreach.--Grantees under this paragraph 
                shall conduct outreach activities to disseminate 
                information about their program and results to 
                workforce investment boards, local governments, 
                educational institutions, and other workforce training 
                organizations.
                    ``(F) Performance levels.--The Secretary shall 
                establish indicators of performance that will be used 
                to evaluate the performance of grantees under this 
                paragraph in carrying out the activities described in 
                this paragraph. The Secretary shall negotiate and reach 
                agreement with each grantee regarding the levels of 
                performance expected to be achieved by the grantee on 
                the indicators of performance.
                    ``(G) Authorization of appropriations.--There are 
                authorized to be appropriated to the Secretary to carry 
                out this subsection $50,000,000 for fiscal years 2011 
                through 2020.
            ``(2) Online health professions training program 
        clearinghouse.--
                    ``(A) Description of grant.--The Secretary may 
                award one or more grants to eligible postsecondary 
                educational institutions to provide the services 
                described in this paragraph.
                    ``(B) Eligibility.--To be eligible to receive a 
                grant under this paragraph, a postsecondary educational 
                institution shall--
                            ``(i) have demonstrated the ability to 
                        disseminate research on best practices for 
                        implementing workforce investment programs; and
                            ``(ii) be a national leader in producing 
                        cutting-edge research on technology related to 
                        workforce investment systems under subtitle B.
                    ``(C) Services.--The postsecondary educational 
                institution that receives a grant under this paragraph 
                shall use such grant--
                            ``(i) to provide technical assistance to 
                        entities that receive grants under paragraph 
                        (1);
                            ``(ii) to collect and nationally 
                        disseminate the data gathered by entities that 
                        receive grants under paragraph (1); and
                            ``(iii) to disseminate the best practices 
                        identified by the National Health Workforce 
                        Online Training Grant Program to other 
                        workforce training organizations.
                    ``(D) Authorization of appropriations.--There are 
                authorized to be appropriated to the Secretary to carry 
                out this subsection $1,000,000 for fiscal years 2011 
                through 2020.''.

SEC. 2592. ACCESS FOR INDIVIDUALS WITH DISABILITIES.

    Title V of the Rehabilitation Act of 1973 (29 U.S.C. 791 et seq.) 
is amended by adding at the end of the following:

``SEC. 510. STANDARDS FOR ACCESSIBILITY OF MEDICAL DIAGNOSTIC 
              EQUIPMENT.

    ``(a) Standards.--Not later than 9 months after the date of 
enactment of the Affordable Health Care for America Act, the 
Architectural and Transportation Barriers Compliance Board (Access 
Board) shall issue guidelines setting forth the minimum technical 
criteria for new medical diagnostic equipment to be purchased for use 
in (or in conjunction with) physician's offices, clinics, emergency 
rooms, hospitals, and other medical settings. The guidelines shall 
ensure that such equipment is accessible to, and usable by, individuals 
with disabilities, including provisions to ensure independent entry to, 
use of, and exit from the equipment by such individuals to the maximum 
extent possible.
    ``(b) Medical Diagnostic Equipment Covered.--The guidelines issued 
under subsection (a) for medical diagnostic equipment shall apply to 
new purchases of equipment that includes examination tables, 
examination chairs (including chairs used for eye examinations or 
procedures, and dental examinations or procedures), weight scales, 
mammography equipment, x-ray machines, and other equipment commonly 
used for diagnostic or examination purposes by health professionals.
    ``(c) Regulations.--Not later than 6 months after the date of the 
issuance of the guidelines under subsection (a), each appropriate 
Federal agency authorized to promulgate regulations under this Act or 
under the Americans with Disabilities Act shall--
            ``(1) prescribe regulations in an accessible format as 
        necessary to carry out the provisions of such Act and section 
        504 of this Act that include accessibility standards that are 
        consistent with the guidelines issued under subsection (a); and
            ``(2) ensure that health care providers and health care 
        plans covered by the Affordable Health Care for America Act 
        meet the requirements of the Americans with Disabilities Act 
        and section 504, including provisions ensuring that individuals 
        with disabilities receive equal access to all aspects of the 
        health care delivery system.
    ``(d) Review and Amend.--The Architectural and Transportation 
Barriers Compliance Board (Access Board) shall periodically review and, 
as appropriate, amend the guidelines as prescribed under subsection 
(a). Not later than 6 months after the date of the issuance of such 
revised guidelines, revised regulations consistent with such guidelines 
shall be promulgated in an accessible format by the appropriate Federal 
agencies described in subsection (c).''.

               DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

SEC. 3001. SHORT TITLE; TABLE OF CONTENTS.

    (a) Short Title.--This division may be cited as the ``Indian Health 
Care Improvement Act Amendments of 2009''.
    (b) Table of Contents.--The table of contents of this division is 
as follows:

               DIVISION D--INDIAN HEALTH CARE IMPROVEMENT

Sec. 3001. Short title; table of contents.
                   TITLE I--AMENDMENTS TO INDIAN LAWS

Sec. 3101. Indian Health Care Improvement At amended.
Sec. 3102. Soboba sanitation facilities.
Sec. 3103. Native American Health and Wellness Foundation.
Sec. 3104. 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.

                   TITLE I--AMENDMENTS TO INDIAN LAWS

SEC. 3101. INDIAN HEALTH CARE IMPROVEMENT AMENDED.

    (a) In General.--The Indian Health Care Improvement Act (25 U.S.C. 
1601 et seq.) is amended to read as follows:

``SECTION 1. SHORT TITLE; TABLE OF CONTENTS.

    ``(a) Short Title.--This Act may be cited as the `Indian Health 
Care Improvement Act'.
    ``(b) Table of Contents.--The table of contents 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.
``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.
``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.
                ``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. Provision of services in Montana.
``Sec. 810. Moratorium.
``Sec. 811. Severability provisions.
``Sec. 812. Use of patient safety organizations.
``Sec. 813. Confidentiality of medical quality assurance records; 
                            qualified immunity for participants.
``Sec. 814. Claremore Indian Hospital.
``Sec. 815. Sense of Congress regarding law enforcement and 
                            methamphetamine issues in Indian country.
``Sec. 816. Permitting implementation through contracts with Tribal 
                            Health Programs.
``Sec. 817. Authorization of appropriations; availability.

``SEC. 2. FINDINGS.

    ``Congress makes the following findings:
            ``(1) Federal health services to maintain and improve the 
        health of the Indians are consonant with and required by the 
        Federal Government's historical and unique legal relationship 
        with, and resulting responsibility to, the American Indian 
        people.
            ``(2) A major national goal of the United States is to 
        provide the resources, processes, and structure that will 
        enable Indian tribes and tribal members to obtain the quantity 
        and quality of health care services and opportunities that will 
        eradicate the health disparities between Indians the general 
        population.
            ``(3) A major national goal of the United States is to 
        provide the quantity and quality of health services which will 
        permit the health status of Indians to be raised to the highest 
        possible level and to encourage the maximum participation of 
        Indians in the planning and management of those services.
            ``(4) Federal health services to Indians have resulted in a 
        reduction in the prevalence and incidence of preventable 
        illnesses among, and unnecessary and premature deaths of, 
        Indians.
            ``(5) Despite such services, the unmet health needs of the 
        American Indian people are severe and the health status of the 
        Indians is far below that of the general population of the 
        United States.

``SEC. 3. DECLARATION OF NATIONAL INDIAN HEALTH POLICY.

    ``Congress declares that it is the policy of this Nation, in 
fulfillment of its special trust responsibilities and legal obligations 
to Indians--
            ``(1) to assure the highest possible health status for 
        Indians and Urban Indians and to provide all resources 
        necessary to effect that policy;
            ``(2) to raise the health status of Indians and Urban 
        Indians to at least the levels set forth in the goals contained 
        within the Health People 2010 or successor objectives;
            ``(3) to the greatest extent possible, to allow Indians to 
        set their own health care priorities and establish goals that 
        reflect their unmet needs;
            ``(4) to increase the proportion of all degrees in the 
        health professions and allied and associated health professions 
        awarded to Indians so that the proportion of Indian health 
        professionals in each Service Area is raised to at least the 
        level of that of the general population;
            ``(5) to require meaningful consultation with Indian 
        Tribes, Tribal Organizations, and urban Indian organizations to 
        implement this Act and the national policy of Indian self-
        determination; and
            ``(6) to provide funding for programs and facilities 
        operated by Indian Tribes, Tribal Organizations, and Urban 
        Indian Organizations in amounts that are not less than the 
        amounts provided to programs and facilities operated directly 
        by the Service.

``SEC. 4. DEFINITIONS.

    ``For purposes of this Act:
            ``(1) The term `accredited and accessible' means on or near 
        a reservation and accredited by a national or regional 
        organization with accrediting authority.
            ``(2) The term `Area Office' means an administrative 
        entity, including a program office, within the Service through 
        which services and funds are provided to the Service Units 
        within a defined geographic area.
            ``(3) The term `Assistant Secretary' means the Assistant 
        Secretary of Indian Health.
            ``(4)(A) The term `behavioral health' means the blending of 
        substance (including alcohol, drugs, inhalants, and tobacco) 
        abuse and mental health prevention and treatment, for the 
        purpose of providing comprehensive services.
            ``(B) The term `behavioral health' includes the joint 
        development of substance abuse and mental health treatment 
        planning and coordinated case management using a 
        multidisciplinary approach.
            ``(5) The term `California Indians' means those Indians who 
        are eligible for health services of the Service pursuant to 
        section 805.
            ``(6) The term `community college' means--
                    ``(A) a tribal college or university, or
                    ``(B) a junior or community college.
            ``(7) The term `contract health service' means health 
        services provided at the expense of the Service or a Tribal 
        Health Program by public or private medical providers or 
        hospitals, other than the Service Unit or the Tribal Health 
        Program at whose expense the services are provided.
            ``(8) The term `Department' means, unless otherwise 
        designated, the Department of Health and Human Services.
            ``(9) The term `disease prevention' means the reduction, 
        limitation, and prevention of disease and its complications and 
        reduction in the consequences of disease, including--
                    ``(A) controlling--
                            ``(i) the development of diabetes;
                            ``(ii) high blood pressure;
                            ``(iii) infectious agents;
                            ``(iv) injuries;
                            ``(v) occupational hazards and 
                        disabilities;
                            ``(vi) sexually transmittable diseases; and
                            ``(vii) toxic agents; and
                    ``(B) providing--
                            ``(i) fluoridation of water; and
                            ``(ii) immunizations.
            ``(10) The term `health profession' means allopathic 
        medicine, family medicine, internal medicine, pediatrics, 
        geriatric medicine, obstetrics and gynecology, podiatric 
        medicine, nursing, public health nursing, dentistry, 
        psychiatry, osteopathy, optometry, pharmacy, psychology, public 
        health, social work, marriage and family therapy, chiropractic 
        medicine, environmental health and engineering, allied health 
        professions, naturopathic medicine, and any other health 
        profession.
            ``(11) The term `health promotion' means--
                    ``(A) fostering social, economic, environmental, 
                and personal factors conducive to health, including 
                raising public awareness about health matters and 
                enabling the people to cope with health problems by 
                increasing their knowledge and providing them with 
                valid information;
                    ``(B) encouraging adequate and appropriate diet, 
                exercise, and sleep;
                    ``(C) promoting education and work in conformity 
                with physical and mental capacity;
                    ``(D) making available safe water and sanitary 
                facilities;
                    ``(E) improving the physical, economic, cultural, 
                psychological, and social environment;
                    ``(F) promoting culturally competent care; and
                    ``(G) providing adequate and appropriate programs, 
                which may include--
                            ``(i) abuse prevention (mental and 
                        physical);
                            ``(ii) community health;
                            ``(iii) community safety;
                            ``(iv) consumer health education;
                            ``(v) diet and nutrition;
                            ``(vi) immunization and other prevention of 
                        communicable diseases, including HIV/AIDS;
                            ``(vii) environmental health;
                            ``(viii) exercise and physical fitness;
                            ``(ix) avoidance of fetal alcohol 
                        disorders;
                            ``(x) first aid and CPR education;
                            ``(xi) human growth and development;
                            ``(xii) injury prevention and personal 
                        safety;
                            ``(xiii) behavioral health;
                            ``(xiv) monitoring of disease indicators 
                        between health care provider visits, through 
                        appropriate means, including Internet-based 
                        health care management systems;
                            ``(xv) personal health and wellness 
                        practices;
                            ``(xvi) personal capacity building;
                            ``(xvii) prenatal, pregnancy, and infant 
                        care;
                            ``(xviii) psychological well-being;
                            ``(xix) reproductive health and family 
                        planning;
                            ``(xx) safe and adequate water;
                            ``(xxi) healthy work environments;
                            ``(xxii) elimination, reduction, and 
                        prevention of contaminants that create 
                        unhealthy household conditions (including mold 
                        and other allergens);
                            ``(xxiii) stress control;
                            ``(xxiv) substance abuse;
                            ``(xxv) sanitary facilities;
                            ``(xxvi) sudden infant death syndrome 
                        prevention;
                            ``(xxvii) tobacco use cessation and 
                        reduction;
                            ``(xxviii) violence prevention; and
                            ``(xxix) activities to promote achievement 
                        of any of the objectives described in section 
                        3(2).
            ``(12) The term `Indian', unless otherwise designated, 
        means any person who is a member of an Indian Tribe or is 
        eligible for health services under section 805, except that, 
        for the purpose of sections 102 and 103, the term also means 
        any individual who--
                    ``(A)(i) irrespective of whether the individual 
                lives on or near a reservation, is a member of a tribe, 
                band, or other organized group of Indians, including 
                those tribes, bands, or groups terminated since 1940 
                and those recognized now or in the future by the State 
                in which they reside; or
                    ``(ii) is a descendant, in the first or second 
                degree, of any such member;
                    ``(B) is an Eskimo or Aleut or other Alaska Native;
                    ``(C) is considered by the Secretary of the 
                Interior to be an Indian for any purpose; or
                    ``(D) is determined to be an Indian under 
                regulations promulgated by the Secretary.
            ``(13) The term `Indian Health Program' means--
                    ``(A) any health program administered directly by 
                the Service;
                    ``(B) any Tribal Health Program; or
                    ``(C) any Indian Tribe or Tribal Organization to 
                which the Secretary provides funding pursuant to 
                section 23 of the Act of June 25, 1910 (25 U.S.C. 47) 
                (commonly known as the `Buy Indian Act').
            ``(14) The term `Indian Tribe' has the meaning given the 
        term in the Indian Self-Determination and Education Assistance 
        Act (25 U.S.C. 450 et seq.).
            ``(15) The term `junior or community college' has the 
        meaning given the term by section 312(f) of the Higher 
        Education Act of 1965 (20 U.S.C. 1058(f)).
            ``(16) The term `reservation' means any federally 
        recognized Indian Tribe's reservation, Pueblo, or colony, 
        including former reservations in Oklahoma, Indian allotments, 
        and Alaska Native Regions established pursuant to the Alaska 
        Native Claims Settlement Act (43 U.S.C. 1601 et seq.).
            ``(17) The term `Secretary', unless otherwise designated, 
        means the Secretary of Health and Human Services.
            ``(18) The term `Service' means the Indian Health Service.
            ``(19) The term `Service Area' means the geographical area 
        served by each Area Office.
            ``(20) The term `Service Unit' means an administrative 
        entity of the Service, or a Tribal Health Program through which 
        services are provided, directly or by contract, to eligible 
        Indians within a defined geographic area.
            ``(21) The term `telehealth' has the meaning given the term 
        in section 330K(a) of the Public Health Service Act (42 U.S.C. 
        254c-16(a)).
            ``(22) The term `telemedicine' means a telecommunications 
        link to an end user through the use of eligible equipment that 
        electronically links health professionals or patients and 
        health professionals at separate sites in order to exchange 
        health care information in audio, video, graphic, or other 
        format for the purpose of providing improved health care 
        services.
            ``(23) The term `tribal college or university' has the 
        meaning given the term in section 316(b)(3) of the Higher 
        Education Act (20 U.S.C. 1059c(b)(3)).
            ``(24) The term `Tribal Health Program' means an Indian 
        Tribe or Tribal Organization that operates any health program, 
        service, function, activity, or facility funded, in whole or 
        part, by the Service through, or provided for in, a contract or 
        compact with the Service under the Indian Self-Determination 
        and Education Assistance Act (25 U.S.C. 450 et seq.).
            ``(25) The term `Tribal Organization' has the meaning given 
        the term in the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.).
            ``(26) The term `Urban Center' means any community which 
        has a sufficient Urban Indian population with unmet health 
        needs to warrant assistance under title V of this Act, as 
        determined by the Secretary.
            ``(27) The term `Urban Indian' means any individual who 
        resides in an Urban Center and who meets 1 or more of the 
        following criteria:
                    ``(A) Irrespective of whether the individual lives 
                on or near a reservation, the individual is a member of 
                a tribe, band, or other organized group of Indians, 
                including those tribes, bands, or groups terminated 
                since 1940 and those tribes, bands, or groups that are 
                recognized by the States in which they reside, or who 
                is a descendant in the first or second degree of any 
                such member.
                    ``(B) The individual is an Eskimo, Aleut, or other 
                Alaska Native.
                    ``(C) The individual is considered by the Secretary 
                of the Interior to be an Indian for any purpose.
                    ``(D) The individual is determined to be an Indian 
                under regulations promulgated by the Secretary.
            ``(28) The term `urban Indian organization' means a 
        nonprofit corporate body that (A) is situated in an Urban 
        Center; (B) is governed by an Urban Indian-controlled board of 
        directors; (C) provides for the participation of all interested 
        Indian groups and individuals; and (D) is capable of legally 
        cooperating with other public and private entities for the 
        purpose of performing the activities described in section 
        503(a).

       ``TITLE I--INDIAN HEALTH, HUMAN RESOURCES, AND DEVELOPMENT

``SEC. 101. PURPOSE.

    ``The purpose of this title is to increase, to the maximum extent 
feasible, the number of Indians entering the health professions and 
providing health services, and to assure an optimum supply of health 
professionals to the Indian Health Programs and urban Indian 
organizations involved in the provision of health services to Indians.

``SEC. 102. HEALTH PROFESSIONS RECRUITMENT PROGRAM FOR INDIANS.

    ``(a) In General.--The Secretary, acting through the Service, shall 
make grants to public or nonprofit private health or educational 
entities, Tribal Health Programs, or urban Indian organizations to 
assist such entities in meeting the costs of--
            ``(1) identifying Indians with a potential for education or 
        training in the health professions and encouraging and 
        assisting them--
                    ``(A) to enroll in courses of study in such health 
                professions; or
                    ``(B) if they are not qualified to enroll in any 
                such courses of study, to undertake such postsecondary 
                education or training as may be required to qualify 
                them for enrollment;
            ``(2) publicizing existing sources of financial aid 
        available to Indians enrolled in any course of study referred 
        to in paragraph (1) or who are undertaking training necessary 
        to qualify them to enroll in any such course of study; or
            ``(3) establishing other programs which the Secretary 
        determines will enhance and facilitate the enrollment of 
        Indians in, and the subsequent pursuit and completion by them 
        of, courses of study referred to in paragraph (1).
    ``(b) Grants.--
            ``(1) Application.--No grant may be made under this section 
        unless an application has been submitted to, and approved by, 
        the Secretary. Such application shall be in such form, 
        submitted in such manner, and contain such information, as the 
        Secretary shall by regulation prescribe pursuant to this Act. 
        The Secretary shall give a preference to applications submitted 
        by Tribal Health Programs or urban Indian organizations.
            ``(2) Amount of grants; payment.--The amount of a grant 
        under this section shall be determined by the Secretary. 
        Payments pursuant to this section may be made in advance or by 
        way of reimbursement, and at such intervals and on such 
        conditions as provided for in regulations issued pursuant to 
        this Act. To the extent not otherwise prohibited by law, grants 
        shall be for 3 years, as provided in regulations issued 
        pursuant to this Act.

``SEC. 103. HEALTH PROFESSIONS PREPARATORY SCHOLARSHIP PROGRAM FOR 
              INDIANS.

    ``(a) Scholarships Authorized.--The Secretary, acting through the 
Service, shall provide scholarship grants to Indians who--
            ``(1) have successfully completed their high school 
        education or high school equivalency; and
            ``(2) have demonstrated the potential to successfully 
        complete courses of study in the health professions.
    ``(b) Purposes.--Scholarship grants provided pursuant to this 
section shall be for the following purposes:
            ``(1) Compensatory preprofessional education of any 
        recipient, such scholarship not to exceed 2 years on a full-
        time basis (or the part-time equivalent thereof, as determined 
        by the Secretary pursuant to regulations issued under this 
        Act).
            ``(2) Pregraduate education of any recipient leading to a 
        baccalaureate degree in an approved course of study preparatory 
        to a field of study in a health profession, such scholarship 
        not to exceed 4 years. An extension of up to 2 years (or the 
        part-time equivalent thereof, as determined by the Secretary 
        pursuant to regulations issued pursuant to this Act) may be 
        approved.
    ``(c) Other Conditions.--Scholarships under this section--
            ``(1) may cover costs of tuition, books, transportation, 
        board, and other necessary related expenses of a recipient 
        while attending school;
            ``(2) shall not be denied solely on the basis of the 
        applicant's scholastic achievement if such applicant has been 
        admitted to, or maintained good standing at, an accredited 
        institution; and
            ``(3) shall not be denied solely by reason of such 
        applicant's eligibility for assistance or benefits under any 
        other Federal program.

``SEC. 104. INDIAN HEALTH PROFESSIONS SCHOLARSHIPS.

    ``(a) In General.--
            ``(1) Authority.--The Secretary, acting through the 
        Service, shall make scholarship grants to Indians who are 
        enrolled full or part time in accredited schools pursuing 
        courses of study in the health professions. Such scholarships 
        shall be designated Indian Health Scholarships and shall be 
        made in accordance with section 338A of the Public Health 
        Services Act (42 U.S.C. 254l), except as provided in subsection 
        (b) of this section.
            ``(2) Determinations by secretary.--The Secretary, acting 
        through the Service, shall determine--
                    ``(A) who shall receive scholarship grants under 
                subsection (a); and
                    ``(B) the distribution of the scholarships among 
                health professions on the basis of the relative needs 
                of Indians for additional service in the health 
                professions.
            ``(3) Certain delegation not allowed.--The administration 
        of this section shall be a responsibility of the Assistant 
        Secretary and shall not be delegated in a contract or compact 
        under the Indian Self-Determination and Education Assistance 
        Act (25 U.S.C. 450 et seq.).
    ``(b) Active Duty Service Obligation.--
            ``(1) Obligation met.--The active duty service obligation 
        under a written contract with the Secretary under this section 
        that an Indian has entered into shall, if that individual is a 
        recipient of an Indian Health Scholarship, be met in full-time 
        practice equal to 1 year for each school year for which the 
        participant receives a scholarship award under this part, or 2 
        years, whichever is greater, by service in 1 or more of the 
        following:
                    ``(A) In an Indian Health Program.
                    ``(B) In a program assisted under title V of this 
                Act.
                    ``(C) In the private practice of the applicable 
                profession if, as determined by the Secretary, in 
                accordance with guidelines promulgated by the 
                Secretary, such practice is situated in a physician or 
                other health professional shortage area and addresses 
                the health care needs of a substantial number of 
                Indians.
                    ``(D) In a teaching capacity in a tribal college or 
                university nursing program (or a related health 
                profession program) if, as determined by the Secretary, 
                the health service provided to Indians would not 
                decrease.
            ``(2) Obligation deferred.--At the request of any 
        individual who has entered into a contract referred to in 
        paragraph (1) and who receives a health professions degree 
        requiring postgraduate training for licensure or to improve 
        clinical skills, the Secretary shall defer the active duty 
        service obligation of that individual under that contract, in 
        order that such individual may complete any internship, 
        residency, or other advanced clinical training that is required 
        for the practice of that health profession, for an appropriate 
        period (in years, as determined by the Secretary), subject to 
        the following conditions:
                    ``(A) No period of internship, residency, or other 
                advanced clinical training shall be counted as 
                satisfying any period of obligated service under this 
                subsection.
                    ``(B) The active duty service obligation of that 
                individual shall commence not later than 90 days after 
                the completion of that advanced clinical training (or 
                by a date specified by the Secretary).
                    ``(C) The active duty service obligation will be 
                served in the health profession of that individual in a 
                manner consistent with paragraph (1).
                    ``(D) A recipient of a scholarship under this 
                section may, at the election of the recipient, meet the 
                active duty service obligation described in paragraph 
                (1) by service in a program specified under that 
                paragraph that--
                            ``(i) is located on the reservation of the 
                        Indian Tribe in which the recipient is 
                        enrolled; or
                            ``(ii) serves the Indian Tribe in which the 
                        recipient is enrolled.
            ``(3) Priority when making assignments.--Subject to 
        paragraph (2), the Secretary, in making assignments of Indian 
        Health Scholarship recipients required to meet the active duty 
        service obligation described in paragraph (1), shall give 
        priority to assigning individuals to service in those programs 
        specified in paragraph (1) that have a need for health 
        professionals to provide health care services as a result of 
        individuals having breached contracts entered into under this 
        section.
    ``(c) Part-time Students.--In the case of an individual receiving a 
scholarship under this section who is enrolled part time in an approved 
course of study--
            ``(1) such scholarship shall be for a period of years not 
        to exceed the part-time equivalent of 4 years, as determined by 
        the Secretary;
            ``(2) the period of obligated service described in 
        subsection (b)(1) shall be equal to the greater of--
                    ``(A) the part-time equivalent of 1 year for each 
                year for which the individual was provided a 
                scholarship (as determined by the Secretary); or
                    ``(B) 2 years; and
            ``(3) the amount of the monthly stipend specified in 
        section 338A(g)(1)(B) of the Public Health Service Act (42 
        U.S.C. 254l(g)(1)(B)) shall be reduced pro rata (as determined 
        by the Secretary) based on the number of hours such student is 
        enrolled.
    ``(d) Breach of Contract.--
            ``(1) Specified breaches.--An individual shall be liable to 
        the United States for the amount which has been paid to the 
        individual, or on behalf of the individual, under a contract 
        entered into with the Secretary under this section on or after 
        the date of enactment of the Indian Health Care Improvement Act 
        Amendments of 2009 if that individual--
                    ``(A) fails to maintain an acceptable level of 
                academic standing in the educational institution in 
                which he or she is enrolled (such level determined by 
                the educational institution under regulations of the 
                Secretary);
                    ``(B) is dismissed from such educational 
                institution for disciplinary reasons;
                    ``(C) voluntarily terminates the training in such 
                an educational institution for which he or she is 
                provided a scholarship under such contract before the 
                completion of such training; or
                    ``(D) fails to accept payment, or instructs the 
                educational institution in which he or she is enrolled 
                not to accept payment, in whole or in part, of a 
                scholarship under such contract, in lieu of any service 
                obligation arising under such contract.
            ``(2) Other breaches.--If for any reason not specified in 
        paragraph (1) an individual breaches a written contract by 
        failing either to begin such individual's service obligation 
        required under such contract or to complete such service 
        obligation, the United States shall be entitled to recover from 
        the individual an amount determined in accordance with the 
        formula specified in subsection (l) of section 110 in the 
        manner provided for in such subsection.
            ``(3) Cancellation upon death of recipient.--Upon the death 
        of an individual who receives an Indian Health Scholarship, any 
        outstanding obligation of that individual for service or 
        payment that relates to that scholarship shall be canceled.
            ``(4) Waivers and suspensions.--The Secretary shall provide 
        for the partial or total waiver or suspension of any obligation 
        of service or payment of a recipient of an Indian Health 
        Scholarship if the Secretary determines that--
                    ``(A) it is not possible for the recipient to meet 
                that obligation or make that payment;
                    ``(B) requiring that recipient to meet that 
                obligation or make that payment would result in extreme 
                hardship to the recipient; or
                    ``(C) the enforcement of the requirement to meet 
                the obligation or make the payment would be 
                unconscionable.
            ``(5) Extreme hardship.--Notwithstanding any other 
        provision of law, in any case of extreme hardship or for other 
        good cause shown, the Secretary may waive, in whole or in part, 
        the right of the United States to recover funds made available 
        under this section.
            ``(6) Bankruptcy.--Notwithstanding any other provision of 
        law, with respect to a recipient of an Indian Health 
        Scholarship, no obligation for payment may be released by a 
        discharge in bankruptcy under title 11, United States Code, 
        unless that discharge is granted after the expiration of the 5-
        year period beginning on the initial date on which that payment 
        is due, and only if the bankruptcy court finds that the 
        nondischarge of the obligation would be unconscionable.

``SEC. 105. AMERICAN INDIANS INTO PSYCHOLOGY PROGRAM.

    ``(a) Grants Authorized.--The Secretary, acting through the 
Service, shall make grants of not more than $300,000 to each of 9 
colleges and universities for the purpose of developing and maintaining 
Indian psychology career recruitment programs as a means of encouraging 
Indians to enter the behavioral health field. These programs shall be 
located at various locations throughout the country to maximize their 
availability to Indian students and new programs shall be established 
in different locations from time to time.
    ``(b) Quentin N. Burdick Program Grant.--The Secretary shall 
provide a grant authorized under subsection (a) to develop and maintain 
a program at the University of North Dakota to be known as the `Quentin 
N. Burdick American Indians Into Psychology Program'. Such program 
shall, to the maximum extent feasible, coordinate with the Quentin N. 
Burdick Indian Health Programs authorized under section 117(b), the 
Quentin N. Burdick American Indians Into Nursing Program authorized 
under section 115(e), and existing university research and 
communications networks.
    ``(c) Regulations.--The Secretary shall issue regulations pursuant 
to this Act for the competitive awarding of grants provided under this 
section.
    ``(d) Conditions of Grant.--Applicants under this section shall 
agree to provide a program which, at a minimum--
            ``(1) provides outreach and recruitment for health 
        professions to Indian communities including elementary, 
        secondary, and accredited and accessible community colleges 
        that will be served by the program;
            ``(2) incorporates a program advisory board comprised of 
        representatives from the tribes and communities that will be 
        served by the program;
            ``(3) provides summer enrichment programs to expose Indian 
        students to the various fields of psychology through research, 
        clinical, and experimental activities;
            ``(4) provides stipends to undergraduate and graduate 
        students to pursue a career in psychology;
            ``(5) develops affiliation agreements with tribal colleges 
        and universities, the Service, university affiliated programs, 
        and other appropriate accredited and accessible entities to 
        enhance the education of Indian students;
            ``(6) to the maximum extent feasible, uses existing 
        university tutoring, counseling, and student support services; 
        and
            ``(7) to the maximum extent feasible, employs qualified 
        Indians in the program.
    ``(e) Active Duty Service Requirement.--The active duty service 
obligation prescribed under section 338C of the Public Health Service 
Act (42 U.S.C. 254m) shall be met by each graduate who receives a 
stipend described in subsection (d)(4) that is funded under this 
section. Such obligation shall be met by service--
            ``(1) in an Indian Health Program;
            ``(2) in a program assisted under title V of this Act; or
            ``(3) in the private practice of psychology if, as 
        determined by the Secretary, in accordance with guidelines 
        promulgated by the Secretary, such practice is situated in a 
        physician or other health professional shortage area and 
        addresses the health care needs of a substantial number of 
        Indians.
    ``(f) Authorization of Appropriations.--There is authorized to be 
appropriated such sums as may be necessary to carry out this section.

``SEC. 106. SCHOLARSHIP PROGRAMS FOR INDIAN TRIBES.

    ``(a) In General.--
            ``(1) Grants authorized.--The Secretary, acting through the 
        Service, shall make grants to Tribal Health Programs for the 
        purpose of providing scholarships for Indians to serve as 
        health professionals in Indian communities.
            ``(2) Amount.--Amounts available under paragraph (1) for 
        any fiscal year shall not exceed 5 percent of the amounts 
        available for each fiscal year for Indian Health Scholarships 
        under section 104.
            ``(3) Application.--An application for a grant under 
        paragraph (1) shall be in such form and contain such 
        agreements, assurances, and information as consistent with this 
        section.
    ``(b) Requirements.--
            ``(1) In general.--A Tribal Health Program receiving a 
        grant under subsection (a) shall provide scholarships to 
        Indians in accordance with the requirements of this section.
            ``(2) Costs.--With respect to costs of providing any 
        scholarship pursuant to subsection (a)--
                    ``(A) 80 percent of the costs of the scholarship 
                shall be paid from the funds made available pursuant to 
                subsection (a)(1) provided to the Tribal Health 
                Program; and
                    ``(B) 20 percent of such costs may be paid from any 
                other source of funds.
    ``(c) Course of Study.--A Tribal Health Program shall provide 
scholarships under this section only to Indians enrolled or accepted 
for enrollment in a course of study (approved by the Secretary) in 1 of 
the health professions contemplated by this Act.
    ``(d) Contract.--
            ``(1) In general.--In providing scholarships under 
        subsection (b), the Secretary and the Tribal Health Program 
        shall enter into a written contract with each recipient of such 
        scholarship.
            ``(2) Requirements.--Such contract shall--
                    ``(A) obligate such recipient to provide service in 
                an Indian Health Program or urban Indian organization, 
                in the same Service Area where the Tribal Health 
                Program providing the scholarship is located, for--
                            ``(i) a number of years for which the 
                        scholarship is provided (or the part-time 
                        equivalent thereof, as determined by the 
                        Secretary), or for a period of 2 years, 
                        whichever period is greater; or
                            ``(ii) such greater period of time as the 
                        recipient and the Tribal Health Program may 
                        agree;
                    ``(B) provide that the amount of the scholarship--
                            ``(i) may only be expended for--
                                    ``(I) tuition expenses, other 
                                reasonable educational expenses, and 
                                reasonable living expenses incurred in 
                                attendance at the educational 
                                institution; and
                                    ``(II) payment to the recipient of 
                                a monthly stipend of not more than the 
                                amount authorized by section 
                                338(g)(1)(B) of the Public Health 
                                Service Act (42 U.S.C. 254m(g)(1)(B)), 
                                with such amount to be reduced pro rata 
                                (as determined by the Secretary) based 
                                on the number of hours such student is 
                                enrolled, and not to exceed, for any 
                                year of attendance for which the 
                                scholarship is provided, the total 
                                amount required for the year for the 
                                purposes authorized in this clause; and
                            ``(ii) may not exceed, for any year of 
                        attendance for which the scholarship is 
                        provided, the total amount required for the 
                        year for the purposes authorized in clause (i);
                    ``(C) require the recipient of such scholarship to 
                maintain an acceptable level of academic standing as 
                determined by the educational institution in accordance 
                with regulations issued pursuant to this Act; and
                    ``(D) require the recipient of such scholarship to 
                meet the educational and licensure requirements 
                appropriate to each health profession.
            ``(3) Service in other service areas.--The contract may 
        allow the recipient to serve in another Service Area, provided 
        the Tribal Health Program and Secretary approve and services 
        are not diminished to Indians in the Service Area where the 
        Tribal Health Program providing the scholarship is located.
    ``(e) Breach of Contract.--
            ``(1) Specific breaches.--An individual who has entered 
        into a written contract with the Secretary and a Tribal Health 
        Program under subsection (d) shall be liable to the United 
        States for the Federal share of the amount which has been paid 
        to him or her, or on his or her behalf, under the contract if 
        that individual--
                    ``(A) fails to maintain an acceptable level of 
                academic standing in the educational institution in 
                which he or she is enrolled (such level as determined 
                by the educational institution under regulations of the 
                Secretary);
                    ``(B) is dismissed from such educational 
                institution for disciplinary reasons;
                    ``(C) voluntarily terminates the training in such 
                an educational institution for which he or she is 
                provided a scholarship under such contract before the 
                completion of such training; or
                    ``(D) fails to accept payment, or instructs the 
                educational institution in which he or she is enrolled 
                not to accept payment, in whole or in part, of a 
                scholarship under such contract, in lieu of any service 
                obligation arising under such contract.
            ``(2) Other breaches.--If for any reason not specified in 
        paragraph (1), an individual breaches a written contract by 
        failing to either begin such individual's service obligation 
        required under such contract or to complete such service 
        obligation, the United States shall be entitled to recover from 
        the individual an amount determined in accordance with the 
        formula specified in subsection (l) of section 110 in the 
        manner provided for in such subsection.
            ``(3) Cancellation upon death of recipient.--Upon the death 
        of an individual who receives an Indian Health Scholarship, any 
        outstanding obligation of that individual for service or 
        payment that relates to that scholarship shall be canceled.
            ``(4) Information.--The Secretary may carry out this 
        subsection on the basis of information received from Tribal 
        Health Programs involved or on the basis of information 
        collected through such other means as the Secretary deems 
        appropriate.
    ``(f) Relation to Social Security Act.--The recipient of a 
scholarship under this section shall agree, in providing health care 
pursuant to the requirements herein--
            ``(1) not to discriminate against an individual seeking 
        care on the basis of the ability of the individual to pay for 
        such care or on the basis that payment for such care will be 
        made pursuant to a program established in title XVIII of the 
        Social Security Act or pursuant to the programs established in 
        title XIX or title XXI of such Act; and
            ``(2) to accept assignment under section 1842(b)(3)(B)(ii) 
        of the Social Security Act for all services for which payment 
        may be made under part B of title XVIII of such Act, and to 
        enter into an appropriate agreement with the State agency that 
        administers the State plan for medical assistance under title 
        XIX, or the State child health plan under title XXI, of such 
        Act to provide service to individuals entitled to medical 
        assistance or child health assistance, respectively, under the 
        plan.
    ``(g) Continuance of Funding.--The Secretary shall make payments 
under this section to a Tribal Health Program for any fiscal year 
subsequent to the first fiscal year of such payments unless the 
Secretary determines that, for the immediately preceding fiscal year, 
the Tribal Health Program has not complied with the requirements of 
this section.

``SEC. 107. INDIAN HEALTH SERVICE EXTERN PROGRAMS.

    ``(a) Employment Preference.--Any individual who receives a 
scholarship pursuant to section 104 or 106 shall be given preference 
for employment in the Service, or may be employed by a Tribal Health 
Program or an urban Indian organization, or other agencies of the 
Department as available, during any nonacademic period of the year.
    ``(b) Not Counted Toward Active Duty Service Obligation.--Periods 
of employment pursuant to this subsection shall not be counted in 
determining fulfillment of the service obligation incurred as a 
condition of the scholarship.
    ``(c) Timing; Length of Employment.--Any individual enrolled in a 
program, including a high school program, authorized under section 
102(a) may be employed by the Service or by a Tribal Health Program or 
an urban Indian organization during any nonacademic period of the year. 
Any such employment shall not exceed 120 days during any calendar year.
    ``(d) Nonapplicability of Competitive Personnel System.--Any 
employment pursuant to this section shall be made without regard to any 
competitive personnel system or agency personnel limitation and to a 
position which will enable the individual so employed to receive 
practical experience in the health profession in which he or she is 
engaged in study. Any individual so employed shall receive payment for 
his or her services comparable to the salary he or she would receive if 
he or she were employed in the competitive system. Any individual so 
employed shall not be counted against any employment ceiling affecting 
the Service or the Department.

``SEC. 108. CONTINUING EDUCATION ALLOWANCES.

    ``In order to encourage scholarship and stipend recipients under 
sections 104, 105, 106, and 115 and health professionals, including 
community health representatives and emergency medical technicians, to 
join or continue in an Indian Health Program and to provide their 
services in the rural and remote areas where a significant portion of 
Indians reside, the Secretary, acting through the Service, may--
            ``(1) provide programs or allowances to transition into an 
        Indian Health Program, including licensing, board or 
        certification examination assistance, and technical assistance 
        in fulfilling service obligations under sections 104, 105, 106, 
        and 115; and
            ``(2) provide programs or allowances to health 
        professionals employed in an Indian Health Program to enable 
        them for a period of time each year prescribed by regulation of 
        the Secretary to take leave of their duty stations for 
        professional consultation, management, leadership, and 
        refresher training courses.

``SEC. 109. COMMUNITY HEALTH REPRESENTATIVE PROGRAM.

    ``(a) In General.--Under the authority of the Act of November 2, 
1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the 
Secretary, acting through the Service, shall maintain a Community 
Health Representative Program under which Indian Health Programs--
            ``(1) provide for the training of Indians as community 
        health representatives; and
            ``(2) use such community health representatives in the 
        provision of health care, health promotion, and disease 
        prevention services to Indian communities.
    ``(b) Duties.--The Community Health Representative Program of the 
Service, shall--
            ``(1) provide a high standard of training for community 
        health representatives to ensure that the community health 
        representatives provide quality health care, health promotion, 
        and disease prevention services to the Indian communities 
        served by the Program;
            ``(2) in order to provide such training, develop and 
        maintain a curriculum that--
                    ``(A) combines education in the theory of health 
                care with supervised practical experience in the 
                provision of health care; and
                    ``(B) provides instruction and practical experience 
                in health promotion and disease prevention activities, 
                with appropriate consideration given to lifestyle 
                factors that have an impact on Indian health status, 
                such as alcoholism, family dysfunction, and poverty;
            ``(3) maintain a system which identifies the needs of 
        community health representatives for continuing education in 
        health care, health promotion, and disease prevention and 
        develop programs that meet the needs for continuing education;
            ``(4) maintain a system that provides close supervision of 
        Community Health Representatives;
            ``(5) maintain a system under which the work of Community 
        Health Representatives is reviewed and evaluated; and
            ``(6) promote traditional health care practices of the 
        Indian Tribes served consistent with the Service standards for 
        the provision of health care, health promotion, and disease 
        prevention.

``SEC. 110. INDIAN HEALTH SERVICE LOAN REPAYMENT PROGRAM.

    ``(a) Establishment.--The Secretary, acting through the Service, 
shall establish and administer a program to be known as the Service 
Loan Repayment Program (hereinafter referred to as the `Loan Repayment 
Program') in order to ensure an adequate supply of trained health 
professionals necessary to maintain accreditation of, and provide 
health care services to Indians through, Indian Health Programs and 
urban Indian organizations.
    ``(b) Eligible Individuals.--To be eligible to participate in the 
Loan Repayment Program, an individual must--
            ``(1)(A) be enrolled--
                    ``(i) in a course of study or program in an 
                accredited educational institution (as determined by 
                the Secretary under section 338B(b)(1)(c)(i) of the 
                Public Health Service Act (42 U.S.C. 254l-
                1(b)(1)(c)(i))) and be scheduled to complete such 
                course of study in the same year such individual 
                applies to participate in such program; or
                    ``(ii) in an approved graduate training program in 
                a health profession; or
            ``(B) have--
                    ``(i) a degree in a health profession; and
                    ``(ii) a license to practice a health profession;
            ``(2)(A) be eligible for, or hold, an appointment as a 
        commissioned officer in the Regular or Reserve Corps of the 
        Public Health Service;
            ``(B) meet the professional standards for civil service 
        employment in the Service; or
            ``(C) be employed in an Indian Health Program or urban 
        Indian organization without a service obligation; and
            ``(3) submit to the Secretary an application for a contract 
        described in subsection (e).
    ``(c) Application.--
            ``(1) Information to be included with forms.--In 
        disseminating application forms and contract forms to 
        individuals desiring to participate in the Loan Repayment 
        Program, the Secretary shall include with such forms a fair 
        summary of the rights and liabilities of an individual whose 
        application is approved (and whose contract is accepted) by the 
        Secretary, including in the summary a clear explanation of the 
        damages to which the United States is entitled under subsection 
        (l) in the case of the individual's breach of contract. The 
        Secretary shall provide such individuals with sufficient 
        information regarding the advantages and disadvantages of 
        service as a commissioned officer in the Regular or Reserve 
        Corps of the Public Health Service or a civilian employee of 
        the Service to enable the individual to make a decision on an 
        informed basis.
            ``(2) Clear language.--The application form, contract form, 
        and all other information furnished by the Secretary under this 
        section shall be written in a manner calculated to be 
        understood by the average individual applying to participate in 
        the Loan Repayment Program.
            ``(3) Timely availability of forms.--The Secretary shall 
        make such application forms, contract forms, and other 
        information available to individuals desiring to participate in 
        the Loan Repayment Program on a date sufficiently early to 
        ensure that such individuals have adequate time to carefully 
        review and evaluate such forms and information.
    ``(d) Priorities.--
            ``(1) List.--Consistent with subsection (j), the Secretary 
        shall annually--
                    ``(A) identify the positions in each Indian Health 
                Program or urban Indian organization for which there is 
                a need or a vacancy; and
                    ``(B) rank those positions in order of priority.
            ``(2) Approvals.--Consistent with the priority determined 
        under paragraph (1), the Secretary, in determining which 
        applications under the Loan Repayment Program to approve (and 
        which contracts to accept), shall--
                    ``(A) give first priority to applications made by 
                individual Indians; and
                    ``(B) after making determinations on all 
                applications submitted by individual Indians as 
                required under subparagraph (A), give priority to--
                            ``(i) individuals recruited through the 
                        efforts of an Indian Health Program or urban 
                        Indian organization; and
                            ``(ii) other individuals based on the 
                        priority rankings under paragraph (1).
    ``(e) Recipient Contracts.--
            ``(1) Contract required.--An individual becomes a 
        participant in the Loan Repayment Program only upon the 
        Secretary and the individual entering into a written contract 
        described in paragraph (2).
            ``(2) Contents of contract.--The written contract referred 
        to in this section between the Secretary and an individual 
        shall contain--
                    ``(A) an agreement under which--
                            ``(i) subject to subparagraph (C), the 
                        Secretary agrees--
                                    ``(I) to pay loans on behalf of the 
                                individual in accordance with the 
                                provisions of this section; and
                                    ``(II) to accept (subject to the 
                                availability of appropriated funds for 
                                carrying out this section) the 
                                individual into the Service or place 
                                the individual with a Tribal Health 
                                Program or urban Indian organization as 
                                provided in clause (ii)(III); and
                            ``(ii) subject to subparagraph (C), the 
                        individual agrees--
                                    ``(I) to accept loan payments on 
                                behalf of the individual;
                                    ``(II) in the case of an individual 
                                described in subsection (b)(1)--
                                            ``(aa) to maintain 
                                        enrollment in a course of study 
                                        or training described in 
                                        subsection (b)(1)(A) until the 
                                        individual completes the course 
                                        of study or training; and
                                            ``(bb) while enrolled in 
                                        such course of study or 
                                        training, to maintain an 
                                        acceptable level of academic 
                                        standing (as determined under 
                                        regulations of the Secretary by 
                                        the educational institution 
                                        offering such course of study 
                                        or training); and
                                    ``(III) to serve for a time period 
                                (in this section referred to as the 
                                `period of obligated service') equal to 
                                2 years or such longer period as the 
                                individual may agree to serve in the 
                                full-time clinical practice of such 
                                individual's profession in an Indian 
                                Health Program or urban Indian 
                                organization to which the individual 
                                may be assigned by the Secretary;
                    ``(B) a provision permitting the Secretary to 
                extend for such longer additional periods, as the 
                individual may agree to, the period of obligated 
                service agreed to by the individual under subparagraph 
                (A)(ii)(III);
                    ``(C) a provision that any financial obligation of 
                the United States arising out of a contract entered 
                into under this section and any obligation of the 
                individual which is conditioned thereon is contingent 
                upon funds being appropriated for loan repayments under 
                this section;
                    ``(D) a statement of the damages to which the 
                United States is entitled under subsection (k) for the 
                individual's breach of the contract; and
                    ``(E) such other statements of the rights and 
                liabilities of the Secretary and of the individual, not 
                inconsistent with this section.
    ``(f) Deadline for Decision on Application.--The Secretary shall 
provide written notice to an individual within 21 days on--
            ``(1) the Secretary's approving, under subsection (e)(1), 
        of the individual's participation in the Loan Repayment 
        Program, including extensions resulting in an aggregate period 
        of obligated service in excess of 4 years; or
            ``(2) the Secretary's disapproving an individual's 
        participation in such Program.
    ``(g) Payments.--
            ``(1) In general.--A loan repayment provided for an 
        individual under a written contract under the Loan Repayment 
        Program shall consist of payment, in accordance with paragraph 
        (2), on behalf of the individual of the principal, interest, 
        and related expenses on government and commercial loans 
        received by the individual regarding the undergraduate or 
        graduate education of the individual (or both), which loans 
        were made for--
                    ``(A) tuition expenses;
                    ``(B) all other reasonable educational expenses, 
                including fees, books, and laboratory expenses, 
                incurred by the individual; and
                    ``(C) reasonable living expenses as determined by 
                the Secretary.
            ``(2) Amount.--For each year of obligated service that an 
        individual contracts to serve under subsection (e), the 
        Secretary may pay up to $35,000 or an amount equal to the 
        amount specified in section 338B(g)(2)(A) of the Public Health 
        Service Act, whichever is more, on behalf of the individual for 
        loans described in paragraph (1). In making a determination of 
        the amount to pay for a year of such service by an individual, 
        the Secretary shall consider the extent to which each such 
        determination--
                    ``(A) affects the ability of the Secretary to 
                maximize the number of contracts that can be provided 
                under the Loan Repayment Program from the amounts 
                appropriated for such contracts;
                    ``(B) provides an incentive to serve in Indian 
                Health Programs and urban Indian organizations with the 
                greatest shortages of health professionals; and
                    ``(C) provides an incentive with respect to the 
                health professional involved remaining in an Indian 
                Health Program or urban Indian organization with such a 
                health professional shortage, and continuing to provide 
                primary health services, after the completion of the 
                period of obligated service under the Loan Repayment 
                Program.
            ``(3) Timing.--Any arrangement made by the Secretary for 
        the making of loan repayments in accordance with this 
        subsection shall provide that any repayments for a year of 
        obligated service shall be made no later than the end of the 
        fiscal year in which the individual completes such year of 
        service.
            ``(4) Reimbursements for tax liability.--For the purpose of 
        providing reimbursements for tax liability resulting from a 
        payment under paragraph (2) on behalf of an individual, the 
        Secretary--
                    ``(A) in addition to such payments, may make 
                payments to the individual in an amount equal to not 
                less than 20 percent and not more than 39 percent of 
                the total amount of loan repayments made for the 
                taxable year involved; and
                    ``(B) may make such additional payments as the 
                Secretary determines to be appropriate with respect to 
                such purpose.
            ``(5) Payment schedule.--The Secretary may enter into an 
        agreement with the holder of any loan for which payments are 
        made under the Loan Repayment Program to establish a schedule 
        for the making of such payments.
    ``(h) Employment Ceiling.--Notwithstanding any other provision of 
law, individuals who have entered into written contracts with the 
Secretary under this section shall not be counted against any 
employment ceiling affecting the Department while those individuals are 
undergoing academic training.
    ``(i) Recruitment.--The Secretary shall conduct recruiting programs 
for the Loan Repayment Program and other manpower programs of the 
Service at educational institutions training health professionals or 
specialists identified in subsection (a).
    ``(j) Applicability of Law.--Section 214 of the Public Health 
Service Act (42 U.S.C. 215) shall not apply to individuals during their 
period of obligated service under the Loan Repayment Program.
    ``(k) Assignment of Individuals.--The Secretary, in assigning 
individuals to serve in Indian Health Programs or urban Indian 
organizations pursuant to contracts entered into under this section, 
shall--
            ``(1) ensure that the staffing needs of Tribal Health 
        Programs and urban Indian organizations receive consideration 
        on an equal basis with programs that are administered directly 
        by the Service; and
            ``(2) give priority to assigning individuals to Indian 
        Health Programs and urban Indian organizations that have a need 
        for health professionals to provide health care services as a 
        result of individuals having breached contracts entered into 
        under this section.
    ``(l) Breach of Contract.--
            ``(1) Specific breaches.--An individual who has entered 
        into a written contract with the Secretary under this section 
        and has not received a waiver under subsection (m) shall be 
        liable, in lieu of any service obligation arising under such 
        contract, to the United States for the amount which has been 
        paid on such individual's behalf under the contract if that 
        individual--
                    ``(A) is enrolled in the final year of a course of 
                study and--
                            ``(i) fails to maintain an acceptable level 
                        of academic standing in the educational 
                        institution in which he or she is enrolled 
                        (such level determined by the educational 
                        institution under regulations of the 
                        Secretary);
                            ``(ii) voluntarily terminates such 
                        enrollment; or
                            ``(iii) is dismissed from such educational 
                        institution before completion of such course of 
                        study; or
                    ``(B) is enrolled in a graduate training program 
                and fails to complete such training program.
            ``(2) Other breaches; formula for amount owed.--If, for any 
        reason not specified in paragraph (1), an individual breaches 
        his or her written contract under this section by failing 
        either to begin, or complete, such individual's period of 
        obligated service in accordance with subsection (e)(2), the 
        United States shall be entitled to recover from such individual 
        an amount to be determined in accordance with the following 
        formula: A=3Z(t-s/t) in which--
                    ``(A) `A' is the amount the United States is 
                entitled to recover;
                    ``(B) `Z' is the sum of the amounts paid under this 
                section to, or on behalf of, the individual and the 
                interest on such amounts which would be payable if, at 
                the time the amounts were paid, they were loans bearing 
                interest at the maximum legal prevailing rate, as 
                determined by the Secretary of the Treasury;
                    ``(C) `t' is the total number of months in the 
                individual's period of obligated service; and
                    ``(D) `s' is the number of months of such period 
                served by such individual in accordance with this 
                section.
            ``(3) Time period for repayment.--Any amount of damages 
        which the United States is entitled to recover under this 
        subsection shall be paid to the United States within the 1-year 
        period beginning on the date of the breach or such longer 
        period beginning on such date as shall be specified by the 
        Secretary.
            ``(4) Deductions in medicare payments.--Amounts not paid 
        within such period shall be subject to collection through 
        deductions in Medicare payments pursuant to section 1892 of the 
        Social Security Act.
            ``(5) Recovery of delinquency.--
                    ``(A) In general.--If damages described in 
                paragraph (4) are delinquent for 3 months, the 
                Secretary shall, for the purpose of recovering such 
                damages--
                            ``(i) use collection agencies contracted 
                        with by the Administrator of General Services; 
                        or
                            ``(ii) enter into contracts for the 
                        recovery of such damages with collection 
                        agencies selected by the Secretary.
                    ``(B) Report.--Each contract for recovering damages 
                pursuant to this subsection shall provide that the 
                contractor will, not less than once each 6 months, 
                submit to the Secretary a status report on the success 
                of the contractor in collecting such damages. Section 
                3718 of title 31, United States Code, shall apply to 
                any such contract to the extent not inconsistent with 
                this subsection.
    ``(m) Waiver or Suspension of Obligation.--
            ``(1) In general.--The Secretary shall by regulation 
        provide for the partial or total waiver or suspension of any 
        obligation of service or payment by an individual under the 
        Loan Repayment Program whenever compliance by the individual is 
        impossible or would involve extreme hardship to the individual 
        and if enforcement of such obligation with respect to any 
        individual would be unconscionable.
            ``(2) Canceled upon death.--Any obligation of an individual 
        under the Loan Repayment Program for service or payment of 
        damages shall be canceled upon the death of the individual.
            ``(3) Hardship waiver.--The Secretary may waive, in whole 
        or in part, the rights of the United States to recover amounts 
        under this section in any case of extreme hardship or other 
        good cause shown, as determined by the Secretary.
            ``(4) Bankruptcy.--Any obligation of an individual under 
        the Loan Repayment Program for payment of damages may be 
        released by a discharge in bankruptcy under title 11 of the 
        United States Code only if such discharge is granted after the 
        expiration of the 5-year period beginning on the first date 
        that payment of such damages is required, and only if the 
        bankruptcy court finds that nondischarge of the obligation 
        would be unconscionable.
    ``(n) Report.--The Secretary shall submit to the President, for 
inclusion in the report required to be submitted to Congress under 
section 801, a report concerning the previous fiscal year which sets 
forth by Service Area the following:
            ``(1) A list of the health professional positions 
        maintained by Indian Health Programs and urban Indian 
        organizations for which recruitment or retention is difficult.
            ``(2) The number of Loan Repayment Program applications 
        filed with respect to each type of health profession.
            ``(3) The number of contracts described in subsection (e) 
        that are entered into with respect to each health profession.
            ``(4) The amount of loan payments made under this section, 
        in total and by health profession.
            ``(5) The number of scholarships that are provided under 
        sections 104 and 106 with respect to each health profession.
            ``(6) The amount of scholarship grants provided under 
        sections 104 and 106, in total and by health profession.
            ``(7) The number of providers of health care that will be 
        needed by Indian Health Programs and urban Indian 
        organizations, by location and profession, during the 3 fiscal 
        years beginning after the date the report is filed.
            ``(8) The measures the Secretary plans to take to fill the 
        health professional positions maintained by Indian Health 
        Programs or urban Indian organizations for which recruitment or 
        retention is difficult.

``SEC. 111. SCHOLARSHIP AND LOAN REPAYMENT RECOVERY FUND.

    ``(a) Establishment.--There is established in the Treasury of the 
United States a fund to be known as the Indian Health Scholarship and 
Loan Repayment Recovery Fund (hereafter in this section referred to as 
the `LRRF'). The LRRF shall consist of such amounts as may be collected 
from individuals under section 104(d), section 106(e), and section 
110(l) for breach of contract, such funds as may be appropriated to the 
LRRF, and interest earned on amounts in the LRRF. All amounts 
collected, appropriated, or earned relative to the LRRF shall remain 
available until expended.
    ``(b) Use of Funds.--
            ``(1) By secretary.--Amounts in the LRRF may be expended by 
        the Secretary, acting through the Service, to make payments to 
        an Indian Health Program--
                    ``(A) to which a scholarship recipient under 
                section 104 and 106 or a loan repayment program 
                participant under section 110 has been assigned to meet 
                the obligated service requirements pursuant to such 
                sections; and
                    ``(B) that has a need for a health professional to 
                provide health care services as a result of such 
                recipient or participant having breached the contract 
                entered into under section 104, 106, or 110.
            ``(2) By tribal health programs.--A Tribal Health Program 
        receiving payments pursuant to paragraph (1) may expend the 
        payments to provide scholarships or recruit and employ, 
        directly or by contract, health professionals to provide health 
        care services.
    ``(c) Investment of Funds.--The Secretary of the Treasury shall 
invest such amounts of the LRRF as the Secretary of Health and Human 
Services determines are not required to meet current withdrawals from 
the LRRF. Such investments may be made only in interest bearing 
obligations of the United States. For such purpose, such obligations 
may be acquired on original issue at the issue price, or by purchase of 
outstanding obligations at the market price.
    ``(d) Sale of Obligations.--Any obligation acquired by the LRRF may 
be sold by the Secretary of the Treasury at the market price.

``SEC. 112. RECRUITMENT ACTIVITIES.

    ``(a) Reimbursement for Travel.--The Secretary, acting through the 
Service, may reimburse health professionals seeking positions with 
Indian Health Programs or urban Indian organizations, including 
individuals considering entering into a contract under section 110 and 
their spouses, for actual and reasonable expenses incurred in traveling 
to and from their places of residence to an area in which they may be 
assigned for the purpose of evaluating such area with respect to such 
assignment.
    ``(b) Recruitment Personnel.--The Secretary, acting through the 
Service, shall assign 1 individual in each Area Office to be 
responsible on a full-time basis for recruitment activities.

``SEC. 113. INDIAN RECRUITMENT AND RETENTION PROGRAM.

    ``(a) In General.--The Secretary, acting through the Service, shall 
fund, on a competitive basis, innovative demonstration projects for a 
period not to exceed 3 years to enable Indian Health Programs and urban 
Indian organizations to recruit, place, and retain health professionals 
to meet their staffing needs.
    ``(b) Eligible Entities; Application.--Any Indian Health Program or 
Urban Indian organization may submit an application for funding of a 
project pursuant to this section.

``SEC. 114. ADVANCED TRAINING AND RESEARCH.

    ``(a) Demonstration Program.--The Secretary, acting through the 
Service, shall establish a demonstration project to enable health 
professionals who have worked in an Indian Health Program or urban 
Indian organization for a substantial period of time to pursue advanced 
training or research areas of study for which the Secretary determines 
a need exists.
    ``(b) Service Obligation.--An individual who participates in a 
program under subsection (a), where the educational costs are borne by 
the Service, shall incur an obligation to serve in an Indian Health 
Program or urban Indian organization for a period of obligated service 
equal to at least the period of time during which the individual 
participates in such program. In the event that the individual fails to 
complete such obligated service, the individual shall be liable to the 
United States for the period of service remaining. In such event, with 
respect to individuals entering the program after the date of enactment 
of the Indian Health Care Improvement Act Amendments of 2009, the 
United States shall be entitled to recover from such individual an 
amount to be determined in accordance with the formula specified in 
subsection (l) of section 110 in the manner provided for in such 
subsection.
    ``(c) Equal Opportunity for Participation.--Health professionals 
from Tribal Health Programs and urban Indian organizations shall be 
given an equal opportunity to participate in the program under 
subsection (a).

``SEC. 115. QUENTIN N. BURDICK AMERICAN INDIANS INTO NURSING PROGRAM.

    ``(a) Grants Authorized.--For the purpose of increasing the number 
of nurses, nurse midwives, and nurse practitioners who deliver health 
care services to Indians, the Secretary, acting through the Service, 
shall provide grants to the following:
            ``(1) Public or private schools of nursing.
            ``(2) Tribal colleges or universities.
            ``(3) Nurse midwife programs and advanced practice nurse 
        programs that are provided by any tribal college or university 
        accredited nursing program, or in the absence of such, any 
        other public or private institutions.
    ``(b) Use of Grants.--Grants provided under subsection (a) may be 
used for 1 or more of the following:
            ``(1) To recruit individuals for programs which train 
        individuals to be nurses, nurse midwives, or advanced practice 
        nurses.
            ``(2) To provide scholarships to Indians enrolled in such 
        programs that may pay the tuition charged for such program and 
        other expenses incurred in connection with such program, 
        including books, fees, room and board, and stipends for living 
        expenses.
            ``(3) To provide a program that encourages nurses, nurse 
        midwives, and advanced practice nurses to provide, or continue 
        to provide, health care services to Indians.
            ``(4) To provide a program that increases the skills of, 
        and provides continuing education to, nurses, nurse midwives, 
        and advanced practice nurses.
            ``(5) To provide any program that is designed to achieve 
        the purpose described in subsection (a).
    ``(c) Applications.--Each application for a grant under subsection 
(a) shall include such information as the Secretary may require to 
establish the connection between the program of the applicant and a 
health care facility that primarily serves Indians.
    ``(d) Preferences for Grant Recipients.--In providing grants under 
subsection (a), the Secretary shall extend a preference to the 
following:
            ``(1) Programs that provide a preference to Indians.
            ``(2) Programs that train nurse midwives or advanced 
        practice nurses.
            ``(3) Programs that are interdisciplinary.
            ``(4) Programs that are conducted in cooperation with a 
        program for gifted and talented Indian students.
            ``(5) Programs conducted by tribal colleges and 
        universities.
    ``(e) Quentin N. Burdick Program Grant.--The Secretary shall 
provide 1 of the grants authorized under subsection (a) to establish 
and maintain a program at the University of North Dakota to be known as 
the `Quentin N. Burdick American Indians Into Nursing Program'. Such 
program shall, to the maximum extent feasible, coordinate with the 
Quentin N. Burdick Indian Health Programs established under section 
117(b) and the Quentin N. Burdick American Indians Into Psychology 
Program established under section 105(b).
    ``(f) Active Duty Service Obligation.--The active duty service 
obligation prescribed under section 338C of the Public Health Service 
Act (42 U.S.C. 254m) shall be met by each individual who receives 
training or assistance described in paragraph (1) or (2) of subsection 
(b) that is funded by a grant provided under subsection (a). Such 
obligation shall be met by service--
            ``(1) in the Service;
            ``(2) in a program of an Indian Tribe or Tribal 
        Organization conducted under the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450 et seq.) (including 
        programs under agreements with the Bureau of Indian Affairs);
            ``(3) in a program assisted under title V of this Act;
            ``(4) in the private practice of nursing if, as determined 
        by the Secretary, in accordance with guidelines promulgated by 
        the Secretary, such practice is situated in a physician or 
        other health shortage area and addresses the health care needs 
        of a substantial number of Indians; or
            ``(5) in a teaching capacity in a tribal college or 
        university nursing program (or a related health profession 
        program) if, as determined by the Secretary, health services 
        provided to Indians would not decrease.

``SEC. 116. TRIBAL CULTURAL ORIENTATION.

    ``(a) Cultural Education of Employees.--The Secretary, acting 
through the Service, shall require that appropriate employees of the 
Service who serve Indian Tribes in each Service Area receive 
educational instruction in the history and culture of such Indian 
Tribes and their relationship to the Service.
    ``(b) Program.--In carrying out subsection (a), the Secretary shall 
establish a program which shall, to the extent feasible--
            ``(1) be developed in consultation with the affected Indian 
        Tribes, Tribal Organizations, and urban Indian organizations;
            ``(2) be carried out through tribal colleges or 
        universities;
            ``(3) include instruction in American Indian studies; and
            ``(4) describe the use and place of traditional health care 
        practices of the Indian Tribes in the Service Area.

``SEC. 117. INMED PROGRAM.

    ``(a) Grants Authorized.--The Secretary, acting through the 
Service, is authorized to provide grants to colleges and universities 
for the purpose of maintaining and expanding the Indian health careers 
recruitment program known as the `Indians Into Medicine Program' 
(hereinafter in this section referred to as `INMED') as a means of 
encouraging Indians to enter the health professions.
    ``(b) Quentin N. Burdick Grant.--The Secretary shall provide 1 of 
the grants authorized under subsection (a) to maintain the INMED 
program at the University of North Dakota, to be known as the `Quentin 
N. Burdick Indian Health Programs', unless the Secretary makes a 
determination, based upon program reviews, that the program is not 
meeting the purposes of this section. Such program shall, to the 
maximum extent feasible, coordinate with the Quentin N. Burdick 
American Indians Into Psychology Program established under section 
105(b) and the Quentin N. Burdick American Indians Into Nursing Program 
established under section 115.
    ``(c) Regulations.--The Secretary, pursuant to this Act, shall 
develop regulations to govern grants pursuant to this section.
    ``(d) Requirements.--Applicants for grants provided under this 
section shall agree to provide a program which--
            ``(1) provides outreach and recruitment for health 
        professions to Indian communities including elementary and 
        secondary schools and community colleges located on 
        reservations which will be served by the program;
            ``(2) incorporates a program advisory board comprised of 
        representatives from the Indian Tribes and Indian communities 
        which will be served by the program;
            ``(3) provides summer preparatory programs for Indian 
        students who need enrichment in the subjects of math and 
        science in order to pursue training in the health professions;
            ``(4) provides tutoring, counseling, and support to 
        students who are enrolled in a health career program of study 
        at the respective college or university; and
            ``(5) to the maximum extent feasible, employs qualified 
        Indians in the program.

``SEC. 118. HEALTH TRAINING PROGRAMS OF COMMUNITY COLLEGES.

    ``(a) Grants To Establish Programs.--
            ``(1) In general.--The Secretary, acting through the 
        Service, shall award grants to accredited and accessible 
        community colleges for the purpose of assisting such community 
        colleges in the establishment of programs which provide 
        education in a health profession leading to a degree or diploma 
        in a health profession for individuals who desire to practice 
        such profession on or near a reservation or in an Indian Health 
        Program.
            ``(2) Amount of grants.--The amount of any grant awarded to 
        a community college under paragraph (1) for the first year in 
        which such a grant is provided to the community college shall 
        not exceed $250,000.
    ``(b) Grants for Maintenance and Recruiting.--
            ``(1) In general.--The Secretary, acting through the 
        Service, shall award grants to accredited and accessible 
        community colleges that have established a program described in 
        subsection (a)(1) for the purpose of maintaining the program 
        and recruiting students for the program.
            ``(2) Requirements.--Grants may only be made under this 
        section to a community college which--
                    ``(A) is accredited;
                    ``(B) has a relationship with a hospital facility, 
                Service facility, or hospital that could provide 
                training of nurses or health professionals;
                    ``(C) has entered into an agreement with an 
                accredited college or university medical school, the 
                terms of which--
                            ``(i) provide a program that enhances the 
                        transition and recruitment of students into 
                        advanced baccalaureate or graduate programs 
                        that train health professionals; and
                            ``(ii) stipulate certifications necessary 
                        to approve internship and field placement 
                        opportunities at Indian Health Programs;
                    ``(D) has a qualified staff which has the 
                appropriate certifications;
                    ``(E) is capable of obtaining State or regional 
                accreditation of the program described in subsection 
                (a)(1); and
                    ``(F) agrees to provide for Indian preference for 
                applicants for programs under this section.
    ``(c) Technical Assistance.--The Secretary shall encourage 
community colleges described in subsection (b)(2) to establish and 
maintain programs described in subsection (a)(1) by--
            ``(1) entering into agreements with such colleges for the 
        provision of qualified personnel of the Service to teach 
        courses of study in such programs; and
            ``(2) providing technical assistance and support to such 
        colleges.
    ``(d) Advanced Training.--
            ``(1) Required.--Any program receiving assistance under 
        this section that is conducted with respect to a health 
        profession shall also offer courses of study which provide 
        advanced training for any health professional who--
                    ``(A) has already received a degree or diploma in 
                such health profession; and
                    ``(B) provides clinical services on or near a 
                reservation or for an Indian Health Program.
            ``(2) May be offered at alternate site.--Such courses of 
        study may be offered in conjunction with the college or 
        university with which the community college has entered into 
        the agreement required under subsection (b)(2)(C).
    ``(e) Priority.--Where the requirements of subsection (b) are met, 
grant award priority shall be provided to tribal colleges and 
universities in Service Areas where they exist.

``SEC. 119. RETENTION BONUS.

    ``(a) Bonus Authorized.--The Secretary may pay a retention bonus to 
any health professional employed by, or assigned to, and serving in, an 
Indian Health Program or urban Indian organization either as a civilian 
employee or as a commissioned officer in the Regular or Reserve Corps 
of the Public Health Service who--
            ``(1) is assigned to, and serving in, a position for which 
        recruitment or retention of personnel is difficult;
            ``(2) the Secretary determines is needed by Indian Health 
        Programs and urban Indian organizations;
            ``(3) has--
                    ``(A) completed 2 years of employment with an 
                Indian Health Program or urban Indian organization; or
                    ``(B) completed any service obligations incurred as 
                a requirement of--
                            ``(i) any Federal scholarship program; or
                            ``(ii) any Federal education loan repayment 
                        program; and
            ``(4) enters into an agreement with an Indian Health 
        Program or urban Indian organization for continued employment 
        for a period of not less than 1 year.
    ``(b) Rates.--The Secretary may establish rates for the retention 
bonus which shall provide for a higher annual rate for multiyear 
agreements than for single year agreements referred to in subsection 
(a)(4), but in no event shall the annual rate be more than $25,000 per 
annum.
    ``(c) Default of Retention Agreement.--Any health professional 
failing to complete the agreed upon term of service, except where such 
failure is through no fault of the individual, shall be obligated to 
refund to the Government the full amount of the retention bonus for the 
period covered by the agreement, plus interest as determined by the 
Secretary in accordance with section 110(l)(2)(B).
    ``(d) Other Retention Bonus.--The Secretary may pay a retention 
bonus to any health professional employed by a Tribal Health Program if 
such health professional is serving in a position which the Secretary 
determines is--
            ``(1) a position for which recruitment or retention is 
        difficult; and
            ``(2) necessary for providing health care services to 
        Indians.

``SEC. 120. NURSING RESIDENCY PROGRAM.

    ``(a) Establishment of Program.--The Secretary, acting through the 
Service, shall establish a program to enable Indians who are licensed 
practical nurses, licensed vocational nurses, and registered nurses who 
are working in an Indian Health Program or urban Indian organization, 
and have done so for a period of not less than 1 year, to pursue 
advanced training. Such program shall include a combination of 
education and work study in an Indian Health Program or urban Indian 
organization leading to an associate or bachelor's degree (in the case 
of a licensed practical nurse or licensed vocational nurse), a 
bachelor's degree (in the case of a registered nurse), or advanced 
degrees or certifications in nursing and public health.
    ``(b) Service Obligation.--An individual who participates in a 
program under subsection (a), where the educational costs are paid by 
the Service, shall incur an obligation to serve in an Indian Health 
Program or urban Indian organization for a period of obligated service 
equal to 1 year for every year that nonprofessional employee (licensed 
practical nurses, licensed vocational nurses, nursing assistants, and 
various health care technicians), or 2 years for every year that 
professional nurse (associate degree and bachelor-prepared registered 
nurses), participates in such program. In the event that the individual 
fails to complete such obligated service, the United States shall be 
entitled to recover from such individual an amount determined in 
accordance with the formula specified subsection (d)(1) of Section 104 
for individuals failing to graduate from their degree program and 
subsection (l) of Section 110 for individuals failing to start or 
complete the obligated service.

``SEC. 121. COMMUNITY HEALTH AIDE PROGRAM.

    ``(a) General Purposes of Program.--Under the authority of the Act 
of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder 
Act'), the Secretary, acting through the Service, shall develop and 
operate a Community Health Aide Program in Alaska under which the 
Service--
            ``(1) provides for the training of Alaska Natives as health 
        aides or community health practitioners;
            ``(2) uses such aides or practitioners in the provision of 
        health care, health promotion, and disease prevention services 
        to Alaska Natives living in villages in rural Alaska; and
            ``(3) provides for the establishment of teleconferencing 
        capacity in health clinics located in or near such villages for 
        use by community health aides or community health 
        practitioners.
    ``(b) Specific Program Requirements.--The Secretary, acting through 
the Community Health Aide Program of the Service, shall--
            ``(1) using trainers accredited by the Program, provide a 
        high standard of training to community health aides and 
        community health practitioners to ensure that such aides and 
        practitioners provide quality health care, health promotion, 
        and disease prevention services to the villages served by the 
        Program;
            ``(2) in order to provide such training, develop a 
        curriculum that--
                    ``(A) combines education in the theory of health 
                care with supervised practical experience in the 
                provision of health care;
                    ``(B) provides instruction and practical experience 
                in the provision of acute care, emergency care, health 
                promotion, disease prevention, and the efficient and 
                effective management of clinic pharmacies, supplies, 
                equipment, and facilities; and
                    ``(C) promotes the achievement of the health status 
                objectives specified in section 3(2);
            ``(3) establish and maintain a Community Health Aide 
        Certification Board to certify as community health aides or 
        community health practitioners individuals who have 
        successfully completed the training described in paragraph (1) 
        or can demonstrate equivalent experience;
            ``(4) develop and maintain a system which identifies the 
        needs of community health aides and community health 
        practitioners for continuing education in the provision of 
        health care, including the areas described in paragraph (2)(B), 
        and develop programs that meet the needs for such continuing 
        education;
            ``(5) develop and maintain a system that provides close 
        supervision of community health aides and community health 
        practitioners;
            ``(6) develop a system under which the work of community 
        health aides and community health practitioners is reviewed and 
        evaluated to assure the provision of quality health care, 
        health promotion, and disease prevention services; and
            ``(7) ensure that pulpal therapy (not including pulpotomies 
        on deciduous teeth) or extraction of adult teeth can be 
        performed by a dental health aide therapist only after 
        consultation with a licensed dentist who determines that the 
        procedure is a medical emergency that cannot be resolved with 
        palliative treatment, and further that dental health aide 
        therapists are strictly prohibited from performing all other 
        oral or jaw surgeries, provided that uncomplicated extractions 
        shall not be considered oral surgery under this section.
    ``(c) Program Review.--
            ``(1) Neutral panel.--
                    ``(A) Establishment.--The Secretary, acting through 
                the Service, shall establish a neutral panel to carry 
                out the study under paragraph (2).
                    ``(B) Membership.--Members of the neutral panel 
                shall be appointed by the Secretary from among 
                clinicians, economists, community practitioners, oral 
                epidemiologists, and Alaska Natives.
            ``(2) Study.--
                    ``(A) In general.--The neutral panel established 
                under paragraph (1) shall conduct a study of the dental 
                health aide therapist services provided by the 
                Community Health Aide Program under this section to 
                ensure that the quality of care provided through those 
                services is adequate and appropriate.
                    ``(B) Parameters of study.--The Secretary, in 
                consultation with interested parties, including 
                professional dental organizations, shall develop the 
                parameters of the study.
                    ``(C) Inclusions.--The study shall include a 
                determination by the neutral panel with respect to--
                            ``(i) the ability of the dental health aide 
                        therapist services under this section to 
                        address the dental care needs of Alaska 
                        Natives;
                            ``(ii) the quality of care provided through 
                        those services, including any training, 
                        improvement, or additional oversight required 
                        to improve the quality of care; and
                            ``(iii) whether safer and less costly 
                        alternatives to the dental health aide 
                        therapist services exist.
                    ``(D) Consultation.--In carrying out the study 
                under this paragraph, the neutral panel shall consult 
                with Alaska Tribal Organizations with respect to the 
                adequacy and accuracy of the study.
            ``(3) Report.--The neutral panel shall submit to the 
        Secretary, the Committee on Indian Affairs of the Senate, and 
        the Committee on Natural Resources of the House of 
        Representatives a report describing the results of the study 
        under paragraph (2), including a description of--
                    ``(A) any determination of the neutral panel under 
                paragraph (2)(C); and
                    ``(B) any comments received from an Alaska Tribal 
                Organization under paragraph (2)(D).
    ``(d) Nationalization of Program.--
            ``(1) In general.--Except as provided in paragraph (2), the 
        Secretary, acting through the Service, may establish a national 
        Community Health Aide Program in accordance with the program 
        under this section, as the Secretary determines to be 
        appropriate.
            ``(2) Exception.--The national Community Health Aide 
        Program under paragraph (1) shall not include dental health 
        aide therapist services.
            ``(3) Requirement.--In establishing a national program 
        under paragraph (1), the Secretary shall not reduce the amount 
        of funds provided for the Community Health Aide Program 
        described in subsections (a) and (b).

``SEC. 122. TRIBAL HEALTH PROGRAM ADMINISTRATION.

    ``The Secretary shall, by contract or otherwise, provide training 
for individuals in the administration and planning of Tribal Health 
Programs, with priority to Indians.

``SEC. 123. HEALTH PROFESSIONAL CHRONIC SHORTAGE DEMONSTRATION 
              PROGRAMS.

    ``(a) Demonstration Programs Authorized.--The Secretary, acting 
through the Service, may fund demonstration programs for Tribal Health 
Programs to address the chronic shortages of health professionals.
    ``(b) Purposes of Programs.--The purposes of demonstration programs 
funded under subsection (a) shall be--
            ``(1) to provide direct clinical and practical experience 
        at a Service Unit to health profession students and residents 
        from medical schools;
            ``(2) to improve the quality of health care for Indians by 
        assuring access to qualified health care professionals; and
            ``(3) to provide academic and scholarly opportunities for 
        health professionals serving Indians by identifying all 
        academic and scholarly resources of the region.
    ``(c) Advisory Board.--The demonstration programs established 
pursuant to subsection (a) shall incorporate a program advisory board 
composed of representatives from the Indian Tribes and Indian 
communities in the area which will be served by the program.

``SEC. 124. NATIONAL HEALTH SERVICE CORPS.

    ``(a) No Reduction in Services.--The Secretary shall not--
            ``(1) remove a member of the National Health Service Corps 
        from an Indian Health Program or urban Indian organization; or
            ``(2) withdraw funding used to support such member, unless 
        the Secretary, acting through the Service, has ensured that the 
        Indians receiving services from such member will experience no 
        reduction in services.
    ``(b) Treatment of Indian Health Programs.--At the request of an 
Indian Health Program, the services of a member of the National Health 
Service Corps assigned to an Indian Health Program may be limited to 
the persons who are eligible for services from such Program.

``SEC. 125. SUBSTANCE ABUSE COUNSELOR EDUCATIONAL CURRICULA 
              DEMONSTRATION PROGRAMS.

    ``(a) Contracts and Grants.--The Secretary, acting through the 
Service, may enter into contracts with, or make grants to, accredited 
tribal colleges and universities and eligible accredited and accessible 
community colleges to establish demonstration programs to develop 
educational curricula for substance abuse counseling.
    ``(b) Use of Funds.--Funds provided under this section shall be 
used only for developing and providing educational curriculum for 
substance abuse counseling (including paying salaries for instructors). 
Such curricula may be provided through satellite campus programs.
    ``(c) Time Period of Assistance; Renewal.--A contract entered into 
or a grant provided under this section shall be for a period of 3 
years. Such contract or grant may be renewed for an additional 2-year 
period upon the approval of the Secretary.
    ``(d) Criteria for Review and Approval of Applications.--Not later 
than 180 days after the date of enactment of the Indian Health Care 
Improvement Act Amendments of 2009, the Secretary, after consultation 
with Indian Tribes and administrators of tribal colleges and 
universities and eligible accredited and accessible community colleges, 
shall develop and issue criteria for the review and approval of 
applications for funding (including applications for renewals of 
funding) under this section. Such criteria shall ensure that 
demonstration programs established under this section promote the 
development of the capacity of such entities to educate substance abuse 
counselors.
    ``(e) Assistance.--The Secretary shall provide such technical and 
other assistance as may be necessary to enable grant recipients to 
comply with the provisions of this section.
    ``(f) Report.--Each fiscal year, the Secretary shall submit to the 
President, for inclusion in the report which is required to be 
submitted under section 801 for that fiscal year, a report on the 
findings and conclusions derived from the demonstration programs 
conducted under this section during that fiscal year.
    ``(g) Definition.--For the purposes of this section, the term 
`educational curriculum' means 1 or more of the following:
            ``(1) Classroom education.
            ``(2) Clinical work experience.
            ``(3) Continuing education workshops.

``SEC. 126. BEHAVIORAL HEALTH TRAINING AND COMMUNITY EDUCATION 
              PROGRAMS.

    ``(a) Study; List.--The Secretary, acting through the Service, and 
the Secretary of the Interior, in consultation with Indian Tribes and 
Tribal Organizations, shall conduct a study and compile a list of the 
types of staff positions specified in subsection (b) whose 
qualifications include, or should include, training in the 
identification, prevention, education, referral, or treatment of mental 
illness, or dysfunctional and self-destructive behavior.
    ``(b) Positions.--The positions referred to in subsection (a) are--
            ``(1) staff positions within the Bureau of Indian Affairs, 
        including existing positions, in the fields of--
                    ``(A) elementary and secondary education;
                    ``(B) social services and family and child welfare;
                    ``(C) law enforcement and judicial services; and
                    ``(D) alcohol and substance abuse;
            ``(2) staff positions within the Service; and
            ``(3) staff positions similar to those identified in 
        paragraphs (1) and (2) established and maintained by Indian 
        Tribes, Tribal Organizations (without regard to the funding 
        source), and urban Indian organizations.
    ``(c) Training Criteria.--
            ``(1) In general.--The appropriate Secretary shall provide 
        training criteria appropriate to each type of position 
        identified in subsection (b)(1) and (b)(2) and ensure that 
        appropriate training has been, or shall be provided to any 
        individual in any such position. With respect to any such 
        individual in a position identified pursuant to subsection 
        (b)(3), the respective Secretaries shall provide appropriate 
        training to, or provide funds to, an Indian Tribe, Tribal 
        Organization, or urban Indian organization for training of 
        appropriate individuals. In the case of positions funded under 
        a contract or compact under the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450 et seq.), the 
        appropriate Secretary shall ensure that such training costs are 
        included in the contract or compact, as the Secretary 
        determines necessary.
            ``(2) Position specific training criteria.--Position 
        specific training criteria shall be culturally relevant to 
        Indians and Indian Tribes and shall ensure that appropriate 
        information regarding traditional health care practices is 
        provided.
    ``(d) Community Education on Mental Illness.--The Service shall 
develop and implement, on request of an Indian Tribe, Tribal 
Organization, or urban Indian organization, or assist the Indian Tribe, 
Tribal Organization, or urban Indian organization to develop and 
implement, a program of community education on mental illness. In 
carrying out this subsection, the Service shall, upon request of an 
Indian Tribe, Tribal Organization, or urban Indian organization, 
provide technical assistance to the Indian Tribe, Tribal Organization, 
or urban Indian organization to obtain and develop community 
educational materials on the identification, prevention, referral, and 
treatment of mental illness and dysfunctional and self-destructive 
behavior.
    ``(e) Plan.--Not later than 90 days after the date of enactment of 
the Indian Health Care Improvement Act Amendments of 2009, the 
Secretary shall develop a plan under which the Service will increase 
the health care staff providing behavioral health services by at least 
500 positions within 5 years after the date of enactment of this 
section, with at least 200 of such positions devoted to child, 
adolescent, and family services. The plan developed under this 
subsection shall be implemented under the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the `Snyder Act').

``SEC. 127. EXEMPTION FROM PAYMENT OF CERTAIN FEES.

    ``Employees of a Tribal Health Program or an Urban Indian 
Organization shall be exempt from payment of licensing, registration, 
and other fees imposed by a Federal agency to the same extent that 
Commissioned Corps Officers or other employees of the Indian Health 
Service are exempt from such fees.

``SEC. 128. AUTHORIZATION OF APPROPRIATIONS.

    ``There are authorized to be appropriated such sums as may be 
necessary to carry out this title.

                      ``TITLE II--HEALTH SERVICES

``SEC. 201. INDIAN HEALTH CARE IMPROVEMENT FUND.

    ``(a) Use of Funds.--The Secretary, acting through the Service, is 
authorized to expend funds, directly or under the authority of the 
Indian Self-Determination and Education Assistance Act (25 U.S.C. 450 
et seq.), which are appropriated under the authority of this section, 
for the purposes of--
            ``(1) eliminating the deficiencies in health status and 
        health resources of all Indian Tribes;
            ``(2) eliminating backlogs in the provision of health care 
        services to Indians;
            ``(3) meeting the health needs of Indians in an efficient 
        and equitable manner, including the use of telehealth and 
        telemedicine when appropriate;
            ``(4) eliminating inequities in funding for both direct 
        care and contract health service programs; and
            ``(5) augmenting the ability of the Service to meet the 
        following health service responsibilities with respect to those 
        Indian Tribes with the highest levels of health status 
        deficiencies and resource deficiencies:
                    ``(A) Clinical care, including inpatient care, 
                outpatient care (including audiology, clinical eye, and 
                vision care), primary care, secondary and tertiary 
                care, and long-term care.
                    ``(B) Preventive health, including mammography and 
                other cancer screening in accordance with section 207.
                    ``(C) Dental care.
                    ``(D) Mental health, including community mental 
                health services, inpatient mental health services, 
                dormitory mental health services, therapeutic and 
                residential treatment centers, and training of 
                traditional health care practitioners.
                    ``(E) Emergency medical services.
                    ``(F) Treatment and control of, and rehabilitative 
                care related to, alcoholism and drug abuse (including 
                fetal alcohol syndrome) among Indians.
                    ``(G) Injury prevention programs, including data 
                collection and evaluation, demonstration projects, 
                training, and capacity building.
                    ``(H) Home health care.
                    ``(I) Community health representatives.
                    ``(J) Maintenance and improvement.
    ``(b) No Offset or Limitation.--Any funds appropriated under the 
authority of this section shall not be used to offset or limit any 
other appropriations made to the Service under this Act or the Act of 
November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), 
or any other provision of law.
    ``(c) Allocation; Use.--
            ``(1) In general.--Funds appropriated under the authority 
        of this section shall be allocated to Service Units, Indian 
        Tribes, or Tribal Organizations. The funds allocated to each 
        Indian Tribe, Tribal Organization, or Service Unit under this 
        paragraph shall be used by the Indian Tribe, Tribal 
        Organization, or Service Unit under this paragraph to improve 
        the health status and reduce the resource deficiency of each 
        Indian Tribe served by such Service Unit, Indian Tribe, or 
        Tribal Organization.
            ``(2) Apportionment of allocated funds.--The apportionment 
        of funds allocated to a Service Unit, Indian Tribe, or Tribal 
        Organization under paragraph (1) among the health service 
        responsibilities described in subsection (a)(5) shall be 
        determined by the Service in consultation with, and with the 
        active participation of, the affected Indian Tribes and Tribal 
        Organizations.
    ``(d) Provisions Relating to Health Status and Resource 
Deficiencies.--For the purposes of this section, the following 
definitions apply:
            ``(1) Definition.--The term `health status and resource 
        deficiency' means the extent to which--
                    ``(A) the health status objectives set forth in 
                section 3(2) are not being achieved; and
                    ``(B) the Indian Tribe or Tribal Organization does 
                not have available to it the health resources it needs, 
                taking into account the actual cost of providing health 
                care services given local geographic, climatic, rural, 
                or other circumstances.
            ``(2) Available resources.--The health resources available 
        to an Indian Tribe or Tribal Organization include health 
        resources provided by the Service as well as health resources 
        used by the Indian Tribe or Tribal Organization, including 
        services and financing systems provided by any Federal 
        programs, private insurance, and programs of State or local 
        governments.
            ``(3) Process for review of determinations.--The Secretary 
        shall establish procedures which allow any Indian Tribe or 
        Tribal Organization to petition the Secretary for a review of 
        any determination of the extent of the health status and 
        resource deficiency of such Indian Tribe or Tribal 
        Organization.
    ``(e) Eligibility for Funds.--Tribal Health Programs shall be 
eligible for funds appropriated under the authority of this section on 
an equal basis with programs that are administered directly by the 
Service.
    ``(f) Report.--By no later than the date that is 3 years after the 
date of enactment of the Indian Health Care Improvement Act Amendments 
of 2009, the Secretary shall submit to Congress the current health 
status and resource deficiency report of the Service for each Service 
Unit, including newly recognized or acknowledged Indian Tribes. Such 
report shall set out--
            ``(1) the methodology then in use by the Service for 
        determining Tribal health status and resource deficiencies, as 
        well as the most recent application of that methodology;
            ``(2) the extent of the health status and resource 
        deficiency of each Indian Tribe served by the Service or a 
        Tribal Health Program;
            ``(3) the amount of funds necessary to eliminate the health 
        status and resource deficiencies of all Indian Tribes served by 
        the Service or a Tribal Health Program; and
            ``(4) an estimate of--
                    ``(A) the amount of health service funds 
                appropriated under the authority of this Act, or any 
                other Act, including the amount of any funds 
                transferred to the Service for the preceding fiscal 
                year which is allocated to each Service Unit, Indian 
                Tribe, or Tribal Organization;
                    ``(B) the number of Indians eligible for health 
                services in each Service Unit or Indian Tribe or Tribal 
                Organization; and
                    ``(C) the number of Indians using the Service 
                resources made available to each Service Unit, Indian 
                Tribe or Tribal Organization, and, to the extent 
                available, information on the waiting lists and number 
                of Indians turned away for services due to lack of 
                resources.
    ``(g) Inclusion in Base Budget.--Funds appropriated under this 
section for any fiscal year shall be included in the base budget of the 
Service for the purpose of determining appropriations under this 
section in subsequent fiscal years.
    ``(h) Clarification.--Nothing in this section is intended to 
diminish the primary responsibility of the Service to eliminate 
existing backlogs in unmet health care needs, nor are the provisions of 
this section intended to discourage the Service from undertaking 
additional efforts to achieve equity among Indian Tribes and Tribal 
Organizations.
    ``(i) Funding Designation.--Any funds appropriated under the 
authority of this section shall be designated as the `Indian Health 
Care Improvement Fund'.

``SEC. 202. HEALTH PROMOTION AND DISEASE PREVENTION SERVICES.

    ``(a) Findings.--Congress finds that health promotion and disease 
prevention activities--
            ``(1) improve the health and well-being of Indians; and
            ``(2) reduce the expenses for health care of Indians.
    ``(b) Provision of Services.--The Secretary, acting through the 
Service, shall provide health promotion and disease prevention services 
to Indians to achieve the health status objectives set forth in section 
3(2).
    ``(c) Evaluation.--The Secretary, after obtaining input from the 
affected Tribal Health Programs, shall submit to the President for 
inclusion in the report which is required to be submitted to Congress 
under section 801 an evaluation of--
            ``(1) the health promotion and disease prevention needs of 
        Indians;
            ``(2) the health promotion and disease prevention 
        activities which would best meet such needs;
            ``(3) the internal capacity of the Service and Tribal 
        Health Programs to meet such needs; and
            ``(4) the resources which would be required to enable the 
        Service and Tribal Health Programs to undertake the health 
        promotion and disease prevention activities necessary to meet 
        such needs.

``SEC. 203. DIABETES PREVENTION, TREATMENT, AND CONTROL.

    ``(a) Determinations Regarding Diabetes.--The Secretary, acting 
through the Service, and in consultation with Indian Tribes and Tribal 
Organizations, shall determine--
            ``(1) by Indian Tribe and by Service Unit, the incidence 
        of, and the types of complications resulting from, diabetes 
        among Indians; and
            ``(2) based on the determinations made pursuant to 
        paragraph (1), the measures (including patient education and 
        effective ongoing monitoring of disease indicators) each 
        Service Unit should take to reduce the incidence of, and 
        prevent, treat, and control the complications resulting from, 
        diabetes among Indian Tribes within that Service Unit.
    ``(b) Diabetes Screening.--To the extent medically indicated and 
with informed consent, the Secretary shall screen each Indian who 
receives services from the Service for diabetes and for conditions 
which indicate a high risk that the individual will become diabetic and 
establish a cost-effective approach to ensure ongoing monitoring of 
disease indicators. Such screening and monitoring may be conducted by a 
Tribal Health Program and may be conducted through appropriate 
Internet-based health care management programs.
    ``(c) Diabetes Projects.--The Secretary shall continue to maintain 
each model diabetes project in existence on the date of enactment of 
the Indian Health Care Improvement Act Amendments of 2009.
    ``(d) Dialysis Programs.--The Secretary is authorized to provide, 
through the Service, Indian Tribes, and Tribal Organizations, dialysis 
programs, including the purchase of dialysis equipment and the 
provision of necessary staffing.
    ``(e) Other Duties of the Secretary.--
            ``(1) In general.--The Secretary shall, to the extent 
        funding is available--
                    ``(A) in each Area Office, consult with Indian 
                Tribes and Tribal Organizations regarding programs for 
                the prevention, treatment, and control of diabetes;
                    ``(B) establish in each Area Office a registry of 
                patients with diabetes to track the incidence of 
                diabetes and the complications from diabetes in that 
                area; and
                    ``(C) ensure that data collected in each Area 
                Office regarding diabetes and related complications 
                among Indians are disseminated to all other Area 
                Offices, subject to applicable patient privacy laws.
            ``(2) Diabetes control officers.--
                    ``(A) In general.--The Secretary may establish and 
                maintain in each Area Office a position of diabetes 
                control officer to coordinate and manage any activity 
                of that Area Office relating to the prevention, 
                treatment, or control of diabetes to assist the 
                Secretary in carrying out a program under this section 
                or section 330C of the Public Health Service Act (42 
                U.S.C. 254c-3).
                    ``(B) Certain activities.--Any activity carried out 
                by a diabetes control officer under subparagraph (A) 
                that is the subject of a contract or compact under the 
                Indian Self-Determination and Education Assistance Act 
                (25 U.S.C. 450 et seq.), and any funds made available 
                to carry out such an activity, shall not be divisible 
                for purposes of that Act.

``SEC. 204. SHARED SERVICES FOR LONG-TERM CARE.

    ``(a) Long-term Care.--Notwithstanding any other provision of law, 
the Secretary, acting through the Service, is authorized to provide 
directly, or enter into contracts or compacts under the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450 et seq.) with 
Indian Tribes or Tribal Organizations for, the delivery of long-term 
care (including health care services associated with long-term care) 
provided in a facility to Indians. Such agreements shall provide for 
the sharing of staff or other services between the Service or a Tribal 
Health Program and a long-term care or related facility owned and 
operated (directly or through a contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 U.S.C. 450 et 
seq.)) by such Indian Tribe or Tribal Organization.
    ``(b) Contents of Agreements.--An agreement entered into pursuant 
to subsection (a)--
            ``(1) may, at the request of the Indian Tribe or Tribal 
        Organization, delegate to such Indian Tribe or Tribal 
        Organization such powers of supervision and control over 
        Service employees as the Secretary deems necessary to carry out 
        the purposes of this section;
            ``(2) shall provide that expenses (including salaries) 
        relating to services that are shared between the Service and 
        the Tribal Health Program be allocated proportionately between 
        the Service and the Indian Tribe or Tribal Organization; and
            ``(3) may authorize such Indian Tribe or Tribal 
        Organization to construct, renovate, or expand a long-term care 
        or other similar facility (including the construction of a 
        facility attached to a Service facility).
    ``(c) Minimum Requirement.--Any nursing facility provided for under 
this section shall meet the requirements for nursing facilities under 
section 1919 of the Social Security Act.
    ``(d) Other Assistance.--The Secretary shall provide such technical 
and other assistance as may be necessary to enable applicants to comply 
with the provisions of this section.
    ``(e) Use of Existing or Underused Facilities.--The Secretary shall 
encourage the use of existing facilities that are underused or allow 
the use of swing beds for long-term or similar care.

``SEC. 205. HEALTH SERVICES RESEARCH.

    ``(a) In General.--The Secretary, acting through the Service, shall 
make funding available for research to further the performance of the 
health service responsibilities of Indian Health Programs.
    ``(b) Coordination of Resources and Activities.--The Secretary 
shall also, to the maximum extent practicable, coordinate departmental 
research resources and activities to address relevant Indian Health 
Program research needs.
    ``(c) Availability.--Tribal Health Programs shall be given an equal 
opportunity to compete for, and receive, research funds under this 
section.
    ``(d) Use of Funds.--This funding may be used for both clinical and 
nonclinical research.
    ``(e) Evaluation and Dissemination.--The Secretary shall 
periodically--
            ``(1) evaluate the impact of research conducted under this 
        section; and
            ``(2) disseminate to Tribal Health Programs information 
        regarding that research as the Secretary determines to be 
        appropriate.

``SEC. 206. MAMMOGRAPHY AND OTHER CANCER SCREENING.

    ``The Secretary, acting through the Service, shall provide for 
screening as follows:
            ``(1) Screening mammography (as defined in section 1861(jj) 
        of the Social Security Act) for Indian women at a frequency 
        appropriate to such women under accepted and appropriate 
        national standards, and under such terms and conditions as are 
        consistent with standards established by the Secretary to 
        ensure the safety and accuracy of screening mammography under 
        part B of title XVIII of such Act.
            ``(2) Other cancer screening that receives an A or B rating 
        as recommended by the United States Preventive Services Task 
        Force established under section 915(a)(1) of the Public Health 
        Service Act (42 U.S.C. 299b-4(a)(1)). The Secretary shall 
        ensure that screening provided for under this paragraph 
        complies with the recommendations of the Task Force with 
        respect to--
                    ``(A) frequency;
                    ``(B) the population to be served;
                    ``(C) the procedure or technology to be used;
                    ``(D) evidence of effectiveness; and
                    ``(E) other matters that the Secretary determines 
                appropriate.

``SEC. 207. PATIENT TRAVEL COSTS.

    ``(a) Definition of Qualified Escort.--In this section, the term 
`qualified escort' means--
            ``(1) an adult escort (including a parent, guardian, or 
        other family member) who is required because of the physical or 
        mental condition, or age, of the applicable patient;
            ``(2) a health professional for the purpose of providing 
        necessary medical care during travel by the applicable patient; 
        or
            ``(3) other escorts, as the Secretary or applicable Indian 
        Health Program determines to be appropriate.
    ``(b) Provision of Funds.--The Secretary, acting through the 
Service, is authorized to provide funds for the following patient 
travel costs, including qualified escorts, associated with receiving 
health care services provided (either through direct or contract care 
or through a contract or compact under the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.)) under this Act--
            ``(1) emergency air transportation and non-emergency air 
        transportation where ground transportation is infeasible;
            ``(2) transportation by private vehicle (where no other 
        means of transportation is available), specially equipped 
        vehicle, and ambulance; and
            ``(3) transportation by such other means as may be 
        available and required when air or motor vehicle transportation 
        is not available.

``SEC. 208. EPIDEMIOLOGY CENTERS.

    ``(a) Establishment of Centers.--The Secretary shall establish an 
epidemiology center in each Service Area to carry out the functions 
described in subsection (b). Any new center established after the date 
of enactment of the Indian Health Care Improvement Act Amendments of 
2008 may be operated under a grant authorized by subsection (d), but 
funding under such a grant shall not be divisible.
    ``(b) Functions of Centers.--In consultation with and upon the 
request of Indian Tribes, Tribal Organizations, and Urban Indian 
communities, each Service Area epidemiology center established under 
this section shall, with respect to such Service Area--
            ``(1) collect data relating to, and monitor progress made 
        toward meeting, each of the health status objectives of the 
        Service, the Indian Tribes, Tribal Organizations, and Urban 
        Indian communities in the Service Area;
            ``(2) evaluate existing delivery systems, data systems, and 
        other systems that impact the improvement of Indian health;
            ``(3) assist Indian Tribes, Tribal Organizations, and Urban 
        Indian Organizations in identifying their highest priority 
        health status objectives and the services needed to achieve 
        such objectives, based on epidemiological data;
            ``(4) make recommendations for the targeting of services 
        needed by the populations served;
            ``(5) make recommendations to improve health care delivery 
        systems for Indians and Urban Indians;
            ``(6) provide requested technical assistance to Indian 
        Tribes, Tribal Organizations, and Urban Indian Organizations in 
        the development of local health service priorities and 
        incidence and prevalence rates of disease and other illness in 
        the community; and
            ``(7) provide disease surveillance and assist Indian 
        Tribes, Tribal Organizations, and Urban Indian communities to 
        promote public health.
    ``(c) Technical Assistance.--The Director of the Centers for 
Disease Control and Prevention shall provide technical assistance to 
the centers in carrying out the requirements of this section.
    ``(d) Grants for Studies.--
            ``(1) In general.--The Secretary may make grants to Indian 
        Tribes, Tribal Organizations, Indian organizations, and 
        eligible intertribal consortia to conduct epidemiological 
        studies of Indian communities.
            ``(2) Eligible intertribal consortia.--An intertribal 
        consortium or Indian organization is eligible to receive a 
        grant under this subsection if--
                    ``(A) the intertribal consortium is incorporated 
                for the primary purpose of improving Indian health; and
                    ``(B) the intertribal consortium is representative 
                of the Indian Tribes or urban Indian communities in 
                which the intertribal consortium is located.
            ``(3) Applications.--An application for a grant under this 
        subsection shall be submitted in such manner and at such time 
        as the Secretary shall prescribe.
            ``(4) Requirements.--An applicant for a grant under this 
        subsection shall--
                    ``(A) demonstrate the technical, administrative, 
                and financial expertise necessary to carry out the 
                functions described in paragraph (5);
                    ``(B) consult and cooperate with providers of 
                related health and social services in order to avoid 
                duplication of existing services; and
                    ``(C) demonstrate cooperation from Indian Tribes or 
                Urban Indian Organizations in the area to be served.
            ``(5) Use of funds.--A grant awarded under paragraph (1) 
        may be used--
                    ``(A) to carry out the functions described in 
                subsection (b);
                    ``(B) to provide information to and consult with 
                tribal leaders, urban Indian community leaders, and 
                related health staff on health care and health service 
                management issues; and
                    ``(C) in collaboration with Indian Tribes, Tribal 
                Organizations, and urban Indian communities, to provide 
                the Service with information regarding ways to improve 
                the health status of Indians.
    ``(e) Access to Information.--
            ``(1) An epidemiology center operated by a grantee pursuant 
        to a grant awarded under subsection (d) shall be treated as a 
        public health authority for purposes of the Health Insurance 
        Portability and Accountability Act of 1996, as such entities 
        are defined in part 164.501 of title 45, Code of Federal 
        Regulations.
            ``(2) The Secretary shall grant to such epidemiology center 
        access to use of the data, data sets, monitoring systems, 
        delivery systems, and other protected health information in the 
        possession of the Secretary.
            ``(3) The activities of such an epidemiology center shall 
        be for the purposes of research and for preventing and 
        controlling disease, injury, or disability for purposes of the 
        Health Insurance Portability and Accountability Act of 1996 
        (Public Law 104-191; 110 Stat. 2033), as such activities are 
        described in part 164.512 of title 45, Code of Federal 
        Regulations (or a successor regulation).
    ``(f) Funds Not Divisible.--An epidemiology center established 
under this section shall be subject to the provisions of the Indian 
Self-Determination and Education Assistance Act (25 U.S.C. 450 et 
seq.), but the funds for such center shall not be divisible.

``SEC. 209. COMPREHENSIVE SCHOOL HEALTH EDUCATION PROGRAMS.

    ``(a) Funding for Development of Programs.--In addition to carrying 
out any other program for health promotion or disease prevention, the 
Secretary, acting through the Service, is authorized to award grants to 
Indian Tribes and Tribal Organizations to develop comprehensive school 
health education programs for children from pre-school through grade 12 
in schools for the benefit of Indian children.
    ``(b) Use of Grant Funds.--A grant awarded under this section may 
be used for purposes which may include, but are not limited to, the 
following:
            ``(1) Developing health education materials both for 
        regular school programs and afterschool programs.
            ``(2) Training teachers in comprehensive school health 
        education materials.
            ``(3) Integrating school-based, community-based, and other 
        public and private health promotion efforts.
            ``(4) Encouraging healthy, tobacco-free school 
        environments.
            ``(5) Coordinating school-based health programs with 
        existing services and programs available in the community.
            ``(6) Developing school programs on nutrition education, 
        personal health, oral health, and fitness.
            ``(7) Developing behavioral health wellness programs.
            ``(8) Developing chronic disease prevention programs.
            ``(9) Developing substance abuse prevention programs.
            ``(10) Developing injury prevention and safety education 
        programs.
            ``(11) Developing activities for the prevention and control 
        of communicable diseases.
            ``(12) Developing community and environmental health 
        education programs that include traditional health care 
        practitioners.
            ``(13) Violence prevention.
            ``(14) Such other health issues as are appropriate.
    ``(c) Technical Assistance.--Upon request, the Secretary, acting 
through the Service, shall provide technical assistance to Indian 
Tribes and Tribal Organizations in the development of comprehensive 
health education plans and the dissemination of comprehensive health 
education materials and information on existing health programs and 
resources.
    ``(d) Criteria for Review and Approval of Applications.--The 
Secretary, acting through the Service, and in consultation with Indian 
Tribes and Tribal Organizations, shall establish criteria for the 
review and approval of applications for grants awarded under this 
section.
    ``(e) Development of Program for BIA-funded Schools.--
            ``(1) In general.--The Secretary of the Interior, acting 
        through the Bureau of Indian Affairs and in cooperation with 
        the Secretary, acting through the Service, shall develop a 
        comprehensive school health education program for children from 
        preschool through grade 12 in schools for which support is 
        provided by the Bureau of Indian Affairs.
            ``(2) Requirements for programs.--Such programs shall 
        include--
                    ``(A) school programs on nutrition education, 
                personal health, oral health, and fitness;
                    ``(B) behavioral health wellness programs;
                    ``(C) chronic disease prevention programs;
                    ``(D) substance abuse prevention programs;
                    ``(E) injury prevention and safety education 
                programs; and
                    ``(F) activities for the prevention and control of 
                communicable diseases.
            ``(3) Duties of the secretary.--The Secretary of the 
        Interior shall--
                    ``(A) provide training to teachers in comprehensive 
                school health education materials;
                    ``(B) ensure the integration and coordination of 
                school-based programs with existing services and health 
                programs available in the community; and
                    ``(C) encourage healthy, tobacco-free school 
                environments.

``SEC. 210. INDIAN YOUTH PROGRAM.

    ``(a) Program Authorized.--The Secretary, acting through the 
Service, is authorized to establish and administer a program to provide 
grants to Indian Tribes, Tribal Organizations, and urban Indian 
organizations for innovative mental and physical disease prevention and 
health promotion and treatment programs for Indian and urban Indian 
preadolescent and adolescent youths.
    ``(b) Use of Funds.--
            ``(1) Allowable uses.--Funds made available under this 
        section may be used to--
                    ``(A) develop prevention and treatment programs for 
                Indian youth which promote mental and physical health 
                and incorporate cultural values, community and family 
                involvement, and traditional health care practitioners; 
                and
                    ``(B) develop and provide community training and 
                education.
            ``(2) Prohibited use.--Funds made available under this 
        section may not be used to provide services described in 
        section 707(c).
    ``(c) Duties of the Secretary.--The Secretary shall--
            ``(1) disseminate to Indian Tribes, Tribal Organizations, 
        and urban Indian organizations information regarding models for 
        the delivery of comprehensive health care services to Indian 
        and urban Indian adolescents;
            ``(2) encourage the implementation of such models; and
            ``(3) at the request of an Indian Tribe, Tribal 
        Organization, or urban Indian organization, provide technical 
        assistance in the implementation of such models.
    ``(d) Criteria for Review and Approval of Applications.--The 
Secretary, in consultation with Indian Tribes, Tribal Organizations, 
and urban Indian organizations, shall establish criteria for the review 
and approval of applications or proposals under this section.

``SEC. 211. PREVENTION, CONTROL, AND ELIMINATION OF COMMUNICABLE AND 
              INFECTIOUS DISEASES.

    ``(a) Grants Authorized.--The Secretary, acting through the 
Service, and after consultation with the Centers for Disease Control 
and Prevention, may make grants available to Indian Tribes, Tribal 
Organizations, and urban Indian organizations for the following:
            ``(1) Projects for the prevention, control, and elimination 
        of communicable and infectious diseases, including 
        tuberculosis, hepatitis, HIV, respiratory syncytial virus, 
        hanta virus, sexually transmitted diseases, and H. Pylori.
            ``(2) Public information and education programs for the 
        prevention, control, and elimination of communicable and 
        infectious diseases.
            ``(3) Education, training, and clinical skills improvement 
        activities in the prevention, control, and elimination of 
        communicable and infectious diseases for health professionals, 
        including allied health professionals.
            ``(4) Demonstration projects for the screening, treatment, 
        and prevention of hepatitis C virus (HCV).
    ``(b) Application Required.--The Secretary may provide funding 
under subsection (a) only if an application or proposal for funding is 
submitted to the Secretary.
    ``(c) Coordination With Health Agencies.--Indian Tribes, Tribal 
Organizations, and urban Indian organizations receiving funding under 
this section are encouraged to coordinate their activities with the 
Centers for Disease Control and Prevention and State and local health 
agencies.
    ``(d) Technical Assistance; Report.--In carrying out this section, 
the Secretary--
            ``(1) may, at the request of an Indian Tribe, Tribal 
        Organization, or urban Indian organization, provide technical 
        assistance; and
            ``(2) shall prepare and submit a report to Congress 
        biennially on the use of funds under this section and on the 
        progress made toward the prevention, control, and elimination 
        of communicable and infectious diseases among Indians and Urban 
        Indians.

``SEC. 212. OTHER AUTHORITY FOR PROVISION OF SERVICES.

    ``(a) Funding Authorized.--The Secretary may provide funding under 
this Act to meet the objectives set forth in section 3 of this Act 
through health care-related services and programs of the Service, 
Indian Tribes, and Tribal Organizations not otherwise described in this 
Act for the following services:
            ``(1) Hospice care.
            ``(2) Assisted living services.
            ``(3) Long-term care services.
            ``(4) Home- and community-based services.
    ``(b) Eligibility.--The following individuals shall be eligible to 
receive long-term care under this section:
            ``(1) Individuals who are unable to perform a certain 
        number of activities of daily living without assistance.
            ``(2) Individuals with a mental impairment, such as 
        dementia, Alzheimer's disease, or another disabling mental 
        illness, who may be able to perform activities of daily living 
        under supervision.
            ``(3) Such other individuals as an applicable Indian Health 
        Program determines to be appropriate.
    ``(c) Definitions.--For the purposes of this section, the following 
definitions shall apply:
            ``(1) The term `assisted living services' means any service 
        provided by an assisted living facility (as defined in section 
        232(b) of the National Housing Act (12 U.S.C. 1715w(b))), 
        except that such an assisted living facility--
                    ``(A) shall not be required to obtain a license; 
                but
                    ``(B) shall meet all applicable standards for 
                licensure.
            ``(2) The term `home- and community-based services' means 1 
        or more of the services specified in paragraphs (1) through (9) 
        of section 1929(a) of the Social Security Act (42 U.S.C. 
        1396t(a)) (whether provided by the Service or by an Indian 
        Tribe or Tribal Organization pursuant to the Indian Self-
        Determination and Education Assistance Act (25 U.S.C. 450 et 
        seq.)) that are or will be provided in accordance with 
        applicable standards.
            ``(3) The term `hospice care' means the items and services 
        specified in subparagraphs (A) through (H) of section 
        1861(dd)(1) of the Social Security Act (42 U.S.C. 
        1395x(dd)(1)), and such other services which an Indian Tribe or 
        Tribal Organization determines are necessary and appropriate to 
        provide in furtherance of this care.
            ``(4) The term `long-term care services' has the meaning 
        given the term `qualified long-term care services' in section 
        7702B(c) of the Internal Revenue Code of 1986.
    ``(d) Authorization of Convenient Care Services.--The Secretary, 
acting through the Service, Indian Tribes, and Tribal Organizations, 
may also provide funding under this Act to meet the objectives set 
forth in section 3 of this Act for convenient care services programs 
pursuant to section 306(c)(2)(A).

``SEC. 213. INDIAN WOMEN'S HEALTH CARE.

    ``The Secretary, acting through the Service and Indian Tribes, 
Tribal Organizations, and Urban Indian Organizations, shall monitor and 
improve the quality of health care for Indian women of all ages through 
the planning and delivery of programs administered by the Service, in 
order to improve and enhance the treatment models of care for Indian 
women.

``SEC. 214. ENVIRONMENTAL AND NUCLEAR HEALTH HAZARDS.

    ``(a) Studies and Monitoring.--The Secretary and the Service shall 
conduct, in conjunction with other appropriate Federal agencies and in 
consultation with concerned Indian Tribes and Tribal Organizations, 
studies and ongoing monitoring programs to determine trends in the 
health hazards to Indian miners and to Indians on or near reservations 
and Indian communities as a result of environmental hazards which may 
result in chronic or life threatening health problems, such as nuclear 
resource development, petroleum contamination, and contamination of 
water source and of the food chain. Such studies shall include--
            ``(1) an evaluation of the nature and extent of health 
        problems caused by environmental hazards currently exhibited 
        among Indians and the causes of such health problems;
            ``(2) an analysis of the potential effect of ongoing and 
        future environmental resource development on or near 
        reservations and Indian communities, including the cumulative 
        effect over time on health;
            ``(3) an evaluation of the types and nature of activities, 
        practices, and conditions causing or affecting such health 
        problems, including uranium mining and milling, uranium mine 
        tailing deposits, nuclear power plant operation and 
        construction, and nuclear waste disposal; oil and gas 
        production or transportation on or near reservations or Indian 
        communities; and other development that could affect the health 
        of Indians and their water supply and food chain;
            ``(4) a summary of any findings and recommendations 
        provided in Federal and State studies, reports, investigations, 
        and inspections during the 5 years prior to the date of 
        enactment of the Indian Health Care Improvement Act Amendments 
        of 2009 that directly or indirectly relate to the activities, 
        practices, and conditions affecting the health or safety of 
        such Indians; and
            ``(5) the efforts that have been made by Federal and State 
        agencies and resource and economic development companies to 
        effectively carry out an education program for such Indians 
        regarding the health and safety hazards of such development.
    ``(b) Health Care Plans.--Upon completion of such studies, the 
Secretary and the Service shall take into account the results of such 
studies and develop health care plans to address the health problems 
studied under subsection (a). The plans shall include--
            ``(1) methods for diagnosing and treating Indians currently 
        exhibiting such health problems;
            ``(2) preventive care and testing for Indians who may be 
        exposed to such health hazards, including the monitoring of the 
        health of individuals who have or may have been exposed to 
        excessive amounts of radiation or affected by other activities 
        that have had or could have a serious impact upon the health of 
        such individuals; and
            ``(3) a program of education for Indians who, by reason of 
        their work or geographic proximity to such nuclear or other 
        development activities, may experience health problems.
    ``(c) Submission of Report and Plan to Congress.--The Secretary and 
the Service shall submit to Congress the study prepared under 
subsection (a) no later than 18 months after the date of enactment of 
the Indian Health Care Improvement Act Amendments of 2009. The health 
care plan prepared under subsection (b) shall be submitted in a report 
no later than 1 year after the study prepared under subsection (a) is 
submitted to Congress. Such report shall include recommended activities 
for the implementation of the plan, as well as an evaluation of any 
activities previously undertaken by the Service to address such health 
problems.
    ``(d) Intergovernmental Task Force.--
            ``(1) Establishment; members.--There is established an 
        Intergovernmental Task Force to be composed of the following 
        individuals (or their designees):
                    ``(A) The Secretary of Energy.
                    ``(B) The Secretary of the Environmental Protection 
                Agency.
                    ``(C) The Director of the Bureau of Mines.
                    ``(D) The Assistant Secretary for Occupational 
                Safety and Health.
                    ``(E) The Secretary of the Interior.
                    ``(F) The Secretary of Health and Human Services.
                    ``(G) The Director of the Indian Health Service.
            ``(2) Duties.--The Task Force shall--
                    ``(A) identify existing and potential operations 
                related to nuclear resource development or other 
                environmental hazards that affect or may affect the 
                health of Indians on or near a reservation or in an 
                Indian community; and
                    ``(B) enter into activities to correct existing 
                health hazards and ensure that current and future 
                health problems resulting from nuclear resource or 
                other development activities are minimized or reduced.
            ``(3) Chairman; meetings.--The Secretary of Health and 
        Human Services shall be the Chairman of the Task Force. The 
        Task Force shall meet at least twice each year.
    ``(e) Health Services to Certain Employees.--In the case of any 
Indian who--
            ``(1) as a result of employment in or near a uranium mine 
        or mill or near any other environmental hazard, suffers from a 
        work-related illness or condition;
            ``(2) is eligible to receive diagnosis and treatment 
        services from an Indian Health Program; and
            ``(3) by reason of such Indian's employment, is entitled to 
        medical care at the expense of such mine or mill operator or 
        entity responsible for the environmental hazard, the Indian 
        Health Program shall, at the request of such Indian, render 
        appropriate medical care to such Indian for such illness or 
        condition and may be reimbursed for any medical care so 
        rendered to which such Indian is entitled at the expense of 
        such operator or entity from such operator or entity. Nothing 
        in this subsection shall affect the rights of such Indian to 
        recover damages other than such amounts paid to the Indian 
        Health Program from the employer for providing medical care for 
        such illness or condition.

``SEC. 215. ARIZONA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

    ``(a) In General.--For fiscal years beginning with the fiscal year 
ending September 30, 1983, and ending with the fiscal year ending 
September 30, 2025, the State of Arizona shall be designated as a 
contract health service delivery area by the Service for the purpose of 
providing contract health care services to members of federally 
recognized Indian Tribes of Arizona.
    ``(b) Maintenance of Services.--The Service shall not curtail any 
health care services provided to Indians residing on reservations in 
the State of Arizona if such curtailment is due to the provision of 
contract services in such State pursuant to the designation of such 
State as a contract health service delivery area pursuant to subsection 
(a).

``SEC. 216. NORTH DAKOTA AND SOUTH DAKOTA AS CONTRACT HEALTH SERVICE 
              DELIVERY AREA.

    ``(a) In General.--Beginning in fiscal year 2003, the States of 
North Dakota and South Dakota shall be designated as a contract health 
service delivery area by the Service for the purpose of providing 
contract health care services to members of federally recognized Indian 
Tribes of North Dakota and South Dakota.
    ``(b) Limitation.--The Service shall not curtail any health care 
services provided to Indians residing on any reservation, or in any 
county that has a common boundary with any reservation, in the State of 
North Dakota or South Dakota if such curtailment is due to the 
provision of contract services in such States pursuant to the 
designation of such States as a contract health service delivery area 
pursuant to subsection (a).

``SEC. 217. CALIFORNIA CONTRACT HEALTH SERVICES PROGRAM.

    ``(a) Funding Authorized.--The Secretary is authorized to fund a 
program using the California Rural Indian Health Board (hereafter in 
this section referred to as the `CRIHB') as a contract care 
intermediary to improve the accessibility of health services to 
California Indians.
    ``(b) Reimbursement Contract.--The Secretary shall enter into an 
agreement with the CRIHB to reimburse the CRIHB for costs (including 
reasonable administrative costs) incurred pursuant to this section, in 
providing medical treatment under contract to California Indians 
described in section 805(a) throughout the California contract health 
services delivery area described in section 219 with respect to high 
cost contract care cases.
    ``(c) Administrative Expenses.--Not more than 5 percent of the 
amounts provided to the CRIHB under this section for any fiscal year 
may be for reimbursement for administrative expenses incurred by the 
CRIHB during such fiscal year.
    ``(d) Limitation on Payment.--No payment may be made for treatment 
provided hereunder to the extent payment may be made for such treatment 
under the Indian Catastrophic Health Emergency Fund described in 
section 202 or from amounts appropriated or otherwise made available to 
the California contract health service delivery area for a fiscal year.
    ``(e) Advisory Board.--There is established an advisory board which 
shall advise the CRIHB in carrying out this section. The advisory board 
shall be composed of representatives, selected by the CRIHB, from not 
less than 8 Tribal Health Programs serving California Indians covered 
under this section at least \1/2\ of whom of whom are not affiliated 
with the CRIHB.

``SEC. 218. CALIFORNIA AS A CONTRACT HEALTH SERVICE DELIVERY AREA.

    ``The State of California, excluding the counties of Alameda, 
Contra Costa, Los Angeles, Marin, Orange, Sacramento, San Francisco, 
San Mateo, Santa Clara, Kern, Merced, Monterey, Napa, San Benito, San 
Joaquin, San Luis Obispo, Santa Cruz, Solano, Stanislaus, and Ventura, 
shall be designated as a contract health service delivery area by the 
Service for the purpose of providing contract health services to 
California Indians. However, any of the counties listed herein may only 
be included in the contract health services delivery area if funding is 
specifically provided by the Service for such services in those 
counties.

``SEC. 219. CONTRACT HEALTH SERVICES FOR THE TRENTON SERVICE AREA.

    ``(a) Authorization for Services.--The Secretary, acting through 
the Service, is directed to provide contract health services to members 
of the Turtle Mountain Band of Chippewa Indians that reside in the 
Trenton Service Area of Divide, McKenzie, and Williams counties in the 
State of North Dakota and the adjoining counties of Richland, 
Roosevelt, and Sheridan in the State of Montana.
    ``(b) No Expansion of Eligibility.--Nothing in this section may be 
construed as expanding the eligibility of members of the Turtle 
Mountain Band of Chippewa Indians for health services provided by the 
Service beyond the scope of eligibility for such health services that 
applied on May 1, 1986.

``SEC. 220. PROGRAMS OPERATED BY INDIAN TRIBES AND TRIBAL 
              ORGANIZATIONS.

    ``The Service shall provide funds for health care programs, 
functions, services, activities, information technology, and facilities 
operated by Tribal Health Programs on the same basis as such funds are 
provided to programs, functions, services, activities, information 
technology, and facilities operated directly by the Service.

``SEC. 221. LICENSING.

    ``Licensed health care professionals employed by a Tribal Health 
Program shall, if licensed in any State, be exempt from the licensing 
requirements of the State in which the Tribal Health Program performs 
the services described in its contract or compact under the Indian 
Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) 
while performing such services.

``SEC. 222. NOTIFICATION OF PROVISION OF EMERGENCY CONTRACT HEALTH 
              SERVICES.

    ``With respect to an elderly Indian or an Indian with a disability 
receiving emergency medical care or services from a non-Service 
provider or in a non-Service facility under the authority of this Act, 
the time limitation (as a condition of payment) for notifying the 
Service of such treatment or admission shall be 30 days.

``SEC. 223. PROMPT ACTION ON PAYMENT OF CLAIMS.

    ``(a) Deadline for Response.--The Service shall respond to a 
notification of a claim by a provider of a contract care service with 
either an individual purchase order or a denial of the claim within 5 
working days after the receipt of such notification.
    ``(b) Effect of Untimely Response.--If the Service fails to respond 
to a notification of a claim in accordance with subsection (a), the 
Service shall accept as valid the claim submitted by the provider of a 
contract care service.
    ``(c) Deadline for Payment of Valid Claim.--The Service shall pay a 
valid contract care service claim within 30 days after the completion 
of the claim.

``SEC. 224. LIABILITY FOR PAYMENT.

    ``(a) No Patient Liability.--A patient who receives contract health 
care services that are authorized by the Service shall not be liable 
for the payment of any charges or costs associated with the provision 
of such services.
    ``(b) Notification.--The Secretary shall notify a contract care 
provider and any patient who receives contract health care services 
authorized by the Service that such patient is not liable for the 
payment of any charges or costs associated with the provision of such 
services not later than 5 business days after receipt of a notification 
of a claim by a provider of contract care services.
    ``(c) No Recourse.--Following receipt of the notice provided under 
subsection (b), or, if a claim has been deemed accepted under section 
224(b), the provider shall have no further recourse against the patient 
who received the services.

``SEC. 225. OFFICE OF INDIAN MEN'S HEALTH.

    ``(a) Establishment.--The Secretary may establish within the 
Service an office to be known as the `Office of Indian Men's Health' 
(referred to in this section as the `Office').
    ``(b) Director.--
            ``(1) In general.--The Office shall be headed by a 
        director, to be appointed by the Secretary.
            ``(2) Duties.--The director shall coordinate and promote 
        the status of the health of Indian men in the United States.
    ``(c) Report.--Not later than 2 years after the date of enactment 
of the Indian Health Care Improvement Act Amendments of 2009, the 
Secretary, acting through the director of the Office, shall submit to 
Congress a report describing--
            ``(1) any activity carried out by the director as of the 
        date on which the report is prepared; and
            ``(2) any finding of the director with respect to the 
        health of Indian men.

``SEC. 226. CATASTROPHIC HEALTH EMERGENCY FUND.

    ``(a) Establishment.--There is established an Indian Catastrophic 
Health Emergency Fund (hereafter in this section referred to as the 
`CHEF') consisting of--
            ``(1) the amounts deposited under subsection (f); and
            ``(2) the amounts appropriated to CHEF under this section.
    ``(b) Administration.--CHEF shall be administered by the Secretary, 
acting through the headquarters of the Service, solely for the purpose 
of meeting the extraordinary medical costs associated with the 
treatment of victims of disasters or catastrophic illnesses who are 
within the responsibility of the Service.
    ``(c) Conditions on Use of Fund.--No part of CHEF or its 
administration shall be subject to contract or grant under any law, 
including the Indian Self-Determination and Education Assistance Act 
(25 U.S.C. 450 et seq.), nor shall CHEF funds be allocated, 
apportioned, or delegated on an Area Office, Service Unit, or other 
similar basis.
    ``(d) Regulations.--The Secretary shall promulgate regulations 
consistent with the provisions of this section to--
            ``(1) establish a definition of disasters and catastrophic 
        illnesses for which the cost of the treatment provided under 
        contract would qualify for payment from CHEF;
            ``(2) provide that a Service Unit shall not be eligible for 
        reimbursement for the cost of treatment from CHEF until its 
        cost of treating any victim of such catastrophic illness or 
        disaster has reached a certain threshold cost which the 
        Secretary shall establish at--
                    ``(A) the 2000 level of $19,000; and
                    ``(B) for any subsequent year, not less than the 
                threshold cost of the previous year increased by the 
                percentage increase in the medical care expenditure 
                category of the consumer price index for all urban 
                consumers (United States city average) for the 12-month 
                period ending with December of the previous year;
            ``(3) establish a procedure for the reimbursement of the 
        portion of the costs that exceeds such threshold cost incurred 
        by--
                    ``(A) Service Units; or
                    ``(B) whenever otherwise authorized by the Service, 
                non-Service facilities or providers;
            ``(4) establish a procedure for payment from CHEF in cases 
        in which the exigencies of the medical circumstances warrant 
        treatment prior to the authorization of such treatment by the 
        Service; and
            ``(5) establish a procedure that will ensure that no 
        payment shall be made from CHEF to any provider of treatment to 
        the extent that such provider is eligible to receive payment 
        for the treatment from any other Federal, State, local, or 
        private source of reimbursement for which the patient is 
        eligible.
    ``(e) No Offset or Limitation.--Amounts appropriated to CHEF under 
this section shall not be used to offset or limit appropriations made 
to the Service under the authority of the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the `Snyder Act'), or any other law.
    ``(f) Deposit of Reimbursement Funds.--There shall be deposited 
into CHEF all reimbursements to which the Service is entitled from any 
Federal, State, local, or private source (including third party 
insurance) by reason of treatment rendered to any victim of a disaster 
or catastrophic illness the cost of which was paid from CHEF.

``SEC. 227. AUTHORIZATION OF APPROPRIATIONS.

    ``There are authorized to be appropriated such sums as may be 
necessary to carry out this title.

                        ``TITLE III--FACILITIES

``SEC. 301. CONSULTATION; CONSTRUCTION AND RENOVATION OF FACILITIES; 
              REPORTS.

    ``(a) Prerequisites for Expenditure of Funds.--Prior to the 
expenditure of, or the making of any binding commitment to expend, any 
funds appropriated for the planning, design, construction, or 
renovation of facilities pursuant to the Act of November 2, 1921 (25 
U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary, acting 
through the Service, shall--
            ``(1) consult with any Indian Tribe that would be 
        significantly affected by such expenditure for the purpose of 
        determining and, whenever practicable, honoring tribal 
        preferences concerning size, location, type, and other 
        characteristics of any facility on which such expenditure is to 
        be made; and
            ``(2) ensure, whenever practicable and applicable, that 
        such facility meets the construction standards of any 
        accrediting body recognized by the Secretary for the purposes 
        of the Medicare, Medicaid, and SCHIP programs under titles 
        XVIII, XIX, and XXI of the Social Security Act by not later 
        than 1 year after the date on which the construction or 
        renovation of such facility is completed.
    ``(b) Closures.--
            ``(1) Evaluation required.--Notwithstanding any other 
        provision of law, no facility operated by the Service may be 
        closed if the Secretary has not submitted to Congress, not less 
        than 1 year and not more than 2 years before the date of the 
        proposed closure, an evaluation, completed not more than 2 
        years before such submission, of the impact of the proposed 
        closure that specifies, in addition to other considerations--
                    ``(A) the accessibility of alternative health care 
                resources for the population served by such facility;
                    ``(B) the cost-effectiveness of such closure;
                    ``(C) the quality of health care to be provided to 
                the population served by such facility after such 
                closure;
                    ``(D) the availability of contract health care 
                funds to maintain existing levels of service;
                    ``(E) the views of the Indian Tribes served by such 
                facility concerning such closure;
                    ``(F) the level of use of such facility by all 
                eligible Indians; and
                    ``(G) the distance between such facility and the 
                nearest operating Service hospital.
            ``(2) Exception for certain temporary closures.--Paragraph 
        (1) shall not apply to any temporary closure of a facility or 
        any portion of a facility if such closure is necessary for 
        medical, environmental, or construction safety reasons.
    ``(c) Health Care Facility Priority System.--
            ``(1) In general.--
                    ``(A) Priority system.--The Secretary, acting 
                through the Service, shall maintain a health care 
                facility priority system, which--
                            ``(i) shall be developed in consultation 
                        with Indian Tribes and Tribal Organizations;
                            ``(ii) shall give Indian Tribes' needs the 
                        highest priority;
                            ``(iii)(I) may include the lists required 
                        in paragraph (2)(B)(ii); and
                            ``(II) shall include the methodology 
                        required in paragraph (2)(B)(v); and
                            ``(III) may include such other facilities, 
                        and such renovation or expansion needs of any 
                        health care facility, as the Service, Indian 
                        Tribes, and Tribal Organizations may identify; 
                        and
                            ``(iv) shall provide an opportunity for the 
                        nomination of planning, design, and 
                        construction projects by the Service, Indian 
                        Tribes, and Tribal Organizations for 
                        consideration under the priority system at 
                        least once every 3 years, or more frequently as 
                        the Secretary determines to be appropriate.
                    ``(B) Needs of facilities under isdeaa 
                agreements.--The Secretary shall ensure that the 
                planning, design, construction, renovation, and 
                expansion needs of Service and non-Service facilities 
                operated under contracts or compacts in accordance with 
                the Indian Self-Determination and Education Assistance 
                Act (25 U.S.C. 450 et seq.) are fully and equitably 
                integrated into the health care facility priority 
                system.
                    ``(C) Criteria for evaluating needs.--For purposes 
                of this subsection, the Secretary, in evaluating the 
                needs of facilities operated under a contract or 
                compact under the Indian Self-Determination and 
                Education Assistance Act (25 U.S.C. 450 et seq.), shall 
                use the criteria used by the Secretary in evaluating 
                the needs of facilities operated directly by the 
                Service.
                    ``(D) Priority of certain projects protected.--The 
                priority of any project established under the 
                construction priority system in effect on the date of 
                enactment of the Indian Health Care Improvement Act 
                Amendments of 2009 shall not be affected by any change 
                in the construction priority system taking place after 
                that date if the project--
                            ``(i) was identified in the fiscal year 
                        2008 Service budget justification as--
                                    ``(I) 1 of the 10 top-priority 
                                inpatient projects;
                                    ``(II) 1 of the 10 top-priority 
                                outpatient projects;
                                    ``(III) 1 of the 10 top-priority 
                                staff quarters developments; or
                                    ``(IV) 1 of the 10 top-priority 
                                Youth Regional Treatment Centers;
                            ``(ii) had completed both Phase I and Phase 
                        II of the construction priority system in 
                        effect on the date of enactment of such Act; or
                            ``(iii) is not included in clause (i) or 
                        (ii) and is selected, as determined by the 
                        Secretary--
                                    ``(I) on the initiative of the 
                                Secretary; or
                                    ``(II) pursuant to a request of an 
                                Indian Tribe or Tribal Organization.
            ``(2) Report; contents.--
                    ``(A) Initial comprehensive report.--
                            ``(i) Definitions.--In this subparagraph:
                                    ``(I) Facilities appropriation 
                                advisory board.--The term `Facilities 
                                Appropriation Advisory Board' means the 
                                advisory board, comprised of 12 members 
                                representing Indian tribes and 2 
                                members representing the Service, 
                                established at the discretion of the 
                                Assistant Secretary--
                                            ``(aa) to provide advice 
                                        and recommendations for 
                                        policies and procedures of the 
                                        programs funded pursuant to 
                                        facilities appropriations; and
                                            ``(bb) to address other 
                                        facilities issues.
                                    ``(II) Facilities needs assessment 
                                workgroup.--The term `Facilities Needs 
                                Assessment Workgroup' means the 
                                workgroup established at the discretion 
                                of the Assistant Secretary--
                                            ``(aa) to review the health 
                                        care facilities construction 
                                        priority system; and
                                            ``(bb) to make 
                                        recommendations to the 
                                        Facilities Appropriation 
                                        Advisory Board for revising the 
                                        priority system.
                            ``(ii) Initial report.--
                                    ``(I) In general.--Not later than 1 
                                year after the date of enactment of the 
                                Indian Health Care Improvement Act 
                                Amendments of 2009, the Secretary shall 
                                submit to the Committee on Indian 
                                Affairs of the Senate and the Committee 
                                on Natural Resources of the House of 
                                Representatives a report that describes 
                                the comprehensive, national, ranked 
                                list of all health care facilities 
                                needs for the Service, Indian Tribes, 
                                and Tribal Organizations (including 
                                inpatient health care facilities, 
                                outpatient health care facilities, 
                                specialized health care facilities 
                                (such as for long-term care and alcohol 
                                and drug abuse treatment), wellness 
                                centers, staff quarters and hostels 
                                associated with health care facilities, 
                                and the renovation and expansion needs, 
                                if any, of such facilities) developed 
                                by the Service, Indian Tribes, and 
                                Tribal Organizations for the Facilities 
                                Needs Assessment Workgroup and the 
                                Facilities Appropriation Advisory 
                                Board.
                                    ``(II) Inclusions.--The initial 
                                report shall include--
                                            ``(aa) the methodology and 
                                        criteria used by the Service in 
                                        determining the needs and 
                                        establishing the ranking of the 
                                        facilities needs; and
                                            ``(bb) such other 
                                        information as the Secretary 
                                        determines to be appropriate.
                            ``(iii) Updates of report.--Beginning in 
                        calendar year 2011, the Secretary shall--
                                    ``(I) update the report under 
                                clause (ii) not less frequently that 
                                once every 5 years; and
                                    ``(II) include the updated report 
                                in the appropriate annual report under 
                                subparagraph (B) for submission to 
                                Congress under section 801.
                    ``(B) Annual reports.--The Secretary shall submit 
                to the President, for inclusion in the report required 
                to be transmitted to Congress under section 801, a 
                report which sets forth the following:
                            ``(i) A description of the health care 
                        facility priority system of the Service 
                        established under paragraph (1).
                            ``(ii) Health care facilities lists, which 
                        may include--
                                    ``(I) the 10 top-priority inpatient 
                                health care facilities;
                                    ``(II) the 10 top-priority 
                                outpatient health care facilities;
                                    ``(III) the 10 top-priority 
                                specialized health care facilities 
                                (such as long-term care and alcohol and 
                                drug abuse treatment);
                                    ``(IV) the 10 top-priority staff 
                                quarters developments associated with 
                                health care facilities; and
                                    ``(V) the 10 top-priority hostels 
                                associated with health care facilities.
                            ``(iii) The justification for such order of 
                        priority.
                            ``(iv) The projected cost of such projects.
                            ``(v) The methodology adopted by the 
                        Service in establishing priorities under its 
                        health care facility priority system.
            ``(3) Requirements for preparation of reports.--In 
        preparing the report required under paragraph (2), the 
        Secretary shall--
                    ``(A) consult with and obtain information on all 
                health care facilities needs from Indian Tribes, Tribal 
                Organizations, and urban Indian organizations; and
                    ``(B) review the total unmet needs of all Indian 
                Tribes, Tribal Organizations, and urban Indian 
                organizations for health care facilities (including 
                hostels and staff quarters), including needs for 
                renovation and expansion of existing facilities.
    ``(d) Review of Methodology Used for Health Facilities Construction 
Priority System.--
            ``(1) In general.--Not later than 1 year after the 
        establishment of the priority system under subsection 
        (c)(1)(A), the Comptroller General of the United States shall 
        prepare and finalize a report reviewing the methodologies 
        applied, and the processes followed, by the Service in making 
        each assessment of needs for the list under subsection 
        (c)(2)(A)(ii) and developing the priority system under 
        subsection (c)(1), including a review of--
                    ``(A) the recommendations of the Facilities 
                Appropriation Advisory Board and the Facilities Needs 
                Assessment Workgroup (as those terms are defined in 
                subsection (c)(2)(A)(i)); and
                    ``(B) the relevant criteria used in ranking or 
                prioritizing facilities other than hospitals or 
                clinics.
            ``(2) Submission to congress.--The Comptroller General of 
        the United States shall submit the report under paragraph (1) 
        to--
                    ``(A) the Committees on Indian Affairs and 
                Appropriations of the Senate;
                    ``(B) the Committees on Natural Resources and 
                Appropriations of the House of Representatives; and
                    ``(C) the Secretary.
    ``(e) Funding Condition.--All funds appropriated under the Act of 
November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), 
for the planning, design, construction, or renovation of health 
facilities for the benefit of 1 or more Indian Tribes shall be subject 
to the provisions of the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.).
    ``(f) Development of Innovative Approaches.--The Secretary shall 
consult and cooperate with Indian Tribes, Tribal Organizations, and 
urban Indian organizations in developing innovative approaches to 
address all or part of the total unmet need for construction of health 
facilities, including those provided for in other sections of this 
title and other approaches.

``SEC. 302. SANITATION FACILITIES.

    ``(a) Findings.--Congress finds the following:
            ``(1) The provision of sanitation facilities is primarily a 
        health consideration and function.
            ``(2) Indian people suffer an inordinately high incidence 
        of disease, injury, and illness directly attributable to the 
        absence or inadequacy of sanitation facilities.
            ``(3) The long-term cost to the United States of treating 
        and curing such disease, injury, and illness is substantially 
        greater than the short-term cost of providing sanitation 
        facilities and other preventive health measures.
            ``(4) Many Indian homes and Indian communities still lack 
        sanitation facilities.
            ``(5) It is in the interest of the United States, and it is 
        the policy of the United States, that all Indian communities 
        and Indian homes, new and existing, be provided with sanitation 
        facilities.
    ``(b) Facilities and Services.--In furtherance of the findings made 
in subsection (a), Congress reaffirms the primary responsibility and 
authority of the Service to provide the necessary sanitation facilities 
and services as provided in section 7 of the Act of August 5, 1954 (42 
U.S.C. 2004a). Under such authority, the Secretary, acting through the 
Service, is authorized to provide the following:
            ``(1) Financial and technical assistance to Indian Tribes, 
        Tribal Organizations, and Indian communities in the 
        establishment, training, and equipping of utility organizations 
        to operate and maintain sanitation facilities, including the 
        provision of existing plans, standard details, and 
        specifications available in the Department, to be used at the 
        option of the Indian Tribe, Tribal Organization, or Indian 
        community.
            ``(2) Ongoing technical assistance and training to Indian 
        Tribes, Tribal Organizations, and Indian communities in the 
        management of utility organizations which operate and maintain 
        sanitation facilities.
            ``(3) Priority funding for operation and maintenance 
        assistance for, and emergency repairs to, sanitation facilities 
        operated by an Indian Tribe, Tribal Organization or Indian 
        community when necessary to avoid an imminent health threat or 
        to protect the investment in sanitation facilities and the 
        investment in the health benefits gained through the provision 
        of sanitation facilities.
    ``(c) Funding.--Notwithstanding any other provision of law--
            ``(1) the Secretary of Housing and Urban Development is 
        authorized to transfer funds appropriated under the Native 
        American Housing Assistance and Self-Determination Act of 1996 
        (25 U.S.C. 4101 et seq.) to the Secretary of Health and Human 
        Services;
            ``(2) the Secretary of Health and Human Services is 
        authorized to accept and use such funds for the purpose of 
        providing sanitation facilities and services for Indians under 
        section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a);
            ``(3) unless specifically authorized when funds are 
        appropriated, the Secretary shall not use funds appropriated 
        under section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), 
        to provide sanitation facilities to new homes constructed using 
        funds provided by the Department of Housing and Urban 
        Development;
            ``(4) the Secretary of Health and Human Services is 
        authorized to accept from any source, including Federal and 
        State agencies, funds for the purpose of providing sanitation 
        facilities and services and place these funds into contracts or 
        compacts under the Indian Self-Determination and Education 
        Assistance Act (25 U.S.C. 450 et seq.);
            ``(5) except as otherwise prohibited by this section, the 
        Secretary may use funds appropriated under the authority of 
        section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to 
        fund up to 100 percent of the amount of an Indian Tribe's loan 
        obtained under any Federal program for new projects to 
        construct eligible sanitation facilities to serve Indian homes;
            ``(6) except as otherwise prohibited by this section, the 
        Secretary may use funds appropriated under the authority of 
        section 7 of the Act of August 5, 1954 (42 U.S.C. 2004a), to 
        meet matching or cost participation requirements under other 
        Federal and non-Federal programs for new projects to construct 
        eligible sanitation facilities;
            ``(7) all Federal agencies are authorized to transfer to 
        the Secretary funds identified, granted, loaned, or 
        appropriated whereby the Department's applicable policies, 
        rules, and regulations shall apply in the implementation of 
        such projects;
            ``(8) the Secretary of Health and Human Services shall 
        enter into interagency agreements with Federal and State 
        agencies for the purpose of providing financial assistance for 
        sanitation facilities and services under this Act;
            ``(9) the Secretary of Health and Human Services shall, by 
        regulation, establish standards applicable to the planning, 
        design, and construction of sanitation facilities funded under 
        this Act; and
            ``(10) the Secretary of Health and Human Services is 
        authorized to accept payments for goods and services furnished 
        by the Service from appropriate public authorities, nonprofit 
        organizations or agencies, or Indian Tribes, as contributions 
        by that authority, organization, agency, or tribe to agreements 
        made under section 7 of the Act of August 5, 1954 (42 U.S.C. 
        2004a), and such payments shall be credited to the same or 
        subsequent appropriation account as funds appropriated under 
        the authority of section 7 of the Act of August 5, 1954 (42 
        U.S.C. 2004a).
    ``(d) Certain Capabilities Not Prerequisite.--The financial and 
technical capability of an Indian Tribe, Tribal Organization, or Indian 
community to safely operate, manage, and maintain a sanitation facility 
shall not be a prerequisite to the provision or construction of 
sanitation facilities by the Secretary.
    ``(e) Financial Assistance.--The Secretary is authorized to provide 
financial assistance to Indian Tribes, Tribal Organizations, and Indian 
communities in an amount equal to the Federal share of the costs of 
operating, managing, and maintaining the facilities provided under the 
plan described in subsection (h)(1)(F).
    ``(f) Operation, Management, and Maintenance of Facilities.--The 
Indian Tribe has the primary responsibility to establish, collect, and 
use reasonable user fees, or otherwise set aside funding, for the 
purpose of operating, managing, and maintaining sanitation facilities. 
If a sanitation facility serving a community that is operated by an 
Indian Tribe or Tribal Organization is threatened with imminent failure 
and such operator lacks capacity to maintain the integrity or the 
health benefits of the sanitation facility, then the Secretary is 
authorized to assist the Indian Tribe, Tribal Organization, or Indian 
community in the resolution of the problem on a short-term basis 
through cooperation with the emergency coordinator or by providing 
operation, management, and maintenance service.
    ``(g) ISDEAA Program Funded on Equal Basis.--Tribal Health Programs 
shall be eligible (on an equal basis with programs that are 
administered directly by the Service) for--
            ``(1) any funds appropriated pursuant to this section; and
            ``(2) any funds appropriated for the purpose of providing 
        sanitation facilities.
    ``(h) Report.--
            ``(1) Required; contents.--The Secretary, in consultation 
        with the Secretary of Housing and Urban Development, Indian 
        Tribes, Tribal Organizations, and tribally designated housing 
        entities (as defined in section 4 of the Native American 
        Housing Assistance and Self-Determination Act of 1996 (25 
        U.S.C. 4103)) shall submit to the President, for inclusion in 
        the report required to be transmitted to Congress under section 
        801, a report which sets forth--
                    ``(A) the current Indian sanitation facility 
                priority system of the Service;
                    ``(B) the methodology for determining sanitation 
                deficiencies and needs;
                    ``(C) the criteria on which the deficiencies and 
                needs will be evaluated;
                    ``(D) the level of initial and final sanitation 
                deficiency for each type of sanitation facility for 
                each project of each Indian Tribe or Indian community;
                    ``(E) the amount and most effective use of funds, 
                derived from whatever source, necessary to accommodate 
                the sanitation facilities needs of new homes assisted 
                with funds under the Native American Housing Assistance 
                and Self-Determination Act (25 U.S.C. 4101 et seq.), 
                and to reduce the identified sanitation deficiency 
                levels of all Indian Tribes and Indian communities to 
                level I sanitation deficiency as defined in paragraph 
                (3)(A); and
                    ``(F) a 10-year plan to provide sanitation 
                facilities to serve existing Indian homes and Indian 
                communities and new and renovated Indian homes.
            ``(2) Uniform methodology.--The methodology used by the 
        Secretary in determining, preparing cost estimates for, and 
        reporting sanitation deficiencies for purposes of paragraph (1) 
        shall be applied uniformly to all Indian Tribes and Indian 
        communities.
            ``(3) Sanitation deficiency levels.--For purposes of this 
        subsection, the sanitation deficiency levels for an individual, 
        Indian Tribe, or Indian community sanitation facility to serve 
        Indian homes are determined as follows:
                    ``(A) A level I deficiency exists if a sanitation 
                facility serving an individual, Indian Tribe, or Indian 
                community--
                            ``(i) complies with all applicable water 
                        supply, pollution control, and solid waste 
                        disposal laws; and
                            ``(ii) deficiencies relate to routine 
                        replacement, repair, or maintenance needs.
                    ``(B) A level II deficiency exists if a sanitation 
                facility serving an individual, Indian Tribe, or Indian 
                community substantially or recently complied with all 
                applicable water supply, pollution control, and solid 
                waste laws and any deficiencies relate to--
                            ``(i) small or minor capital improvements 
                        needed to bring the facility back into 
                        compliance;
                            ``(ii) capital improvements that are 
                        necessary to enlarge or improve the facilities 
                        in order to meet the current needs for domestic 
                        sanitation facilities; or
                            ``(iii) the lack of equipment or training 
                        by an Indian Tribe, Tribal Organization, or an 
                        Indian community to properly operate and 
                        maintain the sanitation facilities.
                    ``(C) A level III deficiency exists if a sanitation 
                facility serving an individual, Indian Tribe or Indian 
                community meets 1 or more of the following conditions--
                            ``(i) water or sewer service in the home is 
                        provided by a haul system with holding tanks 
                        and interior plumbing;
                            ``(ii) major significant interruptions to 
                        water supply or sewage disposal occur 
                        frequently, requiring major capital 
                        improvements to correct the deficiencies; or
                            ``(iii) there is no access to or no 
                        approved or permitted solid waste facility 
                        available.
                    ``(D) A level IV deficiency exists--
                            ``(i) if a sanitation facility for an 
                        individual home, an Indian Tribe, or an Indian 
                        community exists but--
                                    ``(I) lacks--
                                            ``(aa) a safe water supply 
                                        system; or
                                            ``(bb) a waste disposal 
                                        system;
                                    ``(II) contains no piped water or 
                                sewer facilities; or
                                    ``(III) has become inoperable due 
                                to a major component failure; or
                            ``(ii) if only a washeteria or central 
                        facility exists in the community.
                    ``(E) A level V deficiency exists in the absence of 
                a sanitation facility, where individual homes do not 
                have access to safe drinking water or adequate 
                wastewater (including sewage) disposal.
    ``(i) Definitions.--For purposes of this section, the following 
terms apply:
            ``(1) Indian community.--The term `Indian community' means 
        a geographic area, a significant proportion of whose 
        inhabitants are Indians and which is served by or capable of 
        being served by a facility described in this section.
            ``(2) Sanitation facilities.--The terms `sanitation 
        facility' and `sanitation facilities' mean safe and adequate 
        water supply systems, sanitary sewage disposal systems, and 
        sanitary solid waste systems (and all related equipment and 
        support infrastructure).

``SEC. 303. PREFERENCE TO INDIANS AND INDIAN FIRMS.

    ``(a) Buy Indian Act.--The Secretary, acting through the Service, 
may use the negotiating authority of section 23 of the Act of June 25, 
1910 (25 U.S.C. 47, commonly known as the `Buy Indian Act'), to give 
preference to any Indian or any enterprise, partnership, corporation, 
or other type of business organization owned and controlled by an 
Indian or Indians including former or currently federally recognized 
Indian Tribes in the State of New York (hereinafter referred to as an 
`Indian firm') in the construction and renovation of Service facilities 
pursuant to section 301 and in the construction of sanitation 
facilities pursuant to section 302. Such preference may be accorded by 
the Secretary unless the Secretary finds, pursuant to regulations, that 
the project or function to be contracted for will not be satisfactory 
or such project or function cannot be properly completed or maintained 
under the proposed contract. The Secretary, in arriving at such a 
finding, shall consider whether the Indian or Indian firm will be 
deficient with respect to--
            ``(1) ownership and control by Indians;
            ``(2) equipment;
            ``(3) bookkeeping and accounting procedures;
            ``(4) substantive knowledge of the project or function to 
        be contracted for;
            ``(5) adequately trained personnel; or
            ``(6) other necessary components of contract performance.
    ``(b) Pay Rates.--For the purposes of implementing the provisions 
of this title, the Secretary shall assure that the rates of pay for 
personnel engaged in the construction or renovation of facilities 
constructed or renovated in whole or in part by funds made available 
pursuant to this title are not less than the prevailing local wage 
rates for similar work as determined in accordance with the Act of 
March 3, 1931 (40 U.S.C. 276a-276a-5, known as the Davis-Bacon Act).
    ``(c) Labor Standards.--For the purposes of implementing the 
provisions of this title, contracts for the construction or renovation 
of health care facilities, staff quarters, and sanitation facilities, 
and related support infrastructure, funded in whole or in part with 
funds made available pursuant to this title, shall contain a provision 
requiring compliance with subchapter IV of chapter 31 of title 40, 
United States Code (commonly known as the `Davis-Bacon Act').

``SEC. 304. EXPENDITURE OF NON-SERVICE FUNDS FOR RENOVATION.

    ``(a) In General.--Notwithstanding any other provision of law, if 
the requirements of subsection (c) are met, the Secretary, acting 
through the Service, is authorized to accept any major expansion, 
renovation, or modernization by any Indian Tribe or Tribal Organization 
of any Service facility or of any other Indian health facility operated 
pursuant to a contract or compact under the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.), including--
            ``(1) any plans or designs for such expansion, renovation, 
        or modernization; and
            ``(2) any expansion, renovation, or modernization for which 
        funds appropriated under any Federal law were lawfully 
        expended.
    ``(b) Priority List.--
            ``(1) In general.--The Secretary shall maintain a separate 
        priority list to address the needs for increased operating 
        expenses, personnel, or equipment for such facilities. The 
        methodology for establishing priorities shall be developed 
        through regulations. The list of priority facilities will be 
        revised annually in consultation with Indian Tribes and Tribal 
        Organizations.
            ``(2) Report.--The Secretary shall submit to the President, 
        for inclusion in the report required to be transmitted to 
        Congress under section 801, the priority list maintained 
        pursuant to paragraph (1).
    ``(c) Requirements.--The requirements of this subsection are met 
with respect to any expansion, renovation, or modernization if--
            ``(1) the Indian Tribe or Tribal Organization--
                    ``(A) provides notice to the Secretary of its 
                intent to expand, renovate, or modernize; and
                    ``(B) applies to the Secretary to be placed on a 
                separate priority list to address the needs of such new 
                facilities for increased operating expenses, personnel, 
                or equipment; and
            ``(2) the expansion, renovation, or modernization--
                    ``(A) is approved by the appropriate area director 
                of the Service for Federal facilities; and
                    ``(B) is administered by the Indian Tribe or Tribal 
                Organization in accordance with any applicable 
                regulations prescribed by the Secretary with respect to 
                construction or renovation of Service facilities.
    ``(d) Additional Requirement for Expansion.--In addition to the 
requirements under subsection (c), for any expansion, the Indian Tribe 
or Tribal Organization shall provide to the Secretary additional 
information pursuant to regulations, including additional staffing, 
equipment, and other costs associated with the expansion.
    ``(e) Closure or Conversion of Facilities.--If any Service facility 
which has been expanded, renovated, or modernized by an Indian Tribe or 
Tribal Organization under this section ceases to be used as a Service 
facility during the 20-year period beginning on the date such 
expansion, renovation, or modernization is completed, such Indian Tribe 
or Tribal Organization shall be entitled to recover from the United 
States an amount which bears the same ratio to the value of such 
facility at the time of such cessation as the value of such expansion, 
renovation, or modernization (less the total amount of any funds 
provided specifically for such facility under any Federal program that 
were expended for such expansion, renovation, or modernization) bore to 
the value of such facility at the time of the completion of such 
expansion, renovation, or modernization.

``SEC. 305. FUNDING FOR THE CONSTRUCTION, EXPANSION, AND MODERNIZATION 
              OF SMALL AMBULATORY CARE FACILITIES.

    ``(a) Grants.--
            ``(1) In general.--The Secretary, acting through the 
        Service, shall make grants to Indian Tribes and Tribal 
        Organizations for the construction, expansion, or modernization 
        of facilities for the provision of ambulatory care services to 
        eligible Indians (and noneligible persons pursuant to 
        subsections (b)(2) and (c)(1)(C)). A grant made under this 
        section may cover up to 100 percent of the costs of such 
        construction, expansion, or modernization. For the purposes of 
        this section, the term `construction' includes the replacement 
        of an existing facility.
            ``(2) Grant agreement required.--A grant under paragraph 
        (1) may only be made available to a Tribal Health Program 
        operating an Indian health facility (other than a facility 
        owned or constructed by the Service, including a facility 
        originally owned or constructed by the Service and transferred 
        to an Indian Tribe or Tribal Organization).
    ``(b) Use of Grant Funds.--
            ``(1) Allowable uses.--A grant awarded under this section 
        may be used for the construction, expansion, or modernization 
        (including the planning and design of such construction, 
        expansion, or modernization) of an ambulatory care facility--
                    ``(A) located apart from a hospital;
                    ``(B) not funded under section 301 or section 306; 
                and
                    ``(C) which, upon completion of such construction 
                or modernization will--
                            ``(i) have a total capacity appropriate to 
                        its projected service population;
                            ``(ii) provide annually no fewer than 150 
                        patient visits by eligible Indians and other 
                        users who are eligible for services in such 
                        facility in accordance with section 806(c)(2); 
                        and
                            ``(iii) provide ambulatory care in a 
                        Service Area (specified in the contract or 
                        compact under the Indian Self-Determination and 
                        Education Assistance Act (25 U.S.C. 450 et 
                        seq.)) with a population of no fewer than 1,500 
                        eligible Indians and other users who are 
                        eligible for services in such facility in 
                        accordance with section 806(c)(2).
            ``(2) Additional allowable use.--The Secretary may also 
        reserve a portion of the funding provided under this section 
        and use those reserved funds to reduce an outstanding debt 
        incurred by Indian Tribes or Tribal Organizations for the 
        construction, expansion, or modernization of an ambulatory care 
        facility that meets the requirements under paragraph (1). The 
        provisions of this section shall apply, except that such 
        applications for funding under this paragraph shall be 
        considered separately from applications for funding under 
        paragraph (1).
            ``(3) Use only for certain portion of costs.--A grant 
        provided under this section may be used only for the cost of 
        that portion of a construction, expansion, or modernization 
        project that benefits the Service population identified above 
        in subsection (b)(1)(C) (ii) and (iii). The requirements of 
        clauses (ii) and (iii) of paragraph (1)(C) shall not apply to 
        an Indian Tribe or Tribal Organization applying for a grant 
        under this section for a health care facility located or to be 
        constructed on an island or when such facility is not located 
        on a road system providing direct access to an inpatient 
        hospital where care is available to the Service population.
    ``(c) Grants.--
            ``(1) Application.--No grant may be made under this section 
        unless an application or proposal for the grant has been 
        approved by the Secretary in accordance with applicable 
        regulations and has set forth reasonable assurance by the 
        applicant that, at all times after the construction, expansion, 
        or modernization of a facility carried out using a grant 
        received under this section--
                    ``(A) adequate financial support will be available 
                for the provision of services at such facility;
                    ``(B) such facility will be available to eligible 
                Indians without regard to ability to pay or source of 
                payment; and
                    ``(C) such facility will, as feasible without 
                diminishing the quality or quantity of services 
                provided to eligible Indians, serve noneligible persons 
                on a cost basis.
            ``(2) Priority.--In awarding grants under this section, the 
        Secretary shall give priority to Indian Tribes and Tribal 
        Organizations that demonstrate--
                    ``(A) a need for increased ambulatory care 
                services; and
                    ``(B) insufficient capacity to deliver such 
                services.
            ``(3) Peer review panels.--The Secretary may provide for 
        the establishment of peer review panels, as necessary, to 
        review and evaluate applications and proposals and to advise 
        the Secretary regarding such applications using the criteria 
        developed pursuant to subsection (a)(1).
    ``(d) Reversion of Facilities.--If any facility (or portion 
thereof) with respect to which funds have been paid under this section, 
ceases, at any time after completion of the construction, expansion, or 
modernization carried out with such funds, to be used for the purposes 
of providing health care services to eligible Indians, all of the 
right, title, and interest in and to such facility (or portion thereof) 
shall transfer to the United States unless otherwise negotiated by the 
Service and the Indian Tribe or Tribal Organization.
    ``(e) Funding Nonrecurring.--Funding provided under this section 
shall be nonrecurring and shall not be available for inclusion in any 
individual Indian Tribe's tribal share for an award under the Indian 
Self-Determination and Education Assistance Act (25 U.S.C. 450 et seq.) 
or for reallocation or redesign thereunder.

``SEC. 306. INDIAN HEALTH CARE DELIVERY DEMONSTRATION PROJECT.

    ``(a) Health Care Demonstration Projects.--The Secretary, acting 
through the Service, is authorized to make grants to, and enter into 
construction contracts or construction project agreements with, Indian 
Tribes or Tribal Organizations under the Indian Self-Determination and 
Education Assistance Act (25 U.S.C. 450 et seq.) for the purpose of 
carrying out a health care delivery demonstration project to test 
alternative means of delivering health care and services to Indians 
through facilities.
    ``(b) Use of Funds.--The Secretary, in approving projects pursuant 
to this section, may authorize such contracts for the construction and 
renovation of hospitals, health centers, health stations, and other 
facilities to deliver health care services and is authorized to--
            ``(1) waive any leasing prohibition;
            ``(2) permit carryover of funds appropriated for the 
        provision of health care services;
            ``(3) permit the use of other available funds;
            ``(4) permit the use of funds or property donated from any 
        source for project purposes;
            ``(5) provide for the reversion of donated real or personal 
        property to the donor; and
            ``(6) permit the use of Service funds to match other funds, 
        including Federal funds.
    ``(c) Regulations.--The Secretary shall develop and promulgate 
regulations, not later than 1 year after the date of enactment of the 
Indian Health Care Improvement Act Amendments of 2009, for the review 
and approval of applications submitted under this section.
    ``(d) Criteria.--The Secretary may approve projects that meet the 
following criteria:
            ``(1) There is a need for a new facility or program or the 
        reorientation of an existing facility or program.
            ``(2) A significant number of Indians, including those with 
        low health status, will be served by the project.
            ``(3) The project has the potential to deliver services in 
        an efficient and effective manner.
            ``(4) The project is economically viable.
            ``(5) The Indian Tribe or Tribal Organization has the 
        administrative and financial capability to administer the 
        project.
            ``(6) The project is integrated with providers of related 
        health and social services and is coordinated with, and avoids 
        duplication of, existing services.
    ``(e) Peer Review Panels.--The Secretary may provide for the 
establishment of peer review panels, as necessary, to review and 
evaluate applications using the criteria developed pursuant to 
subsection (d).
    ``(f) Priority.--The Secretary shall give priority to applications 
for demonstration projects in each of the following Service Units to 
the extent that such applications are timely filed and meet the 
criteria specified in subsection (d):
            ``(1) Cass Lake, Minnesota.
            ``(2) Mescalero, New Mexico.
            ``(3) Owyhee, Nevada.
            ``(4) Schurz, Nevada.
            ``(5) Ft. Yuma, California.
    ``(g) Technical Assistance.--The Secretary shall provide such 
technical and other assistance as may be necessary to enable applicants 
to comply with the provisions of this section.
    ``(h) Service to Ineligible Persons.--Subject to section 806, the 
authority to provide services to persons otherwise ineligible for the 
health care benefits of the Service and the authority to extend 
hospital privileges in Service facilities to non-Service health 
practitioners as provided in section 806 may be included, subject to 
the terms of such section, in any demonstration project approved 
pursuant to this section.
    ``(i) Equitable Treatment.--For purposes of subsection (d)(1), the 
Secretary shall, in evaluating facilities operated under any contract 
or compact under the Indian Self-Determination and Education Assistance 
Act (25 U.S.C. 450 et seq.), use the same criteria that the Secretary 
uses in evaluating facilities operated directly by the Service.
    ``(j) Equitable Integration of Facilities.--The Secretary shall 
ensure that the planning, design, construction, renovation, and 
expansion needs of Service and non-Service facilities which are the 
subject of a contract or compact under the Indian Self-Determination 
and Education Assistance Act (25 U.S.C. 450 et seq.) for health 
services are fully and equitably integrated into the implementation of 
the health care delivery demonstration projects under this section.

``SEC. 307. LAND TRANSFER.

    ``Notwithstanding any other provision of law, the Bureau of Indian 
Affairs and all other agencies and departments of the United States are 
authorized to transfer, at no cost, land and improvements to the 
Service for the provision of health care services. The Secretary is 
authorized to accept such land and improvements for such purposes.

``SEC. 308. LEASES, CONTRACTS, AND OTHER AGREEMENTS.

    ``The Secretary, acting through the Service, may enter into leases, 
contracts, and other agreements with Indian Tribes and Tribal 
Organizations which hold (1) title to, (2) a leasehold interest in, or 
(3) a beneficial interest in (when title is held by the United States 
in trust for the benefit of an Indian Tribe) facilities used or to be 
used for the administration and delivery of health services by an 
Indian Health Program. Such leases, contracts, or agreements may 
include provisions for construction or renovation and provide for 
compensation to the Indian Tribe or Tribal Organization of rental and 
other costs consistent with section 105(l) of the Indian Self-
Determination and Education Assistance Act (25 U.S.C. 450j(l)) and 
regulations thereunder.

``SEC. 309. STUDY ON LOANS, LOAN GUARANTEES, AND LOAN REPAYMENT.

    ``(a) In General.--The Secretary, in consultation with the 
Secretary of the Treasury, Indian Tribes, and Tribal Organizations, 
shall carry out a study to determine the feasibility of establishing a 
loan fund to provide to Indian Tribes and Tribal Organizations direct 
loans or guarantees for loans for the construction of health care 
facilities, including--
            ``(1) inpatient facilities;
            ``(2) outpatient facilities;
            ``(3) staff quarters;
            ``(4) hostels; and
            ``(5) specialized care facilities, such as behavioral 
        health and elder care facilities.
    ``(b) Determinations.--In carrying out the study under subsection 
(a), the Secretary shall determine--
            ``(1) the maximum principal amount of a loan or loan 
        guarantee that should be offered to a recipient from the loan 
        fund;
            ``(2) the percentage of eligible costs, not to exceed 100 
        percent, that may be covered by a loan or loan guarantee from 
        the loan fund (including costs relating to planning, design, 
        financing, site land development, construction, rehabilitation, 
        renovation, conversion, improvements, medical equipment and 
        furnishings, and other facility-related costs and capital 
        purchase (but excluding staffing));
            ``(3) the cumulative total of the principal of direct loans 
        and loan guarantees, respectively, that may be outstanding at 
        any 1 time;
            ``(4) the maximum term of a loan or loan guarantee that may 
        be made for a facility from the loan fund;
            ``(5) the maximum percentage of funds from the loan fund 
        that should be allocated for payment of costs associated with 
        planning and applying for a loan or loan guarantee;
            ``(6) whether acceptance by the Secretary of an assignment 
        of the revenue of an Indian Tribe or Tribal Organization as 
        security for any direct loan or loan guarantee from the loan 
        fund would be appropriate;
            ``(7) whether, in the planning and design of health 
        facilities under this section, users eligible under section 
        806(c) may be included in any projection of patient population;
            ``(8) whether funds of the Service provided through loans 
        or loan guarantees from the loan fund should be eligible for 
        use in matching other Federal funds under other programs;
            ``(9) the appropriateness of, and best methods for, 
        coordinating the loan fund with the health care priority system 
        of the Service under section 301; and
            ``(10) any legislative or regulatory changes required to 
        implement recommendations of the Secretary based on results of 
        the study.
    ``(c) Report.--Not later than September 30, 2010, the Secretary 
shall submit to the Committee on Indian Affairs of the Senate and the 
Committee on Natural Resources and the Committee on Energy and Commerce 
of the House of Representatives a report that describes--
            ``(1) the manner of consultation made as required by 
        subsection (a); and
            ``(2) the results of the study, including any 
        recommendations of the Secretary based on results of the study.

``SEC. 310. TRIBAL LEASING.

    ``A Tribal Health Program may lease permanent structures for the 
purpose of providing health care services without obtaining advance 
approval in appropriation Acts.

``SEC. 311. INDIAN HEALTH SERVICE/TRIBAL FACILITIES JOINT VENTURE 
              PROGRAM.

    ``(a) In General.--The Secretary, acting through the Service, shall 
make arrangements with Indian Tribes and Tribal Organizations to 
establish joint venture demonstration projects under which an Indian 
Tribe or Tribal Organization shall expend tribal, private, or other 
available funds, for the acquisition or construction of a health 
facility for a minimum of 10 years, under a no-cost lease, in exchange 
for agreement by the Service to provide the equipment, supplies, and 
staffing for the operation and maintenance of such a health facility. 
An Indian Tribe or Tribal Organization may use tribal funds, private 
sector, or other available resources, including loan guarantees, to 
fulfill its commitment under a joint venture entered into under this 
subsection. An Indian Tribe or Tribal Organization shall be eligible to 
establish a joint venture project if, when it submits a letter of 
intent, it--
            ``(1) has begun but not completed the process of 
        acquisition or construction of a health facility to be used in 
        the joint venture project;
            ``(2) has not begun the process of acquisition or 
        construction of a health facility for use in the joint venture 
        project; or
            ``(3) in its application for a joint venture agreement, 
        agrees--
                    ``(A) to construct a facility for the joint venture 
                which complies with the size and space criteria 
                established by the Service; or
                    ``(B) if the facility it proposes for the joint 
                venture is already in existence or under construction, 
                that only the portion of such facility which complies 
                with the size and space criteria of the Service will be 
                eligible for the joint venture agreement.
    ``(b) Requirements.--The Secretary shall make such an arrangement 
with an Indian Tribe or Tribal Organization only if--
            ``(1) the Secretary first determines that the Indian Tribe 
        or Tribal Organization has the administrative and financial 
        capabilities necessary to complete the timely acquisition or 
        construction of the relevant health facility; and
            ``(2) the Indian Tribe or Tribal Organization meets the 
        need criteria determined using the criteria developed under the 
        health care facility priority system under section 301, unless 
        the Secretary determines, pursuant to regulations, that other 
        criteria will result in a more cost-effective and efficient 
        method of facilitating and completing construction of health 
        care facilities.
    ``(c) Continued Operation.--The Secretary shall negotiate an 
agreement with the Indian Tribe or Tribal Organization regarding the 
continued operation of the facility at the end of the initial 10 year 
no-cost lease period.
    ``(d) Breach of Agreement.--An Indian Tribe or Tribal Organization 
that has entered into a written agreement with the Secretary under this 
section, and that breaches or terminates without cause such agreement, 
shall be liable to the United States for the amount that has been paid 
to the Indian Tribe or Tribal Organization, or paid to a third party on 
the Indian Tribe's or Tribal Organization's behalf, under the 
agreement. The Secretary has the right to recover tangible property 
(including supplies) and equipment, less depreciation, and any funds 
expended for operations and maintenance under this section. The 
preceding sentence does not apply to any funds expended for the 
delivery of health care services, personnel, or staffing.
    ``(e) Recovery for Nonuse.--An Indian Tribe or Tribal Organization 
that has entered into a written agreement with the Secretary under this 
subsection shall be entitled to recover from the United States an 
amount that is proportional to the value of such facility if, at any 
time within the 10-year term of the agreement, the Service ceases to 
use the facility or otherwise breaches the agreement.
    ``(f) Definition.--For the purposes of this section, the term 
`health facility' or `health facilities' includes quarters needed to 
provide housing for staff of the relevant Tribal Health Program.

``SEC. 312. LOCATION OF FACILITIES.

    ``(a) In General.--In all matters involving the reorganization or 
development of Service facilities or in the establishment of related 
employment projects to address unemployment conditions in economically 
depressed areas, the Bureau of Indian Affairs and the Service shall 
give priority to locating such facilities and projects on Indian lands, 
or lands in Alaska owned by any Alaska Native village, or village or 
regional corporation under the Alaska Native Claims Settlement Act (43 
U.S.C. 1601 et seq.), or any land allotted to any Alaska Native, if 
requested by the Indian owner and the Indian Tribe with jurisdiction 
over such lands or other lands owned or leased by the Indian Tribe or 
Tribal Organization. Top priority shall be given to Indian land owned 
by 1 or more Indian Tribes.
    ``(b) Definition.--For purposes of this section, the term `Indian 
lands' means--
            ``(1) all lands within the exterior boundaries of any 
        reservation; and
            ``(2) any lands title to which is held in trust by the 
        United States for the benefit of any Indian Tribe or individual 
        Indian or held by any Indian Tribe or individual Indian subject 
        to restriction by the United States against alienation.

``SEC. 313. MAINTENANCE AND IMPROVEMENT OF HEALTH CARE FACILITIES.

    ``(a) Report.--The Secretary shall submit to the President, for 
inclusion in the report required to be transmitted to Congress under 
section 801, a report which identifies the backlog of maintenance and 
repair work required at both Service and tribal health care facilities, 
including new health care facilities expected to be in operation in the 
next fiscal year. The report shall also identify the need for 
renovation and expansion of existing facilities to support the growth 
of health care programs.
    ``(b) Maintenance of Newly Constructed Space.--The Secretary, 
acting through the Service, is authorized to expend maintenance and 
improvement funds to support maintenance of newly constructed space 
only if such space falls within the approved supportable space 
allocation for the Indian Tribe or Tribal Organization. Supportable 
space allocation shall be defined through the health care facility 
priority system under section 301(c).
    ``(c) Replacement Facilities.--In addition to using maintenance and 
improvement funds for renovation, modernization, and expansion of 
facilities, an Indian Tribe or Tribal Organization may use maintenance 
and improvement funds for construction of a replacement facility if the 
costs of renovation of such facility would exceed a maximum renovation 
cost threshold. The Secretary shall consult with Indian Tribes and 
Tribal Organizations in determining the maximum renovation cost 
threshold.

``SEC. 314. TRIBAL MANAGEMENT OF FEDERALLY OWNED QUARTERS.

    ``(a) Rental Rates.--
            ``(1) Establishment.--Notwithstanding any other provision 
        of law, a Tribal Health Program which operates a hospital or 
        other health facility and the federally owned quarters 
        associated therewith pursuant to a contract or compact under 
        the Indian Self-Determination and Education Assistance Act (25 
        U.S.C. 450 et seq.) shall have the authority to establish the 
        rental rates charged to the occupants of such quarters by 
        providing notice to the Secretary of its election to exercise 
        such authority.
            ``(2) Objectives.--In establishing rental rates pursuant to 
        authority of this subsection, a Tribal Health Program shall 
        endeavor to achieve the following objectives:
                    ``(A) To base such rental rates on the reasonable 
                value of the quarters to the occupants thereof.
                    ``(B) To generate sufficient funds to prudently 
                provide for the operation and maintenance of the 
                quarters, and subject to the discretion of the Tribal 
                Health Program, to supply reserve funds for capital 
                repairs and replacement of the quarters.
            ``(3) Equitable funding.--Any quarters whose rental rates 
        are established by a Tribal Health Program pursuant to this 
        subsection shall remain eligible for quarters improvement and 
        repair funds to the same extent as all federally owned quarters 
        used to house personnel in Services-supported programs.
            ``(4) Notice of rate change.--A Tribal Health Program which 
        exercises the authority provided under this subsection shall 
        provide occupants with no less than 60 days notice of any 
        change in rental rates.
    ``(b) Direct Collection of Rent.--
            ``(1) In general.--Notwithstanding any other provision of 
        law, and subject to paragraph (2), a Tribal Health Program 
        shall have the authority to collect rents directly from Federal 
        employees who occupy such quarters in accordance with the 
        following:
                    ``(A) The Tribal Health Program shall notify the 
                Secretary and the subject Federal employees of its 
                election to exercise its authority to collect rents 
                directly from such Federal employees.
                    ``(B) Upon receipt of a notice described in 
                subparagraph (A), the Federal employees shall pay rents 
                for occupancy of such quarters directly to the Tribal 
                Health Program and the Secretary shall have no further 
                authority to collect rents from such employees through 
                payroll deduction or otherwise.
                    ``(C) Such rent payments shall be retained by the 
                Tribal Health Program and shall not be made payable to 
                or otherwise be deposited with the United States.
                    ``(D) Such rent payments shall be deposited into a 
                separate account which shall be used by the Tribal 
                Health Program for the maintenance (including capital 
                repairs and replacement) and operation of the quarters 
                and facilities as the Tribal Health Program shall 
                determine.
            ``(2) Retrocession of authority.--If a Tribal Health 
        Program which has made an election under paragraph (1) requests 
        retrocession of its authority to directly collect rents from 
        Federal employees occupying federally owned quarters, such 
        retrocession shall become effective on the earlier of--
                    ``(A) the first day of the month that begins no 
                less than 180 days after the Tribal Health Program 
                notifies the Secretary of its desire to retrocede; or
                    ``(B) such other date as may be mutually agreed by 
                the Secretary and the Tribal Health Program.
    ``(c) Rates in Alaska.--To the extent that a Tribal Health Program, 
pursuant to authority granted in subsection (a), establishes rental 
rates for federally owned quarters provided to a Federal employee in 
Alaska, such rents may be based on the cost of comparable private 
rental housing in the nearest established community with a year-round 
population of 1,500 or more individuals.

``SEC. 315. APPLICABILITY OF BUY AMERICAN ACT REQUIREMENT.

    ``(a) Applicability.--The Secretary shall ensure that the 
requirements of the Buy American Act apply to all procurements made 
with funds provided pursuant to section 317. Indian Tribes and Tribal 
Organizations shall be exempt from these requirements.
    ``(b) Effect of Violation.--If it has been finally determined by a 
court or Federal agency that any person intentionally affixed a label 
bearing a `Made in America' inscription or any inscription with the 
same meaning, to any product sold in or shipped to the United States 
that is not made in the United States, such person shall be ineligible 
to receive any contract or subcontract made with funds provided 
pursuant to section 317, pursuant to the debarment, suspension, and 
ineligibility procedures described in sections 9.400 through 9.409 of 
title 48, Code of Federal Regulations.
    ``(c) Definitions.--For purposes of this section, the term `Buy 
American Act' means title III of the Act entitled `An Act making 
appropriations for the Treasury and Post Office Departments for the 
fiscal year ending June 30, 1934, and for other purposes', approved 
March 3, 1933 (41 U.S.C. 10a et seq.).

``SEC. 316. OTHER FUNDING FOR FACILITIES.

    ``(a) Authority To Accept Funds.--The Secretary is authorized to 
accept from any source, including Federal and State agencies, funds 
that are available for the construction of health care facilities and 
use such funds to plan, design, and construct health care facilities 
for Indians and to place such funds into a contract or compact under 
the Indian Self-Determination and Education Assistance Act (25 U.S.C. 
450 et seq.). Receipt of such funds shall have no effect on the 
priorities established pursuant to section 301.
    ``(b) Interagency Agreements.--The Secretary is authorized to enter 
into interagency agreements with other Federal agencies or State 
agencies and other entities and to accept funds from such Federal or 
State agencies or other sources to provide for the planning, design, 
and construction of health care facilities to be administered by Indian 
Health Programs in order to carry out the purposes of this Act and the 
purposes for which the funds were appropriated or for which the funds 
were otherwise provided.
    ``(c) Transferred Funds.--Any Federal agency to which funds for the 
construction of health care facilities are appropriated is authorized 
to transfer such funds to the Secretary for the construction of health 
care facilities to carry out the purposes of this Act as well as the 
purposes for which such funds are appropriated to such other Federal 
agency.
    ``(d) Establishment of Standards.--The Secretary, through the 
Service, shall establish standards by regulation for the planning, 
design, and construction of health care facilities serving Indians 
under this Act.

``SEC. 317. AUTHORIZATION OF APPROPRIATIONS.

    ``There are authorized to be appropriated such sums as may be 
necessary to carry out this title.

                 ``TITLE IV--ACCESS TO HEALTH SERVICES

``SEC. 401. TREATMENT OF PAYMENTS UNDER SOCIAL SECURITY ACT HEALTH 
              BENEFITS PROGRAMS.

    ``(a) Disregard of Medicare, Medicaid, and SCHIP Payments in 
Determining Appropriations.--Any payments received by an Indian Health 
Program or by an urban Indian organization under title XVIII, XIX, or 
XXI of the Social Security Act for services provided to Indians 
eligible for benefits under such respective titles shall not be 
considered in determining appropriations for the provision of health 
care and services to Indians.
    ``(b) Nonpreferential Treatment.--Nothing in this Act authorizes 
the Secretary to provide services to an Indian with coverage under 
title XVIII, XIX, or XXI of the Social Security Act in preference to an 
Indian without such coverage.
    ``(c) Use of Funds.--
            ``(1) Special fund.--
                    ``(A) 100 percent pass-through of payments due to 
                facilities.--Notwithstanding any other provision of 
                law, but subject to paragraph (2), payments to which a 
                facility of the Service is entitled by reason of a 
                provision of title XVIII or XIX of the Social Security 
                Act shall be placed in a special fund to be held by the 
                Secretary. In making payments from such fund, the 
                Secretary shall ensure that each Service Unit of the 
                Service receives 100 percent of the amount to which the 
                facilities of the Service, for which such Service Unit 
                makes collections, are entitled by reason of a 
                provision of either such title.
                    ``(B) Use of funds.--Amounts received by a facility 
                of the Service under subparagraph (A) by reason of a 
                provision of title XVIII or XIX of the Social Security 
                Act shall first be used (to such extent or in such 
                amounts as are provided in appropriation Acts) for the 
                purpose of making any improvements in the programs of 
                the Service operated by or through such facility which 
                may be necessary to achieve or maintain compliance with 
                the applicable conditions and requirements of such 
                respective title. Any amounts so received that are in 
                excess of the amount necessary to achieve or maintain 
                such conditions and requirements shall, subject to 
                consultation with the Indian Tribes being served by the 
                Service Unit, be used for increasing the facility's 
                capacity to provide, or improving the quality or 
                accessibility of, services.
            ``(2) Direct payment option.--Paragraph (1) shall not apply 
        to a Tribal Health Program upon the election of such Program 
        under subsection (d) to receive payments directly. No payment 
        may be made out of the special fund described in such paragraph 
        with respect to reimbursement made for services provided by 
        such Program during the period of such election.
    ``(d) Direct Billing.--
            ``(1) In general.--Subject to complying with the 
        requirements of paragraph (2), a Tribal Health Program may 
        elect to directly bill for, and receive payment for, health 
        care items and services provided by such Program for which 
        payment is made under title XVIII, XIX, or XXI of the Social 
        Security Act.
            ``(2) Direct reimbursement.--
                    ``(A) Use of funds.--Each Tribal Health Program 
                making the election described in paragraph (1) with 
                respect to a program under title XVIII, XIX, or XXI of 
                the Social Security Act shall be reimbursed directly by 
                that program for items and services furnished without 
                regard to subsection (c)(1), but all amounts so 
                reimbursed shall be used by the Tribal Health Program 
                for the same purposes with respect to such Program for 
                which payment under subparagraph (A) of subsection 
                (c)(1) to a facility of the Service may be used 
                pursuant to subparagraph (B) of such subsection with 
                respect to the Service.
                    ``(B) Audits.--The amounts paid to a Tribal Health 
                Program making the election described in paragraph (1) 
                with respect to a program under title XVIII, XIX, or 
                XXI of the Social Security Act shall be subject to all 
                auditing requirements applicable to the program under 
                such title, as well as all auditing requirements 
                applicable to programs administered by an Indian Health 
                Program. Nothing in the preceding sentence shall be 
                construed as limiting the application of auditing 
                requirements applicable to amounts paid under title 
                XVIII, XIX, or XXI of the Social Security Act.
                    ``(C) Identification of source of payments.--Any 
                Tribal Health Program that receives reimbursements or 
                payments under title XVIII, XIX, or XXI of the Social 
                Security Act shall provide to the Service a list of 
                each provider enrollment number (or other identifier) 
                under which such Program receives such reimbursements 
                or payments.
            ``(3) Examination and implementation of changes.--
                    ``(A) In general.--The Secretary, acting through 
                the Service and with the assistance of the 
                Administrator of the Centers for Medicare & Medicaid 
                Services, shall examine on an ongoing basis and 
                implement any administrative changes that may be 
                necessary to facilitate direct billing and 
                reimbursement under the program established under this 
                subsection, including any agreements with States that 
                may be necessary to provide for direct billing under a 
                program under title XIX or XXI of the Social Security 
                Act.
                    ``(B) Coordination of information.--The Service 
                shall provide the Administrator of the Centers for 
                Medicare & Medicaid Services with copies of the lists 
                submitted to the Service under paragraph (2)(C), 
                enrollment data regarding patients served by the 
                Service (and by Tribal Health Programs, to the extent 
                such data is available to the Service), and such other 
                information as the Administrator may require for 
                purposes of administering title XVIII, XIX, or XXI of 
                the Social Security Act.
            ``(4) Withdrawal from program.--A Tribal Health Program 
        that bills directly under the program established under this 
        subsection may withdraw from participation in the same manner 
        and under the same conditions that an Indian Tribe or Tribal 
        Organization may retrocede a contracted program to the 
        Secretary under the authority of the Indian Self-Determination 
        and Education Assistance Act (25 U.S.C. 450 et seq.). All cost 
        accounting and billing authority under the program established 
        under this subsection shall be returned to the Secretary upon 
        the Secretary's acceptance of the withdrawal of participation 
        in this program.
            ``(5) Termination for failure to comply with 
        requirements.--The Secretary may terminate the participation of 
        a Tribal Health Program or in the direct billing program 
        established under this subsection if the Secretary determines 
        that the Program has failed to comply with the requirements of 
        paragraph (2). The Secretary shall provide a Tribal Health 
        Program with notice of a determination that the Program has 
        failed to comply with any such requirement and a reasonable 
        opportunity to correct such noncompliance prior to terminating 
        the Program's participation in the direct billing program 
        established under this subsection.
    ``(e) Related Provisions Under the Social Security Act.--For 
provisions related to subsections (c) and (d), see sections 1880, 1911, 
and 2107(e)(1)(D) of the Social Security Act.

``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.

    ``(a) Indian Tribes and Tribal Organizations.--The Secretary, 
acting through the Service, shall make grants to or enter into 
contracts with Indian Tribes and Tribal Organizations to assist such 
Tribes and Tribal Organizations in establishing and administering 
programs on or near reservations, trust lands, and Alaska Native 
Villages, including programs to provide outreach and enrollment through 
video, electronic delivery methods, or telecommunication devices that 
allow real-time or time-delayed communication between individual 
Indians and the benefit program, to assist individual Indians--
            ``(1) to enroll for benefits under a program established 
        under title XVIII, XIX, or XXI of the Social Security Act; and
            ``(2) with respect to such programs for which the charging 
        of premiums and cost sharing is not prohibited under such 
        programs, to pay premiums or cost sharing for coverage for such 
        benefits, which may be based on financial need (as determined 
        by the Indian Tribe or Tribes or Tribal Organizations being 
        served based on a schedule of income levels developed or 
        implemented by such Tribe, Tribes, or Tribal Organizations).
    ``(b) Conditions.--The Secretary, acting through the Service, shall 
place conditions as deemed necessary to effect the purpose of this 
section in any grant or contract which the Secretary makes with any 
Indian Tribe or Tribal Organization pursuant to this section. Such 
conditions shall include requirements that the Indian Tribe or Tribal 
Organization successfully undertake--
            ``(1) to determine the population of Indians eligible for 
        the benefits described in subsection (a);
            ``(2) to educate Indians with respect to the benefits 
        available under the respective programs;
            ``(3) to provide transportation for such individual Indians 
        to the appropriate offices for enrollment or applications for 
        such benefits; and
            ``(4) to develop and implement methods of improving the 
        participation of Indians in receiving benefits under such 
        programs.
    ``(c) Application to Urban Indian Organizations.--
            ``(1) In general.--The provisions of subsection (a) shall 
        apply with respect to grants and other funding to urban Indian 
        organizations with respect to populations served by such 
        organizations in the same manner they apply to grants and 
        contracts with Indian Tribes and Tribal Organizations with 
        respect to programs on or near reservations.
            ``(2) Requirements.--The Secretary shall include in the 
        grants or contracts made or provided under paragraph (1) 
        requirements that are--
                    ``(A) consistent with the requirements imposed by 
                the Secretary under subsection (b);
                    ``(B) appropriate to urban Indian organizations and 
                urban Indians; and
                    ``(C) necessary to effect the purposes of this 
                section.
    ``(d) Facilitating Cooperation in Enrollment and Retention.--The 
Secretary, acting through the Centers for Medicare & Medicaid Services, 
shall consult with States, the Service, Indian Tribes, Tribal 
Organizations, and urban Indian organizations to develop and 
disseminate best practices with respect to facilitating agreements 
between the States and Indian Tribes, Tribal Organizations, and urban 
Indian organizations relating to enrollment and retention of Indians in 
programs established under titles XVIII, XIX, and XXI of the Social 
Security Act.
    ``(e) Agreements To Improve Enrollment of Indians Under Social 
Security Act Health Benefits Programs.--For provisions relating to 
agreements between the Secretary and the Service, Indian Tribes, Tribal 
Organizations, and urban Indian organizations for the collection, 
preparation, and submission of applications by Indians for assistance 
under the Medicaid and children's health insurance programs established 
under titles XIX and XXI of the Social Security Act, and benefits under 
the Medicare program established under title XVIII of such Act, see 
subsections (a) and (b) of section 1139 of the Social Security Act.
    ``(f) Definitions.--In this section:
            ``(1) Premium.--The term `premium' includes any enrollment 
        fee or similar charge.
            ``(2) Cost sharing.--The term `cost sharing' includes any 
        deduction, deductible, copayment, coinsurance, or similar 
        charge.
            ``(3) Benefits.--The term `benefits' means, with respect 
        to--
                    ``(A) title XVIII of the Social Security Act, 
                benefits under such title;
                    ``(B) title XIX of such Act, medical assistance 
                under such title; and
                    ``(C) title XXI of such Act, assistance under such 
                title.

``SEC. 403. REIMBURSEMENT FROM CERTAIN THIRD PARTIES OF COSTS OF HEALTH 
              SERVICES.

    ``(a) Right of Recovery.--Except as provided in subsection (f), the 
United States, an Indian Tribe, or Tribal Organization shall have the 
right to recover from an insurance company, health maintenance 
organization, employee benefit plan, third-party tortfeasor, or any 
other responsible or liable third party (including a political 
subdivision or local governmental entity of a State) the reasonable 
charges incurred by the Secretary, an Indian Tribe, or Tribal 
Organization, or, if higher, the highest amount the third party would 
pay for care and services furnished by providers other than 
governmental entities, in providing health services through the 
Service, an Indian Tribe, or Tribal Organization to any individual to 
the same extent that such individual, or any nongovernmental provider 
of such services, would be eligible to receive damages, reimbursement, 
or indemnification for such charges if--
            ``(1) such services had been provided by a nongovernmental 
        provider; and
            ``(2) such individual had been required to pay such charges 
        or expenses and did pay such charges or expenses.
    ``(b) Limitations on Recoveries From States.--Subsection (a) shall 
provide a right of recovery against any State, only if the injury, 
illness, or disability for which health services were provided is 
covered under--
            ``(1) workers' compensation laws; or
            ``(2) a no-fault automobile accident insurance plan or 
        program.
    ``(c) Nonapplication of Other Laws.--No law of any State, or of any 
political subdivision of a State and no provision of any contract, 
insurance or health maintenance organization policy, employee benefit 
plan, self-insurance plan, managed care plan, or other health care plan 
or program entered into or renewed after the date of the enactment of 
the Indian Health Care Amendments of 1988, shall prevent or hinder the 
right of recovery of the United States, an Indian Tribe, or Tribal 
Organization under subsection (a).
    ``(d) No Effect on Private Rights of Action.--No action taken by 
the United States, an Indian Tribe, or Tribal Organization to enforce 
the right of recovery provided under this section shall operate to deny 
to the injured person the recovery for that portion of the person's 
damage not covered hereunder.
    ``(e) Enforcement.--
            ``(1) In general.--The United States, an Indian Tribe, or 
        Tribal Organization may enforce the right of recovery provided 
        under subsection (a) by--
                    ``(A) intervening or joining in any civil action or 
                proceeding brought--
                            ``(i) by the individual for whom health 
                        services were provided by the Secretary, an 
                        Indian Tribe, or Tribal Organization; or
                            ``(ii) by any representative or heirs of 
                        such individual, or
                    ``(B) instituting a civil action, including a civil 
                action for injunctive relief and other relief and 
                including, with respect to a political subdivision or 
                local governmental entity of a State, such an action 
                against an official thereof.
            ``(2) Notice.--All reasonable efforts shall be made to 
        provide notice of action instituted under paragraph (1)(B) to 
        the individual to whom health services were provided, either 
        before or during the pendency of such action.
            ``(3) Recovery from tortfeasors.--
                    ``(A) In general.--In any case in which an Indian 
                Tribe or Tribal Organization that is authorized or 
                required under a compact or contract issued pursuant to 
                the Indian Self-Determination and Education Assistance 
                Act (25 U.S.C. 450 et seq.) to furnish or pay for 
                health services to a person who is injured or suffers a 
                disease on or after the date of enactment of the Indian 
                Health Care Improvement Act Amendments of 2009 under 
                circumstances that establish grounds for a claim of 
                liability against the tortfeasor with respect to the 
                injury or disease, the Indian Tribe or Tribal 
                Organization shall have a right to recover from the 
                tortfeasor (or an insurer of the tortfeasor) the 
                reasonable value of the health services so furnished, 
                paid for, or to be paid for, in accordance with the 
                Federal Medical Care Recovery Act (42 U.S.C. 2651 et 
                seq.), to the same extent and under the same 
                circumstances as the United States may recover under 
                that Act.
                    ``(B) Treatment.--The right of an Indian Tribe or 
                Tribal Organization to recover under subparagraph (A) 
                shall be independent of the rights of the injured or 
                diseased person served by the Indian Tribe or Tribal 
                Organization.
    ``(f) Limitation.--Absent specific written authorization by the 
governing body of an Indian Tribe for the period of such authorization 
(which may not be for a period of more than 1 year and which may be 
revoked at any time upon written notice by the governing body to the 
Service), the United States shall not have a right of recovery under 
this section if the injury, illness, or disability for which health 
services were provided is covered under a self-insurance plan funded by 
an Indian Tribe, Tribal Organization, or urban Indian organization. 
Where such authorization is provided, the Service may receive and 
expend such amounts for the provision of additional health services 
consistent with such authorization.
    ``(g) Costs and Attorneys' Fees.--In any action brought to enforce 
the provisions of this section, a prevailing plaintiff shall be awarded 
its reasonable attorneys' fees and costs of litigation.
    ``(h) Nonapplication of Claims Filing Requirements.--An insurance 
company, health maintenance organization, self-insurance plan, managed 
care plan, or other health care plan or program (under the Social 
Security Act or otherwise) may not deny a claim for benefits submitted 
by the Service or by an Indian Tribe or Tribal Organization based on 
the format in which the claim is submitted if such format complies with 
the format required for submission of claims under title XVIII of the 
Social Security Act or recognized under section 1175 of such Act.
    ``(i) Application to Urban Indian Organizations.--The previous 
provisions of this section shall apply to urban Indian organizations 
with respect to populations served by such Organizations in the same 
manner they apply to Indian Tribes and Tribal Organizations with 
respect to populations served by such Indian Tribes and Tribal 
Organizations.
    ``(j) Statute of Limitations.--The provisions of section 2415 of 
title 28, United States Code, shall apply to all actions commenced 
under this section, and the references therein to the United States are 
deemed to include Indian Tribes, Tribal Organizations, and urban Indian 
organizations.
    ``(k) Savings.--Nothing in this section shall be construed to limit 
any right of recovery available to the United States, an Indian Tribe, 
or Tribal Organization under the provisions of any applicable, Federal, 
State, or Tribal law, including medical lien laws.

``SEC. 404. CREDITING OF REIMBURSEMENTS.

    ``(a) Retention of Amounts for Use by Program.--Except as provided 
in section 202(f) (relating to the Catastrophic Health Emergency Fund) 
and section 806 (relating to health services for ineligible persons), 
all reimbursements received or recovered, including under section 806, 
by reason of the provision of health services by the Service, by an 
Indian Tribe or Tribal Organization, or by an urban Indian 
organization, shall be credited to the Service, such Indian Tribe or 
Tribal Organization, or such urban Indian organization, respectively, 
and may be used as provided in section 401. In the case of such a 
service provided by or through a Service Unit, such amounts shall be 
credited to such unit and used for such purposes.
    ``(b) No Offset of Amounts.--The Service may not offset or limit 
any amount obligated to any Service Unit or entity receiving funding 
from the Service because of the receipt of reimbursements under 
subsection (a).

``SEC. 405. PURCHASING HEALTH CARE COVERAGE.

    ``(a) Purchasing Coverage.--
            ``(1) In general.--Insofar as amounts are made available 
        under law (including a provision of the Social Security Act, 
        the Indian Self-Determination and Education Assistance Act (25 
        U.S.C. 450 et seq.), or other law, other than under section 
        402) to Indian Tribes, Tribal Organizations, and urban Indian 
        organizations for health benefits for Service beneficiaries, 
        Indian Tribes, Tribal Organizations, and urban Indian 
        organizations may use such amounts to purchase health benefits 
        coverage that qualifies as creditable coverage under section 
        2701(c)(1) of the Public Health Service Act for such 
        beneficiaries, including, subject to paragraph (2), through--
                    ``(A) a tribally owned and operated health care 
                plan;
                    ``(B) a State or locally authorized or licensed 
                health care plan;
                    ``(C) a health insurance provider or managed care 
                organization; or
                    ``(D) a self-insured plan.
            ``(2) Exception.--The coverage provided under paragraph (1) 
        may not include coverage consisting of--
                    ``(A) benefits provided under a health flexible 
                spending arrangement (as defined in section 106(c)(2) 
                of the Internal Revenue Code of 1986); or
                    ``(B) a high deductible health plan (as defined in 
                section 223(c)(2) of such Code), without regard to 
                whether the plan is purchased in conjunction with a 
                health savings account (as defined under section 223(d) 
                of such Code).
            ``(3) Permitting purchase of coverage based on financial 
        need.--The purchase of coverage by an Indian Tribe, Tribal 
        Organization, or urban Indian organization under this 
        subsection may be based on the financial needs of beneficiaries 
        (as determined by the Indian Tribe or Tribes being served based 
        on a schedule of income levels developed or implemented by such 
        Indian Tribe or Tribes).
    ``(b) Expenses for Self-insured Plan.--In the case of a self-
insured plan under subsection (a)(4), the amounts may be used for 
expenses of operating the plan, including administration and insurance 
to limit the financial risks to the entity offering the plan.
    ``(c) Construction.--Nothing in this section shall be construed as 
affecting the use of any amounts not referred to in subsection (a).

``SEC. 406. SHARING ARRANGEMENTS WITH FEDERAL AGENCIES.

    ``(a) Authority.--
            ``(1) In general.--The Secretary may enter into (or expand) 
        arrangements for the sharing of medical facilities and services 
        between the Service, Indian Tribes, and Tribal Organizations 
        and the Department of Veterans Affairs and the Department of 
        Defense.
            ``(2) Consultation by secretary required.--The Secretary 
        may not finalize any arrangement between the Service and a 
        Department described in paragraph (1) without first consulting 
        with the Indian Tribes which will be significantly affected by 
        the arrangement.
    ``(b) Limitations.--The Secretary shall not take any action under 
this section or under subchapter IV of chapter 81 of title 38, United 
States Code, which would impair--
            ``(1) the priority access of any Indian to health care 
        services provided through the Service and the eligibility of 
        any Indian to receive health services through the Service;
            ``(2) the quality of health care services provided to any 
        Indian through the Service;
            ``(3) the priority access of any veteran to health care 
        services provided by the Department of Veterans Affairs;
            ``(4) the quality of health care services provided by the 
        Department of Veterans Affairs or the Department of Defense; or
            ``(5) the eligibility of any Indian who is a veteran to 
        receive health services through the Department of Veterans 
        Affairs.
    ``(c) Reimbursement.--The Service, Indian Tribe, or Tribal 
Organization shall be reimbursed by the Department of Veterans Affairs 
or the Department of Defense (as the case may be) where services are 
provided through the Service, an Indian Tribe, or a Tribal Organization 
to beneficiaries eligible for services from either such Department, 
notwithstanding any other provision of law.
    ``(d) Construction.--Nothing in this section may be construed as 
creating any right of a non-Indian veteran to obtain health services 
from the Service.

``SEC. 407. ELIGIBLE INDIAN VETERAN SERVICES.

    ``(a) Findings; Purpose.--
            ``(1) Findings.--Congress finds that--
                    ``(A) collaborations between the Secretary and the 
                Secretary of Veterans Affairs regarding the treatment 
                of Indian veterans at facilities of the Service should 
                be encouraged to the maximum extent practicable; and
                    ``(B) increased enrollment for services of the 
                Department of Veterans Affairs by veterans who are 
                members of Indian tribes should be encouraged to the 
                maximum extent practicable.
            ``(2) Purpose.--The purpose of this section is to reaffirm 
        the goals stated in the document entitled `Memorandum of 
        Understanding Between the VA/Veterans Health Administration And 
        HHS/Indian Health Service' and dated February 25, 2003 
        (relating to cooperation and resource sharing between the 
        Veterans Health Administration and Service).
    ``(b) Definitions.--In this section:
            ``(1) Eligible indian veteran.--The term `eligible Indian 
        veteran' means an Indian or Alaska Native veteran who receives 
        any medical service that is--
                    ``(A) authorized under the laws administered by the 
                Secretary of Veterans Affairs; and
                    ``(B) administered at a facility of the Service 
                (including a facility operated by an Indian tribe or 
                tribal organization through a contract or compact with 
                the Service under the Indian Self-Determination and 
                Education Assistance Act (25 U.S.C. 450 et seq.)) 
                pursuant to a local memorandum of understanding.
            ``(2) Local memorandum of understanding.--The term `local 
        memorandum of understanding' means a memorandum of 
        understanding between the Secretary (or a designee, including 
        the director of any Area Office of the Service) and the 
        Secretary of Veterans Affairs (or a designee) to implement the 
        document entitled `Memorandum of Understanding Between the VA/
        Veterans Health Administration And HHS/Indian Health Service' 
        and dated February 25, 2003 (relating to cooperation and 
        resource sharing between the Veterans Health Administration and 
        Indian Health Service).
    ``(c) Eligible Indian Veterans' Expenses.--
            ``(1) In general.--Notwithstanding any other provision of 
        law, the Secretary shall provide for veteran-related expenses 
        incurred by eligible Indian veterans as described in subsection 
        (b)(1)(B).
            ``(2) Method of payment.--The Secretary shall establish 
        such guidelines as the Secretary determines to be appropriate 
        regarding the method of payments to the Secretary of Veterans 
        Affairs under paragraph (1).
    ``(d) Tribal Approval of Memoranda.--In negotiating a local 
memorandum of understanding with the Secretary of Veterans Affairs 
regarding the provision of services to eligible Indian veterans, the 
Secretary shall consult with each Indian tribe that would be affected 
by the local memorandum of understanding.
    ``(e) Funding.--
            ``(1) Treatment.--Expenses incurred by the Secretary in 
        carrying out subsection (c)(1) shall not be considered to be 
        Contract Health Service expenses.
            ``(2) Use of funds.--Of funds made available to the 
        Secretary in appropriations Acts for the Service (excluding 
        funds made available for facilities, Contract Health Services, 
        or contract support costs), the Secretary shall use such sums 
        as are necessary to carry out this section.

``SEC. 408. PAYOR OF LAST RESORT.

    ``Indian Health Programs and health care programs operated by Urban 
Indian Organizations shall be the payor of last resort for services 
provided to persons eligible for services from Indian Health Programs 
and Urban Indian Organizations, notwithstanding any Federal, State, or 
local law to the contrary.

``SEC. 409. CONSULTATION.

    ``For provisions related to consultation with representatives of 
Indian Health Programs and urban Indian organizations with respect to 
the health care programs established under titles XVIII, XIX, and XXI 
of the Social Security Act, see section 1139(d) of the Social Security 
Act (42 U.S.C. 1320b-9(d)).

``SEC. 410. STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP).

    ``For provisions relating to--
            ``(1) outreach to families of Indian children likely to be 
        eligible for child health assistance under the State children's 
        health insurance program established under title XXI of the 
        Social Security Act, see sections 2105(c)(2)(C) and 1139(a) of 
        such Act (42 U.S.C. 1397ee(c)(2), 1320b-9); and
            ``(2) ensuring that child health assistance is provided 
        under such program to targeted low-income children who are 
        Indians and that payments are made under such program to Indian 
        Health Programs and urban Indian organizations operating in the 
        State that provide such assistance, see sections 2102(b)(3)(D) 
        and 2105(c)(6)(B) of such Act (42 U.S.C. 1397bb(b)(3)(D), 
        1397ee(c)(6)(B)).

``SEC. 411. PREMIUM AND COST SHARING PROTECTIONS AND ELIGIBILITY 
              DETERMINATIONS UNDER MEDICAID AND SCHIP AND PROTECTION OF 
              CERTAIN INDIAN PROPERTY FROM MEDICAID ESTATE RECOVERY.

    ``For provisions relating to--
            ``(1) premiums or cost sharing protections for Indians 
        furnished items or services directly by Indian Health Programs 
        or through referral under the contract health service under the 
        Medicaid program established under title XIX of the Social 
        Security Act, see sections 1916(j) and 1916A(a)(1) of the 
        Social Security Act (42 U.S.C. 1396o(j), 1396o-1(a)(1));
            ``(2) rules regarding the treatment of certain property for 
        purposes of determining eligibility under such programs, see 
        sections 1902(e)(13) and 2107(e)(1)(B) of such Act (42 U.S.C. 
        1396a(e)(13), 1397gg(e)(1)(B)); and
            ``(3) the protection of certain property from estate 
        recovery provisions under the Medicaid program, see section 
        1917(b)(3)(B) of such Act (42 U.S.C. 1396p(b)(3)(B)).

``SEC. 412. TREATMENT UNDER MEDICAID AND SCHIP MANAGED CARE.

    ``For provisions relating to the treatment of Indians enrolled in a 
managed care entity under the Medicaid program under title XIX of the 
Social Security Act and Indian Health Programs and urban Indian 
organizations that are providers of items or services to such Indian 
enrollees, see sections 1932(h) and 2107(e)(1)(H) of the Social 
Security Act (42 U.S.C. 1396u-2(h), 1397gg(e)(1)(H)).

``SEC. 413. NAVAJO NATION MEDICAID AGENCY FEASIBILITY STUDY.

    ``(a) Study.--The Secretary shall conduct a study to determine the 
feasibility of treating the Navajo Nation as a State for the purposes 
of title XIX of the Social Security Act, to provide services to Indians 
living within the boundaries of the Navajo Nation through an entity 
established having the same authority and performing the same functions 
as single-State Medicaid agencies responsible for the administration of 
the State plan under title XIX of the Social Security Act.
    ``(b) Considerations.--In conducting the study, the Secretary shall 
consider the feasibility of--
            ``(1) assigning and paying all expenditures for the 
        provision of services and related administration funds, under 
        title XIX of the Social Security Act, to Indians living within 
        the boundaries of the Navajo Nation that are currently paid to 
        or would otherwise be paid to the State of Arizona, New Mexico, 
        or Utah;
            ``(2) providing assistance to the Navajo Nation in the 
        development and implementation of such entity for the 
        administration, eligibility, payment, and delivery of medical 
        assistance under title XIX of the Social Security Act;
            ``(3) providing an appropriate level of matching funds for 
        Federal medical assistance with respect to amounts such entity 
        expends for medical assistance for services and related 
        administrative costs; and
            ``(4) authorizing the Secretary, at the option of the 
        Navajo Nation, to treat the Navajo Nation as a State for the 
        purposes of title XIX of the Social Security Act (relating to 
        the State children's health insurance program) under terms 
        equivalent to those described in paragraphs (2) through (4).
    ``(c) Report.--Not later than 3 years after the date of enactment 
of the Indian Health Care Improvement Act Amendments of 2009, the 
Secretary shall submit to the Committee on Indian Affairs and Committee 
on Finance of the Senate and the Committee on Natural Resources and 
Committee on Energy and Commerce of the House of Representatives a 
report that includes--
            ``(1) the results of the study under this section;
            ``(2) a summary of any consultation that occurred between 
        the Secretary and the Navajo Nation, other Indian Tribes, the 
        States of Arizona, New Mexico, and Utah, counties which include 
        Navajo Lands, and other interested parties, in conducting this 
        study;
            ``(3) projected costs or savings associated with 
        establishment of such entity, and any estimated impact on 
        services provided as described in this section in relation to 
        probable costs or savings; and
            ``(4) legislative actions that would be required to 
        authorize the establishment of such entity if such entity is 
        determined by the Secretary to be feasible.

``SEC. 414. EXCEPTION FOR EXCEPTED BENEFITS.

    ``The previous provisions of this title shall not apply to the 
provision of excepted benefits described in paragraph (1)(A) or (3) of 
section 2791(c) of the Public Health Service Act (42 U.S.C. 300gg-
91(c)).

``SEC. 415. AUTHORIZATION OF APPROPRIATIONS.

    ``There are authorized to be appropriated such sums as may be 
necessary to carry out this title.

              ``TITLE V--HEALTH SERVICES FOR URBAN INDIANS

``SEC. 501. PURPOSE.

    ``The purpose of this title is to establish and maintain programs 
in Urban Centers to make health services more accessible and available 
to Urban Indians.

``SEC. 502. CONTRACTS WITH, AND GRANTS TO, URBAN INDIAN ORGANIZATIONS.

    ``Under authority of the Act of November 2, 1921 (25 U.S.C. 13) 
(commonly known as the `Snyder Act'), the Secretary, acting through the 
Service, shall enter into contracts with, or make grants to, urban 
Indian organizations to assist such organizations in the establishment 
and administration, within Urban Centers, of programs which meet the 
requirements set forth in this title. Subject to section 506, the 
Secretary, acting through the Service, shall include such conditions as 
the Secretary considers necessary to effect the purpose of this title 
in any contract into which the Secretary enters with, or in any grant 
the Secretary makes to, any urban Indian organization pursuant to this 
title.

``SEC. 503. CONTRACTS AND GRANTS FOR THE PROVISION OF HEALTH CARE AND 
              REFERRAL SERVICES.

    ``(a) Requirements for Grants and Contracts.--Under authority of 
the Act of November 2, 1921 (25 U.S.C. 13) (commonly known as the 
`Snyder Act'), the Secretary, acting through the Service, shall enter 
into contracts with, and make grants to, urban Indian organizations for 
the provision of health care and referral services for Urban Indians. 
Any such contract or grant shall include requirements that the urban 
Indian organization successfully undertake to--
            ``(1) estimate the population of Urban Indians residing in 
        the Urban Center or centers that the organization proposes to 
        serve who are or could be recipients of health care or referral 
        services;
            ``(2) estimate the current health status of Urban Indians 
        residing in such Urban Center or centers;
            ``(3) estimate the current health care needs of Urban 
        Indians residing in such Urban Center or centers;
            ``(4) provide basic health education, including health 
        promotion and disease prevention education, to Urban Indians;
            ``(5) make recommendations to the Secretary and Federal, 
        State, local, and other resource agencies on methods of 
        improving health service programs to meet the needs of Urban 
        Indians; and
            ``(6) where necessary, provide, or enter into contracts for 
        the provision of, health care services for Urban Indians.
    ``(b) Criteria.--The Secretary, acting through the Service, shall, 
by regulation, prescribe the criteria for selecting urban Indian 
organizations to enter into contracts or receive grants under this 
section. Such criteria shall, among other factors, include--
            ``(1) the extent of unmet health care needs of Urban 
        Indians in the Urban Center or centers involved;
            ``(2) the size of the urban Indian population in the Urban 
        Center or centers involved;
            ``(3) the extent, if any, to which the activities set forth 
        in subsection (a) would duplicate any project funded under this 
        title, or under any current public health service project 
        funded in a manner other than pursuant to this title;
            ``(4) the capability of an urban Indian organization to 
        perform the activities set forth in subsection (a) and to enter 
        into a contract with the Secretary or to meet the requirements 
        for receiving a grant under this section;
            ``(5) the satisfactory performance and successful 
        completion by an urban Indian organization of other contracts 
        with the Secretary under this title;
            ``(6) the appropriateness and likely effectiveness of 
        conducting the activities set forth in subsection (a) in an 
        Urban Center or centers; and
            ``(7) the extent of existing or likely future participation 
        in the activities set forth in subsection (a) by appropriate 
        health and health-related Federal, State, local, and other 
        agencies.
    ``(c) Access to Health Promotion and Disease Prevention Programs.--
The Secretary, acting through the Service, shall facilitate access to 
or provide health promotion and disease prevention services for Urban 
Indians through grants made to urban Indian organizations administering 
contracts entered into or receiving grants under subsection (a).
    ``(d) Immunization Services.--
            ``(1) Access or services provided.--The Secretary, acting 
        through the Service, shall facilitate access to, or provide, 
        immunization services for Urban Indians through grants made to 
        urban Indian organizations administering contracts entered into 
        or receiving grants under this section.
            ``(2) Definition.--For purposes of this subsection, the 
        term `immunization services' means services to provide without 
        charge immunizations against vaccine-preventable diseases.
    ``(e) Behavioral Health Services.--
            ``(1) Access or services provided.--The Secretary, acting 
        through the Service, shall facilitate access to, or provide, 
        behavioral health services for Urban Indians through grants 
        made to urban Indian organizations administering contracts 
        entered into or receiving grants under subsection (a).
            ``(2) Assessment required.--Except as provided by paragraph 
        (3)(A), a grant may not be made under this subsection to an 
        urban Indian organization until that organization has prepared, 
        and the Service has approved, an assessment of the following:
                    ``(A) The behavioral health needs of the urban 
                Indian population concerned.
                    ``(B) The behavioral health services and other 
                related resources available to that population.
                    ``(C) The barriers to obtaining those services and 
                resources.
                    ``(D) The needs that are unmet by such services and 
                resources.
            ``(3) Purposes of grants.--Grants may be made under this 
        subsection for the following:
                    ``(A) To prepare assessments required under 
                paragraph (2).
                    ``(B) To provide outreach, educational, and 
                referral services to Urban Indians regarding the 
                availability of direct behavioral health services, to 
                educate Urban Indians about behavioral health issues 
                and services, and effect coordination with existing 
                behavioral health providers in order to improve 
                services to Urban Indians.
                    ``(C) To provide outpatient behavioral health 
                services to Urban Indians, including the identification 
                and assessment of illness, therapeutic treatments, case 
                management, support groups, family treatment, and other 
                treatment.
                    ``(D) To develop innovative behavioral health 
                service delivery models which incorporate Indian 
                cultural support systems and resources.
    ``(f) Prevention of Child Abuse.--
            ``(1) Access or services provided.--The Secretary, acting 
        through the Service, shall facilitate access to or provide 
        services for Urban Indians through grants to urban Indian 
        organizations administering contracts entered into or receiving 
        grants under subsection (a) to prevent and treat child abuse 
        (including sexual abuse) among Urban Indians.
            ``(2) Evaluation required.--Except as provided by paragraph 
        (3)(A), a grant may not be made under this subsection to an 
        urban Indian organization until that organization has prepared, 
        and the Service has approved, an assessment that documents the 
        prevalence of child abuse in the urban Indian population 
        concerned and specifies the services and programs (which may 
        not duplicate existing services and programs) for which the 
        grant is requested.
            ``(3) Purposes of grants.--Grants may be made under this 
        subsection for the following:
                    ``(A) To prepare assessments required under 
                paragraph (2).
                    ``(B) For the development of prevention, training, 
                and education programs for Urban Indians, including 
                child education, parent education, provider training on 
                identification and intervention, education on reporting 
                requirements, prevention campaigns, and establishing 
                service networks of all those involved in Indian child 
                protection.
                    ``(C) To provide direct outpatient treatment 
                services (including individual treatment, family 
                treatment, group therapy, and support groups) to Urban 
                Indians who are child victims of abuse (including 
                sexual abuse) or adult survivors of child sexual abuse, 
                to the families of such child victims, and to urban 
                Indian perpetrators of child abuse (including sexual 
                abuse).
            ``(4) Considerations when making grants.--In making grants 
        to carry out this subsection, the Secretary shall take into 
        consideration--
                    ``(A) the support for the urban Indian organization 
                demonstrated by the child protection authorities in the 
                area, including committees or other services funded 
                under the Indian Child Welfare Act of 1978 (25 U.S.C. 
                1901 et seq.), if any;
                    ``(B) the capability and expertise demonstrated by 
                the urban Indian organization to address the complex 
                problem of child sexual abuse in the community; and
                    ``(C) the assessment required under paragraph (2).
    ``(g) Other Grants.--The Secretary, acting through the Service, may 
enter into a contract with or make grants to an urban Indian 
organization that provides or arranges for the provision of health care 
services (through satellite facilities, provider networks, or 
otherwise) to Urban Indians in more than 1 Urban Center.

``SEC. 504. USE OF FEDERAL GOVERNMENT FACILITIES AND SOURCES OF SUPPLY.

    ``(a) In General.--The Secretary may permit an urban Indian 
organization that has entered into a contract or received a grant 
pursuant to this title, in carrying out such contract or grant, to use 
existing facilities and all equipment therein or pertaining thereto and 
other personal property owned by the Federal Government within the 
Secretary's jurisdiction under such terms and conditions as may be 
agreed upon for their use and maintenance.
    ``(b) Donations.--Subject to subsection (d), the Secretary may 
donate to an urban Indian organization that has entered into a contract 
or received a grant pursuant to this title any personal or real 
property determined to be excess to the needs of the Indian Health 
Service or the General Services Administration for the purposes of 
carrying out the contract or grant.
    ``(c) Acquisition of Property.--The Secretary may acquire excess or 
surplus government personal or real property for donation, subject to 
subsection (d) to an urban Indian organization that has entered into a 
contract or received a grant pursuant to this title if the Secretary 
determines that the property is appropriate for use by the urban Indian 
organization for a purpose for which a contract or grant is authorized 
under this title.
    ``(d) Priority.--In the event that the Secretary receives a request 
for a specific item of personal or real property described in 
subsections (b) or (c) from an urban Indian organization and from an 
Indian Tribe or Tribal Organization, the Secretary shall give priority 
to the request for donation to the Indian Tribe or Tribal Organization 
if the Secretary receives the request from the Indian Tribe or Tribal 
Organization before the date the Secretary transfers title to the 
property or, if earlier, the date the Secretary transfers the property 
physically, to the urban Indian organization.
    ``(e) Executive Agency Status.--For purposes of section 201(a) of 
the Federal Property and Administrative Services Act of 1949 (40 U.S.C. 
481(a)) (relating to Federal sources of supply), an urban Indian 
organization that has entered into a contract or received a grant 
pursuant to this title may be deemed to be an executive agency when 
carrying out such contract or grant.

``SEC. 505. CONTRACTS AND GRANTS FOR THE DETERMINATION OF UNMET HEALTH 
              CARE NEEDS.

    ``(a) Grants and Contracts Authorized.--Under authority of the Act 
of November 2, 1921 (25 U.S.C. 13) (commonly known as the `Snyder 
Act'), the Secretary, acting through the Service, may enter into 
contracts with or make grants to urban Indian organizations situated in 
Urban Centers for which contracts have not been entered into or grants 
have not been made under section 503.
    ``(b) Purpose.--The purpose of a contract or grant made under this 
section shall be the determination of the matters described in 
subsection (c)(1) in order to assist the Secretary in assessing the 
health status and health care needs of Urban Indians in the Urban 
Center involved and determining whether the Secretary should enter into 
a contract or make a grant under section 503 with respect to the urban 
Indian organization which the Secretary has entered into a contract 
with, or made a grant to, under this section.
    ``(c) Grant and Contract Requirements.--Any contract entered into, 
or grant made, by the Secretary under this section shall include 
requirements that--
            ``(1) the urban Indian organization successfully undertakes 
        to--
                    ``(A) document the health care status and unmet 
                health care needs of urban Indians in the Urban Center 
                involved; and
                    ``(B) with respect to urban Indians in the Urban 
                Center involved, determine the matters described in 
                paragraphs (2), (3), (4), and (7) of section 503(b); 
                and
            ``(2) the urban Indian organization complete performance of 
        the contract, or carry out the requirements of the grant, 
        within 1 year after the date on which the Secretary and such 
        organization enter into such contract, or within 1 year after 
        such organization receives such grant, whichever is applicable.
    ``(d) No Renewals.--The Secretary may not renew any contract 
entered into or grant made under this section.

``SEC. 506. EVALUATIONS; RENEWALS.

    ``(a) Procedures for Evaluations.--The Secretary, acting through 
the Service, shall develop procedures to evaluate compliance with grant 
requirements and compliance with and performance of contracts entered 
into by urban Indian organizations under this title. Such procedures 
shall include provisions for carrying out the requirements of this 
section.
    ``(b) Evaluations.--The Secretary, acting through the Service, 
shall evaluate the compliance of each Urban Indian Organization which 
has entered into a contract or received a grant under section 503 with 
the terms of such contract or grant. For purposes of this evaluation, 
the Secretary shall--
            ``(1) acting through the Service, conduct an annual onsite 
        evaluation of the organization; or
            ``(2) accept in lieu of such onsite evaluation evidence of 
        the organization's provisional or full accreditation by a 
        private independent entity recognized by the Secretary for 
        purposes of conducting quality reviews of providers 
        participating in the Medicare program under title XVIII of the 
        Social Security Act.
    ``(c) Noncompliance; Unsatisfactory Performance.--If, as a result 
of the evaluations conducted under this section, the Secretary 
determines that an urban Indian organization has not complied with the 
requirements of a grant or complied with or satisfactorily performed a 
contract under section 503, the Secretary shall, prior to renewing such 
contract or grant, attempt to resolve with the organization the areas 
of noncompliance or unsatisfactory performance and modify the contract 
or grant to prevent future occurrences of noncompliance or 
unsatisfactory performance. If the Secretary determines that the 
noncompliance or unsatisfactory performance cannot be resolved and 
prevented in the future, the Secretary shall not renew the contract or 
grant with the organization and is authorized to enter into a contract 
or make a grant under section 503 with another urban Indian 
organization which is situated in the same Urban Center as the urban 
Indian organization whose contract or grant is not renewed under this 
section.
    ``(d) Considerations for Renewals.--In determining whether to renew 
a contract or grant with an urban Indian organization under section 503 
which has completed performance of a contract or grant under section 
504, the Secretary shall review the records of the urban Indian 
organization, the reports submitted under section 507, and shall 
consider the results of the onsite evaluations or accreditations under 
subsection (b).

``SEC. 507. OTHER CONTRACT AND GRANT REQUIREMENTS.

    ``(a) Procurement.--Contracts with urban Indian organizations 
entered into pursuant to this title shall be in accordance with all 
Federal contracting laws and regulations relating to procurement except 
that in the discretion of the Secretary, such contracts may be 
negotiated without advertising and need not conform to the provisions 
of sections 1304 and 3131 through 3133 of title 40, United States Code.
    ``(b) Payments Under Contracts or Grants.--
            ``(1) In general.--Payments under any contracts or grants 
        pursuant to this title, notwithstanding any term or condition 
        of such contract or grant--
                    ``(A) may be made in a single advance payment by 
                the Secretary to the urban Indian organization by no 
                later than the end of the first 30 days of the funding 
                period with respect to which the payments apply, unless 
                the Secretary determines through an evaluation under 
                section 505 that the organization is not capable of 
                administering such a single advance payment; and
                    ``(B) if any portion thereof is unexpended by the 
                urban Indian organization during the funding period 
                with respect to which the payments initially apply, 
                shall be carried forward for expenditure with respect 
                to allowable or reimbursable costs incurred by the 
                organization during 1 or more subsequent funding 
                periods without additional justification or 
                documentation by the organization as a condition of 
                carrying forward the availability for expenditure of 
                such funds.
            ``(2) Semiannual and quarterly payments and 
        reimbursements.--If the Secretary determines under paragraph 
        (1)(A) that an urban Indian organization is not capable of 
        administering an entire single advance payment, on request of 
        the urban Indian organization, the payments may be made--
                    ``(A) in semiannual or quarterly payments by not 
                later than 30 days after the date on which the funding 
                period with respect to which the payments apply begins; 
                or
                    ``(B) by way of reimbursement.
    ``(c) Revision or Amendment of Contracts.--Notwithstanding any 
provision of law to the contrary, the Secretary may, at the request and 
consent of an urban Indian organization, revise or amend any contract 
entered into by the Secretary with such organization under this title 
as necessary to carry out the purposes of this title.
    ``(d) Fair and Uniform Services and Assistance.--Contracts with or 
grants to urban Indian organizations and regulations adopted pursuant 
to this title shall include provisions to assure the fair and uniform 
provision to urban Indians of services and assistance under such 
contracts or grants by such organizations.

``SEC. 508. REPORTS AND RECORDS.

    ``(a) Reports.--
            ``(1) In general.--For each fiscal year during which an 
        urban Indian organization receives or expends funds pursuant to 
        a contract entered into or a grant received pursuant to this 
        title, such urban Indian organization shall submit to the 
        Secretary not more frequently than every 6 months, a report 
        that includes the following:
                    ``(A) In the case of a contract or grant under 
                section 503, recommendations pursuant to section 
                503(a)(5).
                    ``(B) Information on activities conducted by the 
                organization pursuant to the contract or grant.
                    ``(C) An accounting of the amounts and purpose for 
                which Federal funds were expended.
                    ``(D) A minimum set of data, using uniformly 
                defined elements, as specified by the Secretary after 
                consultation with urban Indian organizations.
            ``(2) Health status and services.--
                    ``(A) In general.--Not later than 18 months after 
                the date of enactment of the Indian Health Care 
                Improvement Act Amendments of 2009, the Secretary, 
                acting through the Service, shall submit to Congress a 
                report evaluating--
                            ``(i) the health status of urban Indians;
                            ``(ii) the services provided to Indians 
                        pursuant to this title; and
                            ``(iii) areas of unmet needs in the 
                        delivery of health services to urban Indians.
                    ``(B) Consultation and contracts.--In preparing the 
                report under paragraph (1), the Secretary--
                            ``(i) shall consult with urban Indian 
                        organizations; and
                            ``(ii) may enter into a contract with a 
                        national organization representing urban Indian 
                        organizations to conduct any aspect of the 
                        report.
    ``(b) Audit.--The reports and records of the urban Indian 
organization with respect to a contract or grant under this title shall 
be subject to audit by the Secretary and the Comptroller General of the 
United States.
    ``(c) Costs of Audits.--The Secretary shall allow as a cost of any 
contract or grant entered into or awarded under section 502 or 503 the 
cost of an annual independent financial audit conducted by--
            ``(1) a certified public accountant; or
            ``(2) a certified public accounting firm qualified to 
        conduct Federal compliance audits.

``SEC. 509. LIMITATION ON CONTRACT AUTHORITY.

    ``The authority of the Secretary to enter into contracts or to 
award grants under this title shall be to the extent, and in an amount, 
provided for in appropriation Acts.

``SEC. 510. FACILITIES.

    ``(a) Grants.--The Secretary, acting through the Service, may make 
grants to contractors or grant recipients under this title for the 
lease, purchase, renovation, construction, or expansion of facilities, 
including leased facilities, in order to assist such contractors or 
grant recipients in complying with applicable licensure or 
certification requirements.
    ``(b) Loan Fund Study.--The Secretary, acting through the Service, 
may carry out a study to determine the feasibility of establishing a 
loan fund to provide to urban Indian organizations direct loans or 
guarantees for loans for the construction of health care facilities in 
a manner consistent with section 309, including by submitting a report 
in accordance with subsection (c) of that section.

``SEC. 511. DIVISION OF URBAN INDIAN HEALTH.

    ``There is established within the Service a Division of Urban 
Indian Health, which shall be responsible for--
            ``(1) carrying out the provisions of this title;
            ``(2) providing central oversight of the programs and 
        services authorized under this title; and
            ``(3) providing technical assistance to urban Indian 
        organizations.

``SEC. 512. GRANTS FOR ALCOHOL AND SUBSTANCE ABUSE-RELATED SERVICES.

    ``(a) Grants Authorized.--The Secretary, acting through the 
Service, may make grants for the provision of health-related services 
in prevention of, treatment of, rehabilitation of, or school- and 
community-based education regarding, alcohol and substance abuse in 
Urban Centers to those urban Indian organizations with which the 
Secretary has entered into a contract under this title or under section 
201.
    ``(b) Goals.--Each grant made pursuant to subsection (a) shall set 
forth the goals to be accomplished pursuant to the grant. The goals 
shall be specific to each grant as agreed to between the Secretary and 
the grantee.
    ``(c) Criteria.--The Secretary shall establish criteria for the 
grants made under subsection (a), including criteria relating to the 
following:
            ``(1) The size of the urban Indian population.
            ``(2) Capability of the organization to adequately perform 
        the activities required under the grant.
            ``(3) Satisfactory performance standards for the 
        organization in meeting the goals set forth in such grant. The 
        standards shall be negotiated and agreed to between the 
        Secretary and the grantee on a grant-by-grant basis.
            ``(4) Identification of the need for services.
    ``(d) Allocation of Grants.--The Secretary shall develop a 
methodology for allocating grants made pursuant to this section based 
on the criteria established pursuant to subsection (c).
    ``(e) Grants Subject to Criteria.--Any grant received by an urban 
Indian organization under this Act for substance abuse prevention, 
treatment, and rehabilitation shall be subject to the criteria set 
forth in subsection (c).

``SEC. 513. TREATMENT OF CERTAIN DEMONSTRATION PROJECTS.

    ``Notwithstanding any other provision of law, the Tulsa Clinic and 
Oklahoma City Clinic demonstration projects shall--
            ``(1) be permanent programs within the Service's direct 
        care program;
            ``(2) continue to be treated as Service Units and Operating 
        Units in the allocation of resources and coordination of care; 
        and
            ``(3) continue to meet the requirements and definitions of 
        an urban Indian organization in this Act, and shall not be 
        subject to the provisions of the Indian Self-Determination and 
        Education Assistance Act (25 U.S.C. 450 et seq.).

``SEC. 514. URBAN NIAAA TRANSFERRED PROGRAMS.

    ``(a) Grants and Contracts.--The Secretary, through the Division of 
Urban Indian Health, shall make grants or enter into contracts with 
urban Indian organizations, to take effect not later than September 30, 
2010, for the administration of urban Indian alcohol programs that were 
originally established under the National Institute on Alcoholism and 
Alcohol Abuse (hereafter in this section referred to as `NIAAA') and 
transferred to the Service.
    ``(b) Use of Funds.--Grants provided or contracts entered into 
under this section shall be used to provide support for the 
continuation of alcohol prevention and treatment services for urban 
Indian populations and such other objectives as are agreed upon between 
the Service and a recipient of a grant or contract under this section.
    ``(c) Eligibility.--Urban Indian organizations that operate Indian 
alcohol programs originally funded under the NIAAA and subsequently 
transferred to the Service are eligible for grants or contracts under 
this section.
    ``(d) Report.--The Secretary shall evaluate and report to Congress 
on the activities of programs funded under this section not less than 
every 5 years.

``SEC. 515. CONFERRING WITH URBAN INDIAN ORGANIZATIONS.

    ``(a) In General.--The Secretary shall ensure that the Service 
confers or conferences, to the greatest extent practicable, with Urban 
Indian Organizations.
    ``(b) Definition of Confer; Conference.--In this section, the terms 
`confer' and `conference' mean an open and free exchange of information 
and opinions that--
            ``(1) leads to mutual understanding and comprehension; and
            ``(2) emphasizes trust, respect, and shared responsibility.

``SEC. 516. URBAN YOUTH TREATMENT CENTER DEMONSTRATION.

    ``(a) Construction and Operation.--
            ``(1) In general.--The Secretary, acting through the 
        Service, through grant or contract, shall fund the construction 
        and operation of at least 1 residential treatment center in 
        each Service Area that meets the eligibility requirements set 
        forth in subsection (b) to demonstrate the provision of alcohol 
        and substance abuse treatment services to Urban Indian youth in 
        a culturally competent residential setting.
            ``(2) Treatment.--Each residential treatment center 
        described in paragraph (1) shall be in addition to any 
        facilities constructed under section 707(b).
    ``(b) Eligibility Requirements.--To be eligible to obtain a 
facility under subsection (a)(1), a Service Area shall meet the 
following requirements:
            ``(1) There is an Urban Indian Organization in the Service 
        Area.
            ``(2) There reside in the Service Area Urban Indian youth 
        with need for alcohol and substance abuse treatment services in 
        a residential setting.
            ``(3) There is a significant shortage of culturally 
        competent residential treatment services for Urban Indian youth 
        in the Service Area.

``SEC. 517. GRANTS FOR DIABETES PREVENTION, TREATMENT, AND CONTROL.

    ``(a) Grants Authorized.--The Secretary may make grants to those 
urban Indian organizations that have entered into a contract or have 
received a grant under this title for the provision of services for the 
prevention and treatment of, and control of the complications resulting 
from, diabetes among urban Indians.
    ``(b) Goals.--Each grant made pursuant to subsection (a) shall set 
forth the goals to be accomplished under the grant. The goals shall be 
specific to each grant as agreed to between the Secretary and the 
grantee.
    ``(c) Establishment of Criteria.--The Secretary shall establish 
criteria for the grants made under subsection (a) relating to--
            ``(1) the size and location of the urban Indian population 
        to be served;
            ``(2) the need for prevention of and treatment of, and 
        control of the complications resulting from, diabetes among the 
        urban Indian population to be served;
            ``(3) performance standards for the organization in meeting 
        the goals set forth in such grant that are negotiated and 
        agreed to by the Secretary and the grantee;
            ``(4) the capability of the organization to adequately 
        perform the activities required under the grant; and
            ``(5) the willingness of the organization to collaborate 
        with the registry, if any, established by the Secretary under 
        section 203(e)(1)(B) in the Area Office of the Service in which 
        the organization is located.
    ``(d) Funds Subject to Criteria.--Any funds received by an urban 
Indian organization under this Act for the prevention, treatment, and 
control of diabetes among urban Indians shall be subject to the 
criteria developed by the Secretary under subsection (c).

``SEC. 518. COMMUNITY HEALTH REPRESENTATIVES.

    ``The Secretary, acting through the Service, may enter into 
contracts with, and make grants to, urban Indian organizations for the 
employment of Indians trained as health service providers through the 
Community Health Representatives Program under section 109 in the 
provision of health care, health promotion, and disease prevention 
services to urban Indians.

``SEC. 519. EFFECTIVE DATE.

    ``The amendments made by the Indian Health Care Improvement Act 
Amendments of 2009 to this title shall take effect beginning on the 
date of enactment of that Act, regardless of whether the Secretary has 
promulgated regulations implementing such amendments.

``SEC. 520. ELIGIBILITY FOR SERVICES.

    ``Urban Indians shall be eligible for, and the ultimate 
beneficiaries of, health care or referral services provided pursuant to 
this title.

``SEC. 521. AUTHORIZATION OF APPROPRIATIONS.

    ``(a) In General.--There are authorized to be appropriated such 
sums as may be necessary to carry out this title.
    ``(b) Urban Indian Organizations.--The Secretary, acting through 
the Service, is authorized to establish programs, including programs 
for the awarding of grants, for urban Indian organizations that are 
identical to any programs established pursuant to section 126 
(behavioral health training), section 209 (school health education), 
section 211 (prevention of communicable diseases), section 701 
(behavioral health prevention and treatment services), and section 
707(g) (multidrug abuse program).

``SEC. 522. HEALTH INFORMATION TECHNOLOGY.

    ``The Secretary, acting through the Service, may make grants to 
urban Indian organizations under this title for the development, 
adoption, and implementation of health information technology (as 
defined in section 3000(5) of the American Recovery and Reinvestment 
Act), telemedicine services development, and related infrastructure.

                ``TITLE VI--ORGANIZATIONAL IMPROVEMENTS

``SEC. 601. ESTABLISHMENT OF THE INDIAN HEALTH SERVICE AS AN AGENCY OF 
              THE PUBLIC HEALTH SERVICE.

    ``(a) Establishment.--
            ``(1) In general.--In order to more effectively and 
        efficiently carry out the responsibilities, authorities, and 
        functions of the United States to provide health care services 
        to Indians and Indian Tribes, as are or may be hereafter 
        provided by Federal statute or treaties, there is established 
        within the Public Health Service of the Department the Indian 
        Health Service.
            ``(2) Assistant secretary of indian health.--The Service 
        shall be administered by an Assistant Secretary of Indian 
        Health, who shall be appointed by the President, by and with 
        the advice and consent of the Senate. The Assistant Secretary 
        shall report to the Secretary. Effective with respect to an 
        individual appointed by the President, by and with the advice 
        and consent of the Senate, after January 1, 2010, the term of 
        service of the Assistant Secretary shall be 4 years. An 
        Assistant Secretary may serve more than 1 term.
            ``(3) Incumbent.--The individual serving in the position of 
        Director of the Service on the day before the date of enactment 
        of the Indian Health Care Improvement Act Amendments of 2009 
        shall serve as Assistant Secretary.
            ``(4) Advocacy and consultation.--The position of Assistant 
        Secretary is established to, in a manner consistent with the 
        government-to-government relationship between the United States 
        and Indian Tribes--
                    ``(A) facilitate advocacy for the development of 
                appropriate Indian health policy; and
                    ``(B) promote consultation on matters relating to 
                Indian health.
    ``(b) Agency.--The Service shall be an agency within the Public 
Health Service of the Department, and shall not be an office, 
component, or unit of any other agency of the Department.
    ``(c) Duties.--The Assistant Secretary shall--
            ``(1) perform all functions that were, on the day before 
        the date of enactment of the Indian Health Care Improvement Act 
        Amendments of 2009, carried out by or under the direction of 
        the individual serving as Director of the Service on that day;
            ``(2) perform all functions of the Secretary relating to 
        the maintenance and operation of hospital and health facilities 
        for Indians and the planning for, and provision and utilization 
        of, health services for Indians;
            ``(3) administer all health programs under which health 
        care is provided to Indians based upon their status as Indians 
        which are administered by the Secretary, including programs 
        under--
                    ``(A) this Act;
                    ``(B) the Act of November 2, 1921 (25 U.S.C. 13);
                    ``(C) the Act of August 5, 1954 (42 U.S.C. 2001 et 
                seq.);
                    ``(D) the Act of August 16, 1957 (42 U.S.C. 2005 et 
                seq.); and
                    ``(E) the Indian Self-Determination and Education 
                Assistance Act (25 U.S.C. 450 et seq.);
            ``(4) administer all scholarship and loan functions carried 
        out under title I;
            ``(5) report directly to the Secretary concerning all 
        policy- and budget-related matters affecting Indian health;
            ``(6) collaborate with the Assistant Secretary for Health 
        concerning appropriate matters of Indian health that affect the 
        agencies of the Public Health Service;
            ``(7) advise each Assistant Secretary of the Department 
        concerning matters of Indian health with respect to which that 
        Assistant Secretary has authority and responsibility;
            ``(8) advise the heads of other agencies and programs of 
        the Department concerning matters of Indian health with respect 
        to which those heads have authority and responsibility;
            ``(9) coordinate the activities of the Department 
        concerning matters of Indian health; and
            ``(10) perform such other functions as the Secretary may 
        designate.
    ``(d) Authority.--
            ``(1) In general.--The Secretary, acting through the 
        Assistant Secretary, shall have the authority--
                    ``(A) except to the extent provided for in 
                paragraph (2), to appoint and compensate employees for 
                the Service in accordance with title 5, United States 
                Code;
                    ``(B) to enter into contracts for the procurement 
                of goods and services to carry out the functions of the 
                Service; and
                    ``(C) to manage, expend, and obligate all funds 
                appropriated for the Service.
            ``(2) Personnel actions.--Notwithstanding any other 
        provision of law, the provisions of section 12 of the Act of 
        June 18, 1934 (48 Stat. 986; 25 U.S.C. 472), shall apply to all 
        personnel actions taken with respect to new positions created 
        within the Service as a result of its establishment under 
        subsection (a).
    ``(e) References.--Any reference to the Director of the Indian 
Health Service in any other Federal law, Executive order, rule, 
regulation, or delegation of authority, or in any document of or 
relating to the Director of the Indian Health Service, shall be deemed 
to refer to the Assistant Secretary.

``SEC. 602. AUTOMATED MANAGEMENT INFORMATION SYSTEM.

    ``(a) Establishment.--
            ``(1) In general.--The Secretary shall establish an 
        automated management information system for the Service.
            ``(2) Requirements of system.--The information system 
        established under paragraph (1) shall include--
                    ``(A) a financial management system;
                    ``(B) a patient care information system for each 
                area served by the Service;
                    ``(C) privacy protections consistent with the 
                regulations promulgated under section 264(c) of the 
                Health Insurance Portability and Accountability Act of 
                1996 or, to the extent consistent with such 
                regulations, other Federal rules applicable to privacy 
                of automated management information systems of a 
                Federal agency;
                    ``(D) a services-based cost accounting component 
                that provides estimates of the costs associated with 
                the provision of specific medical treatments or 
                services in each Area office of the Service;
                    ``(E) an interface mechanism for patient billing 
                and accounts receivable system; and
                    ``(F) a training component.
    ``(b) Provision of Systems to Tribes and Organizations.--The 
Secretary shall provide each Tribal Health Program automated management 
information systems which--
            ``(1) meet the management information needs of such Tribal 
        Health Program with respect to the treatment by the Tribal 
        Health Program of patients of the Service; and
            ``(2) meet the management information needs of the Service.
    ``(c) Access to Records.--The Service shall provide access of 
patients to their medical or health records which are held by, or on 
behalf of, the Service in accordance with the regulations promulgated 
under section 264(c) of the Health Insurance Portability and 
Accountability Act of 1996 or, to the extent consistent with such 
regulations, other Federal rules applicable to access to health care 
records.
    ``(d) Authority To Enhance Information Technology.--The Secretary, 
acting through the Assistant Secretary, shall have the authority to 
enter into contracts, agreements, or joint ventures with other Federal 
agencies, States, private and nonprofit organizations, for the purpose 
of enhancing information technology in Indian Health Programs and 
facilities.

``SEC. 603. AUTHORIZATION OF APPROPRIATIONS.

    ``There is authorized to be appropriated such sums as may be 
necessary to carry out this title.

                ``TITLE VII--BEHAVIORAL HEALTH PROGRAMS

``SEC. 701. BEHAVIORAL HEALTH PREVENTION AND TREATMENT SERVICES.

    ``(a) Purposes.--The purposes of this section are as follows:
            ``(1) To authorize and direct the Secretary, acting through 
        the Service, to develop a comprehensive behavioral health 
        prevention and treatment program which emphasizes collaboration 
        among alcohol and substance abuse, social services, and mental 
        health programs.
            ``(2) To provide information, direction, and guidance 
        relating to mental illness and dysfunction and self-destructive 
        behavior, including child abuse and family violence, to those 
        Federal, tribal, State, and local agencies responsible for 
        programs in Indian communities in areas of health care, 
        education, social services, child and family welfare, alcohol 
        and substance abuse, law enforcement, and judicial services.
            ``(3) To assist Indian Tribes to identify services and 
        resources available to address mental illness and dysfunctional 
        and self-destructive behavior.
            ``(4) To provide authority and opportunities for Indian 
        Tribes and Tribal Organizations to develop, implement, and 
        coordinate with community-based programs which include 
        identification, prevention, education, referral, and treatment 
        services, including through multidisciplinary resource teams.
            ``(5) To ensure that Indians, as citizens of the United 
        States and of the States in which they reside, have the same 
        access to behavioral health services to which all citizens have 
        access.
            ``(6) To modify or supplement existing programs and 
        authorities in the areas identified in paragraph (2).
    ``(b) Plans.--
            ``(1) Development.--The Secretary, acting through the 
        Service, shall encourage Indian Tribes and Tribal Organizations 
        to develop tribal plans, and urban Indian organizations to 
        develop local plans, and for all such groups to participate in 
        developing areawide plans for Indian Behavioral Health 
        Services. The plans shall include, to the extent feasible, the 
        following components:
                    ``(A) An assessment of the scope of alcohol or 
                other substance abuse, mental illness, and 
                dysfunctional and self-destructive behavior, including 
                suicide, child abuse, and family violence, among 
                Indians, including--
                            ``(i) the number of Indians served who are 
                        directly or indirectly affected by such illness 
                        or behavior; or
                            ``(ii) an estimate of the financial and 
                        human cost attributable to such illness or 
                        behavior.
                    ``(B) An assessment of the existing and additional 
                resources necessary for the prevention and treatment of 
                such illness and behavior, including an assessment of 
                the progress toward achieving the availability of the 
                full continuum of care described in subsection (c).
                    ``(C) An estimate of the additional funding needed 
                by the Service, Indian Tribes, Tribal Organizations, 
                and urban Indian organizations to meet their 
                responsibilities under the plans.
            ``(2) National clearinghouse.--The Secretary, acting 
        through the Service, shall coordinate with existing national 
        clearinghouses and information centers to include at the 
        clearinghouses and centers plans and reports on the outcomes of 
        such plans developed by Indian Tribes, Tribal Organizations, 
        urban Indian organizations, and Service Areas relating to 
        behavioral health. The Secretary shall ensure access to these 
        plans and outcomes by any Indian Tribe, Tribal Organization, 
        urban Indian organization, or the Service.
            ``(3) Technical assistance.--The Secretary shall provide 
        technical assistance to Indian Tribes, Tribal Organizations, 
        and urban Indian organizations in preparation of plans under 
        this section and in developing standards of care that may be 
        used and adopted locally.
    ``(c) Programs.--The Secretary, acting through the Service, shall 
provide, to the extent feasible and if funding is available, programs 
including the following:
            ``(1) Comprehensive care.--A comprehensive continuum of 
        behavioral health care which provides--
                    ``(A) community-based prevention, intervention, 
                outpatient, and behavioral health aftercare;
                    ``(B) detoxification (social and medical);
                    ``(C) acute hospitalization;
                    ``(D) intensive outpatient/day treatment;
                    ``(E) residential treatment;
                    ``(F) transitional living for those needing a 
                temporary, stable living environment that is supportive 
                of treatment and recovery goals;
                    ``(G) emergency shelter;
                    ``(H) intensive case management; and
                    ``(I) diagnostic services.
            ``(2) Child care.--Behavioral health services for Indians 
        from birth through age 17, including--
                    ``(A) preschool and school age fetal alcohol 
                disorder services, including assessment and behavioral 
                intervention;
                    ``(B) mental health and substance abuse services 
                (emotional, organic, alcohol, drug, inhalant, and 
                tobacco);
                    ``(C) identification and treatment of co-occurring 
                disorders and comorbidity;
                    ``(D) prevention of alcohol, drug, inhalant, and 
                tobacco use;
                    ``(E) early intervention, treatment, and aftercare;
                    ``(F) promotion of healthy approaches to risk and 
                safety issues; and
                    ``(G) identification and treatment of neglect and 
                physical, mental, and sexual abuse.
            ``(3) Adult care.--Behavioral health services for Indians 
        from age 18 through 55, including--
                    ``(A) early intervention, treatment, and aftercare;
                    ``(B) mental health and substance abuse services 
                (emotional, alcohol, drug, inhalant, and tobacco), 
                including sex specific services;
                    ``(C) identification and treatment of co-occurring 
                disorders (dual diagnosis) and comorbidity;
                    ``(D) promotion of healthy approaches for risk-
                related behavior;
                    ``(E) treatment services for women at risk of 
                giving birth to a child with a fetal alcohol disorder; 
                and
                    ``(F) sex specific treatment for sexual assault and 
                domestic violence.
            ``(4) Family care.--Behavioral health services for 
        families, including--
                    ``(A) early intervention, treatment, and aftercare 
                for affected families;
                    ``(B) treatment for sexual assault and domestic 
                violence; and
                    ``(C) promotion of healthy approaches relating to 
                parenting, domestic violence, and other abuse issues.
            ``(5) Elder care.--Behavioral health services for Indians 
        56 years of age and older, including--
                    ``(A) early intervention, treatment, and aftercare;
                    ``(B) mental health and substance abuse services 
                (emotional, alcohol, drug, inhalant, and tobacco), 
                including sex specific services;
                    ``(C) identification and treatment of co-occurring 
                disorders (dual diagnosis) and comorbidity;
                    ``(D) promotion of healthy approaches to managing 
                conditions related to aging;
                    ``(E) sex specific treatment for sexual assault, 
                domestic violence, neglect, physical and mental abuse 
                and exploitation; and
                    ``(F) identification and treatment of dementias 
                regardless of cause.
    ``(d) Community Behavioral Health Plan.--
            ``(1) Establishment.--The governing body of any Indian 
        Tribe, Tribal Organization, or urban Indian organization may 
        adopt a resolution for the establishment of a community 
        behavioral health plan providing for the identification and 
        coordination of available resources and programs to identify, 
        prevent, or treat substance abuse, mental illness, or 
        dysfunctional and self-destructive behavior, including child 
        abuse and family violence, among its members or its service 
        population. This plan should include behavioral health 
        services, social services, intensive outpatient services, and 
        continuing aftercare.
            ``(2) Technical assistance.--At the request of an Indian 
        Tribe, Tribal Organization, or urban Indian organization, the 
        Bureau of Indian Affairs and the Service shall cooperate with 
        and provide technical assistance to the Indian Tribe, Tribal 
        Organization, or urban Indian organization in the development 
        and implementation of such plan.
            ``(3) Funding.--The Secretary, acting through the Service, 
        may make funding available to Indian Tribes and Tribal 
        Organizations which adopt a resolution pursuant to paragraph 
        (1) to obtain technical assistance for the development of a 
        community behavioral health plan and to provide administrative 
        support in the implementation of such plan.
    ``(e) Coordination for Availability of Services.--The Secretary, 
acting through the Service, shall coordinate behavioral health 
planning, to the extent feasible, with other Federal agencies and with 
State agencies, to encourage comprehensive behavioral health services 
for Indians regardless of their place of residence.
    ``(f) Mental Health Care Need Assessment.--Not later than 1 year 
after the date of enactment of the Indian Health Care Improvement Act 
Amendments of 2009, the Secretary, acting through the Service, shall 
make an assessment of the need for inpatient mental health care among 
Indians and the availability and cost of inpatient mental health 
facilities which can meet such need. In making such assessment, the 
Secretary shall consider the possible conversion of existing, underused 
Service hospital beds into psychiatric units to meet such need.

``SEC. 702. MEMORANDA OF AGREEMENT WITH THE DEPARTMENT OF THE INTERIOR.

    ``(a) Contents.--Not later than 12 months after the date of 
enactment of the Indian Health Care Improvement Act Amendments of 2009, 
the Secretary, acting through the Service, and the Secretary of the 
Interior shall develop and enter into a memoranda of agreement, or 
review and update any existing memoranda of agreement, as required by 
section 4205 of the Indian Alcohol and Substance Abuse Prevention and 
Treatment Act of 1986 (25 U.S.C. 2411) under which the Secretaries 
address the following:
            ``(1) The scope and nature of mental illness and 
        dysfunctional and self-destructive behavior, including child 
        abuse and family violence, among Indians.
            ``(2) The existing Federal, tribal, State, local, and 
        private services, resources, and programs available to provide 
        behavioral health services for Indians.
            ``(3) The unmet need for additional services, resources, 
        and programs necessary to meet the needs identified pursuant to 
        paragraph (1).
            ``(4)(A) The right of Indians, as citizens of the United 
        States and of the States in which they reside, to have access 
        to behavioral health services to which all citizens have 
        access.
            ``(B) The right of Indians to participate in, and receive 
        the benefit of, such services.
            ``(C) The actions necessary to protect the exercise of such 
        right.
            ``(5) The responsibilities of the Bureau of Indian Affairs 
        and the Service, including mental illness identification, 
        prevention, education, referral, and treatment services 
        (including services through multidisciplinary resource teams), 
        at the central, area, and agency and Service Unit, Service 
        Area, and headquarters levels to address the problems 
        identified in paragraph (1).
            ``(6) A strategy for the comprehensive coordination of the 
        behavioral health services provided by the Bureau of Indian 
        Affairs and the Service to meet the problems identified 
        pursuant to paragraph (1), including--
                    ``(A) the coordination of alcohol and substance 
                abuse programs of the Service, the Bureau of Indian 
                Affairs, and Indian Tribes and Tribal Organizations 
                (developed under the Indian Alcohol and Substance Abuse 
                Prevention and Treatment Act of 1986 (25 U.S.C. 2401 et 
                seq.)) with behavioral health initiatives pursuant to 
                this Act, particularly with respect to the referral and 
                treatment of dually diagnosed individuals requiring 
                behavioral health and substance abuse treatment; and
                    ``(B) ensuring that the Bureau of Indian Affairs 
                and Service programs and services (including 
                multidisciplinary resource teams) addressing child 
                abuse and family violence are coordinated with such 
                non-Federal programs and services.
            ``(7) Directing appropriate officials of the Bureau of 
        Indian Affairs and the Service, particularly at the agency and 
        Service Unit levels, to cooperate fully with tribal requests 
        made pursuant to community behavioral health plans adopted 
        under section 701(c) and section 4206 of the Indian Alcohol and 
        Substance Abuse Prevention and Treatment Act of 1986 (25 U.S.C. 
        2412).
            ``(8) Providing for an annual review of such agreement by 
        the Secretaries which shall be provided to Congress and Indian 
        Tribes and Tribal Organizations.
    ``(b) Specific Provisions Required.--The memoranda of agreement 
updated or entered into pursuant to subsection (a) shall include 
specific provisions pursuant to which the Service shall assume 
responsibility for--
            ``(1) the determination of the scope of the problem of 
        alcohol and substance abuse among Indians, including the number 
        of Indians within the jurisdiction of the Service who are 
        directly or indirectly affected by alcohol and substance abuse 
        and the financial and human cost;
            ``(2) an assessment of the existing and needed resources 
        necessary for the prevention of alcohol and substance abuse and 
        the treatment of Indians affected by alcohol and substance 
        abuse; and
            ``(3) an estimate of the funding necessary to adequately 
        support a program of prevention of alcohol and substance abuse 
        and treatment of Indians affected by alcohol and substance 
        abuse.
    ``(c) Publication.--Each memorandum of agreement entered into or 
renewed (and amendments or modifications thereto) under subsection (a) 
shall be published in the Federal Register. At the same time as 
publication in the Federal Register, the Secretary shall provide a copy 
of such memoranda, amendment, or modification to each Indian Tribe, 
Tribal Organization, and urban Indian organization.

``SEC. 703. COMPREHENSIVE BEHAVIORAL HEALTH PREVENTION AND TREATMENT 
              PROGRAM.

    ``(a) Establishment.--
            ``(1) In general.--The Secretary, acting through the 
        Service, shall provide a program of comprehensive behavioral 
        health, prevention, treatment, and aftercare, including Systems 
        of Care, which shall include--
                    ``(A) prevention, through educational intervention, 
                in Indian communities;
                    ``(B) acute detoxification, psychiatric 
                hospitalization, residential, and intensive outpatient 
                treatment;
                    ``(C) community-based rehabilitation and aftercare;
                    ``(D) community education and involvement, 
                including extensive training of health care, 
                educational, and community-based personnel;
                    ``(E) specialized residential treatment programs 
                for high-risk populations, including pregnant and 
                postpartum women and their children; and
                    ``(F) diagnostic services.
            ``(2) Target populations.--The target population of such 
        programs shall be members of Indian Tribes. Efforts to train 
        and educate key members of the Indian community shall also 
        target employees of health, education, judicial, law 
        enforcement, legal, and social service programs.
    ``(b) Contract Health Services.--
            ``(1) In general.--The Secretary, acting through the 
        Service, may enter into contracts with public or private 
        providers of behavioral health treatment services for the 
        purpose of carrying out the program required under subsection 
        (a).
            ``(2) Provision of assistance.--In carrying out this 
        subsection, the Secretary shall provide assistance to Indian 
        Tribes and Tribal Organizations to develop criteria for the 
        certification of behavioral health service providers and 
        accreditation of service facilities which meet minimum 
        standards for such services and facilities.

``SEC. 704. MENTAL HEALTH TECHNICIAN PROGRAM.

    ``(a) In General.--Under the authority of the Act of November 2, 
1921 (25 U.S.C. 13) (commonly known as the `Snyder Act'), the Secretary 
shall establish and maintain a mental health technician program within 
the Service which--
            ``(1) provides for the training of Indians as mental health 
        technicians; and
            ``(2) employs such technicians in the provision of 
        community-based mental health care that includes 
        identification, prevention, education, referral, and treatment 
        services.
    ``(b) Paraprofessional Training.--In carrying out subsection (a), 
the Secretary, acting through the Service, shall provide high-standard 
paraprofessional training in mental health care necessary to provide 
quality care to the Indian communities to be served. Such training 
shall be based upon a curriculum developed or approved by the Secretary 
which combines education in the theory of mental health care with 
supervised practical experience in the provision of such care.
    ``(c) Supervision and Evaluation of Technicians.--The Secretary, 
acting through the Service, shall supervise and evaluate the mental 
health technicians in the training program.
    ``(d) Traditional Health Care Practices.--The Secretary, acting 
through the Service, shall ensure that the program established pursuant 
to this subsection involves the use and promotion of the traditional 
health care practices of the Indian Tribes to be served.

``SEC. 705. LICENSING REQUIREMENT FOR MENTAL HEALTH CARE WORKERS.

    ``(a) In General.--Subject to the provisions of section 221, and 
except as provided in subsection (b), any individual employed as a 
psychologist, social worker, or marriage and family therapist for the 
purpose of providing mental health care services to Indians in a 
clinical setting under this Act is required to be licensed as a 
psychologist, social worker, or marriage and family therapist, 
respectively.
    ``(b) Trainees.--An individual may be employed as a trainee in 
psychology, social work, or marriage and family therapy to provide 
mental health care services described in subsection (a) if such 
individual--
            ``(1) works under the direct supervision of a licensed 
        psychologist, social worker, or marriage and family therapist, 
        respectively;
            ``(2) is enrolled in or has completed at least 2 years of 
        course work at a post-secondary, accredited education program 
        for psychology, social work, marriage and family therapy, or 
        counseling; and
            ``(3) meets such other training, supervision, and quality 
        review requirements as the Secretary may establish.

``SEC. 706. INDIAN WOMEN TREATMENT PROGRAMS.

    ``(a) Grants.--The Secretary, consistent with section 701, may make 
grants to Indian Tribes, Tribal Organizations, and urban Indian 
organizations to develop and implement a comprehensive behavioral 
health program of prevention, intervention, treatment, and relapse 
prevention services that specifically addresses the cultural, 
historical, social, and child care needs of Indian women, regardless of 
age.
    ``(b) Use of Grant Funds.--A grant made pursuant to this section 
may be used to--
            ``(1) develop and provide community training, education, 
        and prevention programs for Indian women relating to behavioral 
        health issues, including fetal alcohol disorders;
            ``(2) identify and provide psychological services, 
        counseling, advocacy, support, and relapse prevention to Indian 
        women and their families; and
            ``(3) develop prevention and intervention models for Indian 
        women which incorporate traditional health care practices, 
        cultural values, and community and family involvement.
    ``(c) Criteria.--The Secretary, in consultation with Indian Tribes 
and Tribal Organizations, shall establish criteria for the review and 
approval of applications and proposals for funding under this section.
    ``(d) Allocation of Funds for Urban Indian Organizations.--Twenty 
percent of the funds appropriated pursuant to this section shall be 
used to make grants to urban Indian organizations.

``SEC. 707. INDIAN YOUTH PROGRAM.

    ``(a) Detoxification and Rehabilitation.--The Secretary, acting 
through the Service, consistent with section 701, shall develop and 
implement a program for acute detoxification and treatment for Indian 
youths, including behavioral health services. The program shall include 
regional treatment centers designed to include detoxification and 
rehabilitation for both sexes on a referral basis and programs 
developed and implemented by Indian Tribes or Tribal Organizations at 
the local level under the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.). Regional centers shall be 
integrated with the intake and rehabilitation programs based in the 
referring Indian community.
    ``(b) Alcohol and Substance Abuse Treatment Centers or 
Facilities.--
            ``(1) Establishment.--
                    ``(A) In general.--The Secretary, acting through 
                the Service, shall construct, renovate, or, as 
                necessary, purchase, and appropriately staff and 
                operate, at least 1 youth regional treatment center or 
                treatment network in each area under the jurisdiction 
                of an Area Office.
                    ``(B) Area office in california.--For the purposes 
                of this subsection, the Area Office in California shall 
                be considered to be 2 Area Offices, 1 office whose 
                jurisdiction shall be considered to encompass the 
                northern area of the State of California, and 1 office 
                whose jurisdiction shall be considered to encompass the 
                remainder of the State of California for the purpose of 
                implementing California treatment networks.
            ``(2) Funding.--For the purpose of staffing and operating 
        such centers or facilities, funding shall be pursuant to the 
        Act of November 2, 1921 (25 U.S.C. 13).
            ``(3) Location.--A youth treatment center constructed or 
        purchased under this subsection shall be constructed or 
        purchased at a location within the area described in paragraph 
        (1) agreed upon (by appropriate tribal resolution) by a 
        majority of the Indian Tribes to be served by such center.
            ``(4) Specific provision of funds.--
                    ``(A) In general.--Notwithstanding any other 
                provision of this title, the Secretary may, from 
                amounts authorized to be appropriated for the purposes 
                of carrying out this section, make funds available to--
                            ``(i) the Tanana Chiefs Conference, 
                        Incorporated, for the purpose of leasing, 
                        constructing, renovating, operating, and 
                        maintaining a residential youth treatment 
                        facility in Fairbanks, Alaska; and
                            ``(ii) the Southeast Alaska Regional Health 
                        Corporation to staff and operate a residential 
                        youth treatment facility without regard to the 
                        proviso set forth in section 4(l) of the Indian 
                        Self-Determination and Education Assistance Act 
                        (25 U.S.C. 450b(l)).
                    ``(B) Provision of services to eligible youths.--
                Until additional residential youth treatment facilities 
                are established in Alaska pursuant to this section, the 
                facilities specified in subparagraph (A) shall make 
                every effort to provide services to all eligible Indian 
                youths residing in Alaska.
    ``(c) Intermediate Adolescent Behavioral Health Services.--
            ``(1) In general.--The Secretary, acting through the 
        Service, may provide intermediate behavioral health services, 
        which may incorporate Systems of Care, to Indian children and 
        adolescents, including--
                    ``(A) pretreatment assistance;
                    ``(B) inpatient, outpatient, and aftercare 
                services;
                    ``(C) emergency care;
                    ``(D) suicide prevention and crisis intervention; 
                and
                    ``(E) prevention and treatment of mental illness 
                and dysfunctional and self-destructive behavior, 
                including child abuse and family violence.
            ``(2) Use of funds.--Funds provided under this subsection 
        may be used--
                    ``(A) to construct or renovate an existing health 
                facility to provide intermediate behavioral health 
                services;
                    ``(B) to hire behavioral health professionals;
                    ``(C) to staff, operate, and maintain an 
                intermediate mental health facility, group home, sober 
                housing, transitional housing or similar facilities, or 
                youth shelter where intermediate behavioral health 
                services are being provided;
                    ``(D) to make renovations and hire appropriate 
                staff to convert existing hospital beds into adolescent 
                psychiatric units; and
                    ``(E) for intensive home- and community-based 
                services.
            ``(3) Criteria.--The Secretary, acting through the Service, 
        shall, in consultation with Indian Tribes and Tribal 
        Organizations, establish criteria for the review and approval 
        of applications or proposals for funding made available 
        pursuant to this subsection.
    ``(d) Federally Owned Structures.--
            ``(1) In general.--The Secretary, in consultation with 
        Indian Tribes and Tribal Organizations, shall--
                    ``(A) identify and use, where appropriate, 
                federally owned structures suitable for local 
                residential or regional behavioral health treatment for 
                Indian youths; and
                    ``(B) establish guidelines for determining the 
                suitability of any such federally owned structure to be 
                used for local residential or regional behavioral 
                health treatment for Indian youths.
            ``(2) Terms and conditions for use of structure.--Any 
        structure described in paragraph (1) may be used under such 
        terms and conditions as may be agreed upon by the Secretary and 
        the agency having responsibility for the structure and any 
        Indian Tribe or Tribal Organization operating the program.
    ``(e) Rehabilitation and Aftercare Services.--
            ``(1) In general.--The Secretary, Indian Tribes, or Tribal 
        Organizations, in cooperation with the Secretary of the 
        Interior, shall develop and implement within each Service Unit, 
        community-based rehabilitation and follow-up services for 
        Indian youths who are having significant behavioral health 
        problems, and require long-term treatment, community 
        reintegration, and monitoring to support the Indian youths 
        after their return to their home community.
            ``(2) Administration.--Services under paragraph (1) shall 
        be provided by trained staff within the community who can 
        assist the Indian youths in their continuing development of 
        self-image, positive problem-solving skills, and nonalcohol or 
        substance abusing behaviors. Such staff may include alcohol and 
        substance abuse counselors, mental health professionals, and 
        other health professionals and paraprofessionals, including 
        community health representatives.
    ``(f) Inclusion of Family in Youth Treatment Program.--In providing 
the treatment and other services to Indian youths authorized by this 
section, the Secretary, acting through the Service, shall provide for 
the inclusion of family members of such youths in the treatment 
programs or other services as may be appropriate. Not less than 10 
percent of the funds appropriated for the purposes of carrying out 
subsection (e) shall be used for outpatient care of adult family 
members related to the treatment of an Indian youth under that 
subsection.
    ``(g) Multidrug Abuse Program.--The Secretary, acting through the 
Service, shall provide, consistent with section 701, programs and 
services to prevent and treat the abuse of multiple forms of 
substances, including alcohol, drugs, inhalants, and tobacco, among 
Indian youths residing in Indian communities, on or near reservations, 
and in urban areas and provide appropriate mental health services to 
address the incidence of mental illness among such youths.
    ``(h) Indian Youth Mental Health.--The Secretary, acting through 
the Service, shall collect data for the report under section 801 with 
respect to--
            ``(1) the number of Indian youth who are being provided 
        mental health services through the Service and Tribal Health 
        Programs;
            ``(2) a description of, and costs associated with, the 
        mental health services provided for Indian youth through the 
        Service and Tribal Health Programs;
            ``(3) the number of youth referred to the Service or Tribal 
        Health Programs for mental health services;
            ``(4) the number of Indian youth provided residential 
        treatment for mental health and behavioral problems through the 
        Service and Tribal Health Programs, reported separately for on- 
        and off-reservation facilities; and
            ``(5) the costs of the services described in paragraph (4).

``SEC. 708. INDIAN YOUTH TELEMENTAL HEALTH DEMONSTRATION PROJECT.

    ``(a) Purpose.--The purpose of this section is to authorize the 
Secretary to carry out a demonstration project to test the use of 
telemental health services in suicide prevention, intervention and 
treatment of Indian youth, including through--
            ``(1) the use of psychotherapy, psychiatric assessments, 
        diagnostic interviews, therapies for mental health conditions 
        predisposing to suicide, and alcohol and substance abuse 
        treatment;
            ``(2) the provision of clinical expertise to, consultation 
        services with, and medical advice and training for frontline 
        health care providers working with Indian youth;
            ``(3) training and related support for community leaders, 
        family members and health and education workers who work with 
        Indian youth;
            ``(4) the development of culturally relevant educational 
        materials on suicide; and
            ``(5) data collection and reporting.
    ``(b) Definitions.--For the purpose of this section, the following 
definitions shall apply:
            ``(1) Demonstration project.--The term `demonstration 
        project' means the Indian youth telemental health demonstration 
        project authorized under subsection (c).
            ``(2) Telemental health.--The term `telemental health' 
        means the use of electronic information and telecommunications 
        technologies to support long distance mental health care, 
        patient and professional-related education, public health, and 
        health administration.
    ``(c) Authorization.--
            ``(1) In general.--The Secretary is authorized to award 
        grants under the demonstration project for the provision of 
        telemental health services to Indian youth who--
                    ``(A) have expressed suicidal ideas;
                    ``(B) have attempted suicide; or
                    ``(C) have mental health conditions that increase 
                or could increase the risk of suicide.
            ``(2) Eligibility for grants.--Such grants shall be awarded 
        to Indian Tribes and Tribal Organizations that operate 1 or 
        more facilities--
                    ``(A) located in Alaska and part of the Alaska 
                Federal Health Care Access Network;
                    ``(B) reporting active clinical telehealth 
                capabilities; or
                    ``(C) offering school-based telemental health 
                services relating to psychiatry to Indian youth.
            ``(3) Grant period.--The Secretary shall award grants under 
        this section for a period of up to 4 years.
            ``(4) Awarding of grants.--Not more than 5 grants shall be 
        provided under paragraph (1), with priority consideration given 
        to Indian Tribes and Tribal Organizations that--
                    ``(A) serve a particular community or geographic 
                area where there is a demonstrated need to address 
                Indian youth suicide;
                    ``(B) enter in to collaborative partnerships with 
                Indian Health Service or Tribal Health Programs or 
                facilities to provide services under this demonstration 
                project;
                    ``(C) serve an isolated community or geographic 
                area which has limited or no access to behavioral 
                health services; or
                    ``(D) operate a detention facility at which Indian 
                youth are detained.
    ``(d) Use of Funds.--
            ``(1) In general.--An Indian Tribe or Tribal Organization 
        shall use a grant received under subsection (c) for the 
        following purposes:
                    ``(A) To provide telemental health services to 
                Indian youth, including the provision of--
                            ``(i) psychotherapy;
                            ``(ii) psychiatric assessments and 
                        diagnostic interviews, therapies for mental 
                        health conditions predisposing to suicide, and 
                        treatment; and
                            ``(iii) alcohol and substance abuse 
                        treatment.
                    ``(B) To provide clinician-interactive medical 
                advice, guidance and training, assistance in diagnosis 
                and interpretation, crisis counseling and intervention, 
                and related assistance to Service, tribal, or urban 
                clinicians and health services providers working with 
                youth being served under this demonstration project.
                    ``(C) To assist, educate and train community 
                leaders, health education professionals and 
                paraprofessionals, tribal outreach workers, and family 
                members who work with the youth receiving telemental 
                health services under this demonstration project, 
                including with identification of suicidal tendencies, 
                crisis intervention and suicide prevention, emergency 
                skill development, and building and expanding networks 
                among these individuals and with State and local health 
                services providers.
                    ``(D) To develop and distribute culturally 
                appropriate community educational materials on--
                            ``(i) suicide prevention;
                            ``(ii) suicide education;
                            ``(iii) suicide screening;
                            ``(iv) suicide intervention; and
                            ``(v) ways to mobilize communities with 
                        respect to the identification of risk factors 
                        for suicide.
                    ``(E) For data collection and reporting related to 
                Indian youth suicide prevention efforts.
            ``(2) Traditional health care practices.--In carrying out 
        the purposes described in paragraph (1), an Indian Tribe or 
        Tribal Organization may use and promote the traditional health 
        care practices of the Indian Tribes of the youth to be served.
    ``(e) Applications.--To be eligible to receive a grant under 
subsection (c), an Indian Tribe or Tribal Organization shall prepare 
and submit to the Secretary an application, at such time, in such 
manner, and containing such information as the Secretary may require, 
including--
            ``(1) a description of the project that the Indian Tribe or 
        Tribal Organization will carry out using the funds provided 
        under the grant;
            ``(2) a description of the manner in which the project 
        funded under the grant would--
                    ``(A) meet the telemental health care needs of the 
                Indian youth population to be served by the project; or
                    ``(B) improve the access of the Indian youth 
                population to be served to suicide prevention and 
                treatment services;
            ``(3) evidence of support for the project from the local 
        community to be served by the project;
            ``(4) a description of how the families and leadership of 
        the communities or populations to be served by the project 
        would be involved in the development and ongoing operations of 
        the project;
            ``(5) a plan to involve the tribal community of the youth 
        who are provided services by the project in planning and 
        evaluating the mental health care and suicide prevention 
        efforts provided, in order to ensure the integration of 
        community, clinical, environmental, and cultural components of 
        the treatment; and
            ``(6) a plan for sustaining the project after Federal 
        assistance for the demonstration project has terminated.
    ``(f) Collaboration; Reporting to National Clearinghouse.--
            ``(1) Collaboration.--The Secretary, acting through the 
        Service, shall encourage Indian Tribes and Tribal Organizations 
        receiving grants under this section to collaborate to enable 
        comparisons about best practices across projects.
            ``(2) Reporting to national clearinghouse.--The Secretary, 
        acting through the Service, shall also encourage Indian Tribes 
        and Tribal Organizations receiving grants under this section to 
        submit relevant, declassified project information to the 
        national clearinghouse authorized under section 701(b)(2) in 
        order to better facilitate program performance and improve 
        suicide prevention, intervention, and treatment services.
    ``(g) Annual Report.--Each grant recipient shall submit to the 
Secretary an annual report that--
            ``(1) describes the number of telemental health services 
        provided; and
            ``(2) includes any other information that the Secretary may 
        require.
    ``(h) Report to Congress.--Not later than 270 days after the 
termination of the demonstration project, the Secretary shall submit to 
the Committee on Indian Affairs of the Senate and the Committee on 
Natural Resources and Committee on Energy and Commerce of the House of 
Representatives a final report, based on the annual reports provided by 
grant recipients under subsection (h), that--
            ``(1) describes the results of the projects funded by 
        grants awarded under this section, including any data available 
        which indicates the number of attempted suicides;
            ``(2) evaluates the impact of the telemental health 
        services funded by the grants in reducing the number of 
        completed suicides among Indian youth;
            ``(3) evaluates whether the demonstration project should 
        be--
                    ``(A) expanded to provide more than 5 grants; and
                    ``(B) designated a permanent program; and
            ``(4) evaluates the benefits of expanding the demonstration 
        project to include urban Indian organizations.
    ``(i) Authorization of Appropriations.--There is authorized to be 
appropriated such sums as may be necessary to carry out this section.

``SEC. 709. INPATIENT AND COMMUNITY-BASED MENTAL HEALTH FACILITIES 
              DESIGN, CONSTRUCTION, AND STAFFING.

    ``Not later than 1 year after the date of enactment of the Indian 
Health Care Improvement Act Amendments of 2009, the Secretary, acting 
through the Service, may provide, in each area of the Service, not less 
than 1 inpatient mental health care facility, or the equivalent, for 
Indians with behavioral health problems. For the purposes of this 
subsection, California shall be considered to be 2 Area Offices, 1 
office whose location shall be considered to encompass the northern 
area of the State of California and 1 office whose jurisdiction shall 
be considered to encompass the remainder of the State of California. 
The Secretary shall consider the possible conversion of existing, 
underused Service hospital beds into psychiatric units to meet such 
need.

``SEC. 710. TRAINING AND COMMUNITY EDUCATION.

    ``(a) Program.--The Secretary, in cooperation with the Secretary of 
the Interior, shall develop and implement or assist Indian Tribes and 
Tribal Organizations to develop and implement, within each Service Unit 
or tribal program, a program of community education and involvement 
which shall be designed to provide concise and timely information to 
the community leadership of each tribal community. Such program shall 
include education about behavioral health issues to political leaders, 
Tribal judges, law enforcement personnel, members of tribal health and 
education boards, health care providers including traditional 
practitioners, and other critical members of each tribal community. 
Such program may also include community-based training to develop local 
capacity and tribal community provider training for prevention, 
intervention, treatment, and aftercare.
    ``(b) Instruction.--The Secretary, acting through the Service, 
shall provide instruction in the area of behavioral health issues, 
including instruction in crisis intervention and family relations in 
the context of alcohol and substance abuse, child sexual abuse, youth 
alcohol and substance abuse, and the causes and effects of fetal 
alcohol disorders to appropriate employees of the Bureau of Indian 
Affairs and the Service, and to personnel in schools or programs 
operated under any contract with the Bureau of Indian Affairs or the 
Service, including supervisors of emergency shelters and halfway houses 
described in section 4213 of the Indian Alcohol and Substance Abuse 
Prevention and Treatment Act of 1986 (25 U.S.C. 2433).
    ``(c) Training Models.--In carrying out the education and training 
programs required by this section, the Secretary, in consultation with 
Indian Tribes, Tribal Organizations, Indian behavioral health experts, 
and Indian alcohol and substance abuse prevention experts, shall 
develop and provide community-based training models. Such models shall 
address--
            ``(1) the elevated risk of alcohol and behavioral health 
        problems faced by children of alcoholics;
            ``(2) the cultural, spiritual, and multigenerational 
        aspects of behavioral health problem prevention and recovery; 
        and
            ``(3) community-based and multidisciplinary strategies, 
        including Systems of Care, for preventing and treating 
        behavioral health problems.

``SEC. 711. BEHAVIORAL HEALTH PROGRAM.

    ``(a) Innovative Programs.--The Secretary, acting through the 
Service, consistent with section 701, may plan, develop, implement, and 
carry out programs to deliver innovative community-based behavioral 
health services to Indians.
    ``(b) Awards; Criteria.--The Secretary may award a grant for a 
project under subsection (a) to an Indian Tribe or Tribal Organization 
and may consider the following criteria:
            ``(1) The project will address significant unmet behavioral 
        health needs among Indians.
            ``(2) The project will serve a significant number of 
        Indians.
            ``(3) The project has the potential to deliver services in 
        an efficient and effective manner.
            ``(4) The Indian Tribe or Tribal Organization has the 
        administrative and financial capability to administer the 
        project.
            ``(5) The project may deliver services in a manner 
        consistent with traditional health care practices.
            ``(6) The project is coordinated with, and avoids 
        duplication of, existing services.
    ``(c) Equitable Treatment.--For purposes of this subsection, the 
Secretary shall, in evaluating project applications or proposals, use 
the same criteria that the Secretary uses in evaluating any other 
application or proposal for such funding.

``SEC. 712. FETAL ALCOHOL DISORDER PROGRAMS.

    ``(a) Programs.--
            ``(1) Establishment.--The Secretary, consistent with 
        section 701 and acting through the Service, is authorized to 
        establish and operate fetal alcohol disorder programs as 
        provided in this section for the purposes of meeting the health 
        status objectives specified in section 3.
            ``(2) Use of funds.--
                    ``(A) In general.--Funding provided pursuant to 
                this section shall be used for the following:
                            ``(i) To develop and provide for Indians 
                        community and in-school training, education, 
                        and prevention programs relating to fetal 
                        alcohol disorders.
                            ``(ii) To identify and provide behavioral 
                        health treatment to high-risk Indian women and 
                        high-risk women pregnant with an Indian's 
                        child.
                            ``(iii) To identify and provide appropriate 
                        psychological services, educational and 
                        vocational support, counseling, advocacy, and 
                        information to fetal alcohol disorder affected 
                        Indians and their families or caretakers.
                            ``(iv) To develop and implement counseling 
                        and support programs in schools for fetal 
                        alcohol disorder affected Indian children.
                            ``(v) To develop prevention and 
                        intervention models which incorporate 
                        practitioners of traditional health care 
                        practices, cultural values, and community 
                        involvement.
                            ``(vi) To develop, print, and disseminate 
                        education and prevention materials on fetal 
                        alcohol disorder.
                            ``(vii) To develop and implement, in 
                        consultation with Indian Tribes, Tribal 
                        Organizations, and urban Indian organizations, 
                        culturally sensitive assessment and diagnostic 
                        tools including dysmorphology clinics and 
                        multidisciplinary fetal alcohol disorder 
                        clinics for use in Indian communities and Urban 
                        Centers.
                    ``(B) Additional uses.--In addition to any purpose 
                under subparagraph (A), funding provided pursuant to 
                this section may be used for 1 or more of the 
                following:
                            ``(i) Early childhood intervention projects 
                        from birth on to mitigate the effects of fetal 
                        alcohol disorder among Indians.
                            ``(ii) Community-based support services for 
                        Indians and women pregnant with Indian 
                        children.
                            ``(iii) Community-based housing for adult 
                        Indians with fetal alcohol disorder.
            ``(3) Criteria for applications.--The Secretary shall 
        establish criteria for the review and approval of applications 
        for funding under this section.
    ``(b) Services.--The Secretary, acting through the Service, shall--
            ``(1) develop and provide services for the prevention, 
        intervention, treatment, and aftercare for those affected by 
        fetal alcohol disorder in Indian communities; and
            ``(2) provide supportive services, including services to 
        meet the special educational, vocational, school-to-work 
        transition, and independent living needs of adolescent and 
        adult Indians with fetal alcohol disorder.
    ``(c) Task Force.--The Secretary shall establish a task force to be 
known as the Fetal Alcohol Disorder Task Force to advise the Secretary 
in carrying out subsection (b). Such task force shall be composed of 
representatives from the following:
            ``(1) The National Institute on Drug Abuse.
            ``(2) The National Institute on Alcohol and Alcoholism.
            ``(3) The Office of Substance Abuse Prevention.
            ``(4) The National Institute of Mental Health.
            ``(5) The Service.
            ``(6) The Office of Minority Health of the Department of 
        Health and Human Services.
            ``(7) The Administration for Native Americans.
            ``(8) The National Institute of Child Health and Human 
        Development (NICHD).
            ``(9) The Centers for Disease Control and Prevention.
            ``(10) The Bureau of Indian Affairs.
            ``(11) Indian Tribes.
            ``(12) Tribal Organizations.
            ``(13) urban Indian organizations.
            ``(14) Indian fetal alcohol spectrum disorders experts.
    ``(d) Applied Research Projects.--The Secretary, acting through the 
Substance Abuse and Mental Health Services Administration, shall make 
grants to Indian Tribes, Tribal Organizations, and urban Indian 
organizations for applied research projects which propose to elevate 
the understanding of methods to prevent, intervene, treat, or provide 
rehabilitation and behavioral health aftercare for Indians and urban 
Indians affected by fetal alcohol spectrum disorders.
    ``(e) Funding for Urban Indian Organizations.--Ten percent of the 
funds appropriated pursuant to this section shall be used to make 
grants to urban Indian organizations funded under title V.

``SEC. 713. CHILD SEXUAL ABUSE AND PREVENTION TREATMENT PROGRAMS.

    ``(a) Establishment.--The Secretary, acting through the Service, 
shall establish, consistent with section 701, in every Service Area, 
programs involving treatment for--
            ``(1) victims of sexual abuse who are Indian children or 
        children in an Indian household; and
            ``(2) perpetrators of child sexual abuse who are Indian or 
        members of an Indian household.
    ``(b) Use of Funds.--Funding provided pursuant to this section 
shall be used for the following:
            ``(1) To develop and provide community education and 
        prevention programs related to sexual abuse of Indian children 
        or children in an Indian household.
            ``(2) To identify and provide behavioral health treatment 
        to victims of sexual abuse who are Indian children or children 
        in an Indian household, and to their family members who are 
        affected by sexual abuse.
            ``(3) To develop prevention and intervention models which 
        incorporate traditional health care practices, cultural values, 
        and community involvement.
            ``(4) To develop and implement culturally sensitive 
        assessment and diagnostic tools for use in Indian communities 
        and Urban Centers.
            ``(5) To identify and provide behavioral health treatment 
        to Indian perpetrators and perpetrators who are members of an 
        Indian household--
                    ``(A) making efforts to begin offender and 
                behavioral health treatment while the perpetrator is 
                incarcerated or at the earliest possible date if the 
                perpetrator is not incarcerated; and
                    ``(B) providing treatment after the perpetrator is 
                released, until it is determined that the perpetrator 
                is not a threat to children.
    ``(c) Coordination.--The programs established under subsection (a) 
shall be carried out in coordination with programs and services 
authorized under the Indian Child Protection and Family Violence 
Prevention Act (25 U.S.C. 3201 et seq.).

``SEC. 714. DOMESTIC AND SEXUAL VIOLENCE PREVENTION AND TREATMENT.

    ``(a) In General.--The Secretary, in accordance with section 701, 
is authorized to establish in each Service Area programs involving the 
prevention and treatment of--
            ``(1) Indian victims of domestic violence or sexual abuse; 
        and
            ``(2) perpetrators of domestic violence or sexual abuse who 
        are Indian or members of an Indian household.
    ``(b) Use of Funds.--Funds made available to carry out this section 
shall be used--
            ``(1) to develop and implement prevention programs and 
        community education programs relating to domestic violence and 
        sexual abuse;
            ``(2) to provide behavioral health services, including 
        victim support services, and medical treatment (including 
        examinations performed by sexual assault nurse examiners) to 
        Indian victims of domestic violence or sexual abuse;
            ``(3) to purchase rape kits;
            ``(4) to develop prevention and intervention models, which 
        may incorporate traditional health care practices; and
            ``(5) to identify and provide behavioral health treatment 
        to perpetrators who are Indian or members of an Indian 
        household.
    ``(c) Training and Certification.--
            ``(1) In general.--Not later than 1 year after the date of 
        enactment of the Indian Health Care Improvement Act Amendments 
        of 2009, the Secretary shall establish appropriate protocols, 
        policies, procedures, standards of practice, and, if not 
        available elsewhere, training curricula and training and 
        certification requirements for services for victims of domestic 
        violence and sexual abuse.
            ``(2) Report.--Not later than 18 months after the date of 
        enactment of the Indian Health Care Improvement Act Amendments 
        of 2008, the Secretary shall submit to the Committee on Indian 
        Affairs of the Senate and the Committee on Natural Resources of 
        the House of Representatives a report that describes the means 
        and extent to which the Secretary has carried out paragraph 
        (1).
    ``(d) Coordination.--
            ``(1) In general.--The Secretary, in coordination with the 
        Attorney General, Federal and tribal law enforcement agencies, 
        Indian Health Programs, and domestic violence or sexual assault 
        victim organizations, shall develop appropriate victim services 
        and victim advocate training programs--
                    ``(A) to improve domestic violence or sexual abuse 
                responses;
                    ``(B) to improve forensic examinations and 
                collection;
                    ``(C) to identify problems or obstacles in the 
                prosecution of domestic violence or sexual abuse; and
                    ``(D) to meet other needs or carry out other 
                activities required to prevent, treat, and improve 
                prosecutions of domestic violence and sexual abuse.
            ``(2) Report.--Not later than 2 years after the date of 
        enactment of the Indian Health Care Improvement Act Amendments 
        of 2008, the Secretary shall submit to the Committee on Indian 
        Affairs of the Senate and the Committee on Natural Resources of 
        the House of Representatives a report that describes, with 
        respect to the matters described in paragraph (1), the 
        improvements made and needed, problems or obstacles identified, 
        and costs necessary to address the problems or obstacles, and 
        any other recommendations that the Secretary determines to be 
        appropriate.

``SEC. 715. BEHAVIORAL HEALTH RESEARCH.

    ``The Secretary, in consultation with appropriate Federal agencies, 
shall make grants to, or enter into contracts with, Indian Tribes, 
Tribal Organizations, and urban Indian organizations or enter into 
contracts with, or make grants to appropriate institutions for, the 
conduct of research on the incidence and prevalence of behavioral 
health problems among Indians served by the Service, Indian Tribes, or 
Tribal Organizations and among Indians in urban areas. Research 
priorities under this section shall include--
            ``(1) the multifactorial causes of Indian youth suicide, 
        including--
                    ``(A) protective and risk factors and scientific 
                data that identifies those factors; and
                    ``(B) the effects of loss of cultural identity and 
                the development of scientific data on those effects;
            ``(2) the interrelationship and interdependence of 
        behavioral health problems with alcoholism and other substance 
        abuse, suicide, homicides, other injuries, and the incidence of 
        family violence; and
            ``(3) the development of models of prevention techniques.
The effect of the interrelationships and interdependencies referred to 
in paragraph (2) on children, and the development of prevention 
techniques under paragraph (3) applicable to children, shall be 
emphasized.

``SEC. 716. DEFINITIONS.

    ``For the purpose of this title, the following definitions shall 
apply:
            ``(1) Assessment.--The term `assessment' means the 
        systematic collection, analysis, and dissemination of 
        information on health status, health needs, and health 
        problems.
            ``(2) Alcohol-related neurodevelopmental disorders or 
        arnd.--The term `alcohol-related neurodevelopmental disorders' 
        or `ARND' means, with a history of maternal alcohol consumption 
        during pregnancy, central nervous system involvement such as 
        developmental delay, intellectual deficit, or neurologic 
        abnormalities. Behaviorally, there can be problems with 
        irritability, and failure to thrive as infants. As children 
        become older there will likely be hyperactivity, attention 
        deficit, language dysfunction, and perceptual and judgment 
        problems.
            ``(3) Behavioral health aftercare.--The term `behavioral 
        health aftercare' includes those activities and resources used 
        to support recovery following inpatient, residential, intensive 
        substance abuse, or mental health outpatient or outpatient 
        treatment. The purpose is to help prevent or deal with relapse 
        by ensuring that by the time a client or patient is discharged 
        from a level of care, such as outpatient treatment, an 
        aftercare plan has been developed with the client. An aftercare 
        plan may use such resources as a community-based therapeutic 
        group, transitional living facilities, a 12-step sponsor, a 
        local 12-step or other related support group, and other 
        community-based providers.
            ``(4) Dual diagnosis.--The term `dual diagnosis' means 
        coexisting substance abuse and mental illness conditions or 
        diagnosis. Such clients are sometimes referred to as mentally 
        ill chemical abusers (MICAs).
            ``(5) Fetal alcohol spectrum disorders.--
                    ``(A) In general.--The term `fetal alcohol spectrum 
                disorders' includes a range of effects that can occur 
                in an individual whose mother drank alcohol during 
                pregnancy, including physical, mental, behavioral, and/
                or learning disabilities with possible lifelong 
                implications.
                    ``(B) Inclusions.--The term `fetal alcohol spectrum 
                disorders' may include--
                            ``(i) fetal alcohol syndrome (FAS);
                            ``(ii) fetal alcohol effect (FAE);
                            ``(iii) alcohol-related birth defects; and
                            ``(iv) alcohol-related neurodevelopmental 
                        disorders (ARND).
            ``(6) Fetal alcohol syndrome or fas.--The term `fetal 
        alcohol syndrome' or `FAS' means any 1 of a spectrum of effects 
        that may occur when a woman drinks alcohol during pregnancy, 
        the diagnosis of which involves the confirmed presence of the 
        following 3 criteria:
                    ``(A) Craniofacial abnormalities.
                    ``(B) Growth deficits.
                    ``(C) Central nervous system abnormalities.
            ``(7) Rehabilitation.--The term `rehabilitation' means 
        medical and health care services that--
                    ``(A) are recommended by a physician or licensed 
                practitioner of the healing arts within the scope of 
                their practice under applicable law;
                    ``(B) are furnished in a facility, home, or other 
                setting in accordance with applicable standards; and
                    ``(C) have as their purpose any of the following:
                            ``(i) The maximum attainment of physical, 
                        mental, and developmental functioning.
                            ``(ii) Averting deterioration in physical 
                        or mental functional status.
                            ``(iii) The maintenance of physical or 
                        mental health functional status.
            ``(8) Substance abuse.--The term `substance abuse' includes 
        inhalant abuse.
            ``(9) Systems of care.--The term `Systems of Care' means a 
        system for delivering services to children and their families 
        that is child-centered, family-focused and family-driven, 
        community-based, and culturally competent and responsive to the 
        needs of the children and families being served. The systems of 
        care approach values prevention and early identification, 
        smooth transitions for children and families, child and family 
        participation and advocacy, comprehensive array of services, 
        individualized service planning, services in the least 
        restrictive environment, and integrated services with 
        coordinated planning across the child-serving systems.

``SEC. 717. AUTHORIZATION OF APPROPRIATIONS.

    ``There is authorized to be appropriated such sums as may be 
necessary to carry out the provisions of this title.

                      ``TITLE VIII--MISCELLANEOUS

``SEC. 801. REPORTS.

    ``For each fiscal year following the date of enactment of the 
Indian Health Care Improvement Act Amendments of 2009, the Secretary 
shall transmit to Congress a report containing the following:
            ``(1) A report on the progress made in meeting the 
        objectives of this Act, including a review of programs 
        established or assisted pursuant to this Act and assessments 
        and recommendations of additional programs or additional 
        assistance necessary to, at a minimum, provide health services 
        to Indians and ensure a health status for Indians, which are at 
        a parity with the health services available to and the health 
        status of the general population.
            ``(2) A report on whether, and to what extent, new national 
        health care programs, benefits, initiatives, or financing 
        systems have had an impact on the purposes of this Act and any 
        steps that the Secretary may have taken to consult with Indian 
        Tribes, Tribal Organizations, and urban Indian organizations to 
        address such impact, including a report on proposed changes in 
        allocation of funding pursuant to section 807.
            ``(3) A report on the use of health services by Indians--
                    ``(A) on a national and area or other relevant 
                geographical basis;
                    ``(B) by gender and age;
                    ``(C) by source of payment and type of service;
                    ``(D) comparing such rates of use with rates of use 
                among comparable non-Indian populations; and
                    ``(E) provided under contracts.
            ``(4) A report of contractors to the Secretary on Health 
        Care Educational Loan Repayments every 6 months required by 
        section 110.
            ``(5) A general audit report of the Secretary on the Health 
        Care Educational Loan Repayment Program as required by section 
        110(m).
            ``(6) A report of the findings and conclusions of 
        demonstration programs on development of educational curricula 
        for substance abuse counseling as required in section 125(f).
            ``(7) A separate statement which specifies the amount of 
        funds requested to carry out the provisions of section 201.
            ``(8) A report of the evaluations of health promotion and 
        disease prevention as required in section 203(c).
            ``(9) A biennial report to Congress on infectious diseases 
        as required by section 212.
            ``(10) A report on environmental and nuclear health hazards 
        as required by section 215.
            ``(11) An annual report on the status of all health care 
        facilities needs as required by section 301(c)(2)(B) and 
        301(d).
            ``(12) Reports on safe water and sanitary waste disposal 
        facilities as required by section 302(h).
            ``(13) An annual report on the expenditure of non-Service 
        funds for renovation as required by sections 304(b)(2).
            ``(14) A report identifying the backlog of maintenance and 
        repair required at Service and tribal facilities required by 
        section 313(a).
            ``(15) A report providing an accounting of reimbursement 
        funds made available to the Secretary under titles XVIII, XIX, 
        and XXI of the Social Security Act.
            ``(16) A report on any arrangements for the sharing of 
        medical facilities or services, as authorized by section 406.
            ``(17) A report on evaluation and renewal of urban Indian 
        programs under section 505.
            ``(18) A report on the evaluation of programs as required 
        by section 513(d).
            ``(19) A report on alcohol and substance abuse as required 
        by section 701(f).
            ``(20) A report on Indian youth mental health services as 
        required by section 707(h).
            ``(21) A report on the reallocation of base resources if 
        required by section 807.
            ``(22) A report on the movement of patients between Service 
        Units, including--
                    ``(A) a list of those Service Units that have a net 
                increase and those that have a net decrease of patients 
                due to patients assigned to one Service Unit 
                voluntarily choosing to receive service at another 
                Service Unit;
                    ``(B) an analysis of the effect of patient movement 
                on the quality of services for those Service Units 
                experiencing an increase in the number of patients 
                served; and
                    ``(C) what funding changes are necessary to 
                maintain a consistent quality of service at Service 
                Units that have an increase in the number of patients 
                served.
            ``(23) A report on the extent to which health care 
        facilities of the Service, Indian Tribes, Tribal Organizations, 
        and urban Indian organizations comply with credentialing 
        requirements of the Service or licensure requirements of 
        States.

``SEC. 802. REGULATIONS.

    ``(a) Deadlines.--
            ``(1) Procedures.--Not later than 90 days after the date of 
        enactment of the Indian Health Care Improvement Act Amendments 
        of 2009, the Secretary shall initiate procedures under 
        subchapter III of chapter 5 of title 5, United States Code, to 
        negotiate and promulgate such regulations or amendments thereto 
        that are necessary to carry out this Act, except sections 105, 
        115, 117, 202, and 409 through 414. The Secretary may 
        promulgate regulations to carry out such sections using the 
        procedures required by chapter 5 of title 5, United States Code 
        (commonly known as the `Administrative Procedure Act').
            ``(2) Proposed regulations.--Proposed regulations to 
        implement this Act shall be published in the Federal Register 
        by the Secretary no later than 2 years after the date of 
        enactment of the Indian Health Care Improvement Act Amendments 
        of 2009 and shall have no less than a 120-day comment period.
            ``(3) Final regulations.--The Secretary shall publish in 
        the Federal Register final regulations to implement this Act by 
        not later than 3 years after the date of enactment of the 
        Indian Health Care Improvement Act Amendments of 2009.
    ``(b) Committee.--A negotiated rulemaking committee established 
pursuant to section 565 of title 5, United States Code, to carry out 
this section shall have as its members only representatives of the 
Federal Government and representatives of Indian Tribes, and Tribal 
Organizations, a majority of whom shall be nominated by and be 
representatives of Indian Tribes and Tribal Organizations from each 
Service Area.
    ``(c) Adaptation of Procedures.--The Secretary shall adapt the 
negotiated rulemaking procedures to the unique context of self-
governance and the government-to-government relationship between the 
United States and Indian Tribes.
    ``(d) Lack of Regulations.--The lack of promulgated regulations 
shall not limit the effect of this Act.

``SEC. 803. PLAN OF IMPLEMENTATION.

    ``(a) In General.--Not later than 1 year after the date of 
enactment of the Indian Health Care Improvement Act Amendments of 2009, 
the Secretary, in consultation with Indian Tribes, Tribal 
Organizations, and urban Indian organizations, shall submit to Congress 
a plan explaining the manner and schedule, by title and section, by 
which the Secretary will implement the provisions of this Act. This 
consultation may be conducted jointly with the annual budget 
consultation pursuant to the Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.).
    ``(b) Lack of Plan.--The lack of (or failure to submit) such a plan 
shall not limit the effect, or prevent the implementation, of this Act.

``SEC. 804. LIMITATION ON USE OF FUNDS APPROPRIATED TO INDIAN HEALTH 
              SERVICE.

    ``Any limitation on the use of funds contained in an Act providing 
appropriations for the Department for a period with respect to the 
performance of abortions shall apply for that period with respect to 
the performance of abortions using funds contained in an Act providing 
appropriations for the Service.

``SEC. 805. ELIGIBILITY OF CALIFORNIA INDIANS.

    ``(a) In General.--The following California Indians shall be 
eligible for health services provided by the Service:
            ``(1) Any member of a federally recognized Indian Tribe.
            ``(2) Any descendant of an Indian who was residing in 
        California on June 1, 1852, if such descendant--
                    ``(A) is a member of the Indian community served by 
                a local program of the Service; and
                    ``(B) is regarded as an Indian by the community in 
                which such descendant lives.
            ``(3) Any Indian who holds trust interests in public 
        domain, national forest, or reservation allotments in 
        California.
            ``(4) Any Indian in California who is listed on the plans 
        for distribution of the assets of rancherias and reservations 
        located within the State of California under the Act of August 
        18, 1958 (72 Stat. 619), and any descendant of such an Indian.
    ``(b) Clarification.--Nothing in this section may be construed as 
expanding the eligibility of California Indians for health services 
provided by the Service beyond the scope of eligibility for such health 
services that applied on May 1, 1986.

``SEC. 806. HEALTH SERVICES FOR INELIGIBLE PERSONS.

    ``(a) Children.--Any individual who--
            ``(1) has not attained 19 years of age;
            ``(2) is the natural or adopted child, stepchild, foster 
        child, legal ward, or orphan of an eligible Indian; and
            ``(3) is not otherwise eligible for health services 
        provided by the Service,
shall be eligible for all health services provided by the Service on 
the same basis and subject to the same rules that apply to eligible 
Indians until such individual attains 19 years of age. The existing and 
potential health needs of all such individuals shall be taken into 
consideration by the Service in determining the need for, or the 
allocation of, the health resources of the Service. If such an 
individual has been determined to be legally incompetent prior to 
attaining 19 years of age, such individual shall remain eligible for 
such services until 1 year after the date of a determination of 
competency.
    ``(b) Spouses.--Any spouse of an eligible Indian who is not an 
Indian, or who is of Indian descent but is not otherwise eligible for 
the health services provided by the Service, shall be eligible for such 
health services if all such spouses or spouses who are married to 
members of each Indian Tribe being served are made eligible, as a 
class, by an appropriate resolution of the governing body of the Indian 
Tribe or Tribal Organization providing such services. The health needs 
of persons made eligible under this paragraph shall not be taken into 
consideration by the Service in determining the need for, or allocation 
of, its health resources.
    ``(c) Provision of Services to Other Individuals.--
            ``(1) In general.--The Secretary is authorized to provide 
        health services under this subsection through health programs 
        operated directly by the Service to individuals who reside 
        within the Service area of the Service Unit and who are not 
        otherwise eligible for such health services if--
                    ``(A) the Indian Tribes served by such Service Unit 
                request such provision of health services to such 
                individuals; and
                    ``(B) the Secretary and the served Indian Tribes 
                have jointly determined that--
                            ``(i) the provision of such health services 
                        will not result in a denial or diminution of 
                        health services to eligible Indians; and
                            ``(ii) there is no reasonable alternative 
                        health facilities or services, within or 
                        without the Service Unit, available to meet the 
                        health needs of such individuals.
            ``(2) ISDEAA programs.--In the case of health programs and 
        facilities operated under a contract or compact entered into 
        under the Indian Self-Determination and Education Assistance 
        Act (25 U.S.C. 450 et seq.), the governing body of the Indian 
        Tribe or Tribal Organization providing health services under 
        such contract or compact is authorized to determine whether 
        health services should be provided under such contract to 
        individuals who are not eligible for such health services under 
        any other subsection of this section or under any other 
        provision of law. In making such determinations, the governing 
        body of the Indian Tribe or Tribal Organization shall take into 
        account the considerations described in paragraph (1)(B).
            ``(3) Payment for services.--
                    ``(A) In general.--Persons receiving health 
                services provided by the Service under this subsection 
                shall be liable for payment of such health services 
                under a schedule of charges prescribed by the Secretary 
                which, in the judgment of the Secretary, results in 
                reimbursement in an amount not less than the actual 
                cost of providing the health services. Notwithstanding 
                section 404 of this Act or any other provision of law, 
                amounts collected under this subsection, including 
                Medicare, Medicaid, or SCHIP reimbursements under 
                titles XVIII, XIX, and XXI of the Social Security Act, 
                shall be credited to the account of the program 
                providing the service and shall be used for the 
                purposes listed in section 401(d)(2) and amounts 
                collected under this subsection shall be available for 
                expenditure within such program.
                    ``(B) Indigent people.--Health services may be 
                provided by the Secretary through the Service under 
                this subsection to an indigent individual who would not 
                be otherwise eligible for such health services but for 
                the provisions of paragraph (1) only if an agreement 
                has been entered into with a State or local government 
                under which the State or local government agrees to 
                reimburse the Service for the expenses incurred by the 
                Service in providing such health services to such 
                indigent individual.
            ``(4) Revocation of consent for services.--
                    ``(A) Single tribe service area.--In the case of a 
                Service Area which serves only 1 Indian Tribe, the 
                authority of the Secretary to provide health services 
                under paragraph (1) shall terminate at the end of the 
                fiscal year succeeding the fiscal year in which the 
                governing body of the Indian Tribe revokes its 
                concurrence to the provision of such health services.
                    ``(B) Multitribal service area.--In the case of a 
                multitribal Service Area, the authority of the 
                Secretary to provide health services under paragraph 
                (1) shall terminate at the end of the fiscal year 
                succeeding the fiscal year in which at least 51 percent 
                of the number of Indian Tribes in the Service Area 
                revoke their concurrence to the provisions of such 
                health services.
    ``(d) Other Services.--The Service may provide health services 
under this subsection to individuals who are not eligible for health 
services provided by the Service under any other provision of law in 
order to--
            ``(1) achieve stability in a medical emergency;
            ``(2) prevent the spread of a communicable disease or 
        otherwise deal with a public health hazard;
            ``(3) provide care to non-Indian women pregnant with an 
        eligible Indian's child for the duration of the pregnancy 
        through postpartum; or
            ``(4) provide care to immediate family members of an 
        eligible individual if such care is directly related to the 
        treatment of the eligible individual.
    ``(e) Hospital Privileges for Practitioners.--
            ``(1) In general.--Hospital privileges in health facilities 
        operated and maintained by the Service or operated under a 
        contract or compact pursuant to the Indian Self-Determination 
        and Education Assistance Act (25 U.S.C. 450 et seq.) may be 
        extended to non-Service health care practitioners who provide 
        services to individuals described in subsection (a), (b), (c), 
        or (d). Such non-Service health care practitioners may, as part 
        of the privileging process, be designated as employees of the 
        Federal Government for purposes of section 1346(b) and chapter 
        171 of title 28, United States Code (relating to Federal tort 
        claims) only with respect to acts or omissions which occur in 
        the course of providing services to eligible individuals as a 
        part of the conditions under which such hospital privileges are 
        extended.
            ``(2) Definition.--For purposes of this subsection, the 
        term `non-Service health care practitioner' means a 
        practitioner who is not--
                    ``(A) an employee of the Service; or
                    ``(B) an employee of an Indian tribe or tribal 
                organization operating a contract or compact under the 
                Indian Self-Determination and Education Assistance Act 
                or an individual who provides health care services 
                pursuant to a personal services contract with such 
                Indian tribe or tribal organization.
    ``(f) Eligible Indian.--For purposes of this section, the term 
`eligible Indian' means any Indian who is eligible for health services 
provided by the Service without regard to the provisions of this 
section.

``SEC. 807. REALLOCATION OF BASE RESOURCES.

    ``(a) Report Required.--Notwithstanding any other provision of law, 
any allocation of Service funds for a fiscal year that reduces by 5 
percent or more from the previous fiscal year the funding for any 
recurring program, project, or activity of a Service Unit may be 
implemented only after the Secretary has submitted to Congress, under 
section 801, a report on the proposed change in allocation of funding, 
including the reasons for the change and its likely effects.
    ``(b) Exception.--Subsection (a) shall not apply if the total 
amount appropriated to the Service for a fiscal year is at least 5 
percent less than the amount appropriated to the Service for the 
previous fiscal year.

``SEC. 808. RESULTS OF DEMONSTRATION PROJECTS.

    ``The Secretary shall provide for the dissemination to Indian 
Tribes, Tribal Organizations, and urban Indian organizations of the 
findings and results of demonstration projects conducted under this 
Act.

``SEC. 809. PROVISION OF SERVICES IN MONTANA.

    ``(a) Consistent With Court Decision.--The Secretary, acting 
through the Service, shall provide services and benefits for Indians in 
Montana in a manner consistent with the decision of the United States 
Court of Appeals for the Ninth Circuit in McNabb for McNabb v. Bowen, 
829 F.2d 787 (9th Cir. 1987).
    ``(b) Clarification.--The provisions of subsection (a) shall not be 
construed to be an expression of the sense of Congress on the 
application of the decision described in subsection (a) with respect to 
the provision of services or benefits for Indians living in any State 
other than Montana.

``SEC. 810. MORATORIUM.

    ``During the period of the moratorium imposed on implementation of 
the final rule published in the Federal Register on September 16, 1987, 
by the Department of Health and Human Services, relating to eligibility 
for the health care services of the Indian Health Service, the Indian 
Health Service shall provide services pursuant to the criteria for 
eligibility for such services that were in effect on September 15, 
1987, subject to the provisions of sections 805 and 806, until the 
Service has submitted to the Committees on Appropriations of the Senate 
and the House of Representatives a budget request reflecting the 
increased costs associated with the proposed final rule, and the 
request has been included in an appropriations Act and enacted into 
law.

``SEC. 811. SEVERABILITY PROVISIONS.

    ``If any provision of this Act, any amendment made by the Act, or 
the application of such provision or amendment to any person or 
circumstances is held to be invalid, the remainder of this Act, the 
remaining amendments made by this Act, and the application of such 
provisions to persons or circumstances other than those to which it is 
held invalid, shall not be affected thereby.

``SEC. 812. USE OF PATIENT SAFETY ORGANIZATIONS.

    ``The Service, an Indian Tribe, Tribal Organization, or urban 
Indian organization may provide for quality assurance activities 
through the use of a patient safety organization in accordance with 
title IX of the Public Health Service Act.

``SEC. 813. CONFIDENTIALITY OF MEDICAL QUALITY ASSURANCE RECORDS; 
              QUALIFIED IMMUNITY FOR PARTICIPANTS.

    ``(a) Confidentiality of Records.--Medical quality assurance 
records created by or for any Indian Health Program or a health program 
of an Urban Indian Organization as part of a medical quality assurance 
program are confidential and privileged. Such records may not be 
disclosed to any person or entity, except as provided in subsection 
(c).
    ``(b) Prohibition on Disclosure and Testimony.--
            ``(1) In general.--No part of any medical quality assurance 
        record described in subsection (a) may be subject to discovery 
        or admitted into evidence in any judicial or administrative 
        proceeding, except as provided in subsection (c).
            ``(2) Testimony.--A person who reviews or creates medical 
        quality assurance records for any Indian Health Program or 
        Urban Indian Organization who participates in any proceeding 
        that reviews or creates such records may not be permitted or 
        required to testify in any judicial or administrative 
        proceeding with respect to such records or with respect to any 
        finding, recommendation, evaluation, opinion, or action taken 
        by such person or body in connection with such records except 
        as provided in this section.
    ``(c) Authorized Disclosure and Testimony.--
            ``(1) In general.--Subject to paragraph (2), a medical 
        quality assurance record described in subsection (a) may be 
        disclosed, and a person referred to in subsection (b) may give 
        testimony in connection with such a record, only as follows:
                    ``(A) To a Federal executive agency or private 
                organization, if such medical quality assurance record 
                or testimony is needed by such agency or organization 
                to perform licensing or accreditation functions related 
                to any Indian Health Program or to a health program of 
                an Urban Indian Organization to perform monitoring, 
                required by law, of such program or organization.
                    ``(B) To an administrative or judicial proceeding 
                commenced by a present or former Indian Health Program 
                or Urban Indian Organization provider concerning the 
                termination, suspension, or limitation of clinical 
                privileges of such health care provider.
                    ``(C) To a governmental board or agency or to a 
                professional health care society or organization, if 
                such medical quality assurance record or testimony is 
                needed by such board, agency, society, or organization 
                to perform licensing, credentialing, or the monitoring 
                of professional standards with respect to any health 
                care provider who is or was an employee of any Indian 
                Health Program or Urban Indian Organization.
                    ``(D) To a hospital, medical center, or other 
                institution that provides health care services, if such 
                medical quality assurance record or testimony is needed 
                by such institution to assess the professional 
                qualifications of any health care provider who is or 
                was an employee of any Indian Health Program or Urban 
                Indian Organization and who has applied for or been 
                granted authority or employment to provide health care 
                services in or on behalf of such program or 
                organization.
                    ``(E) To an officer, employee, or contractor of the 
                Indian Health Program or Urban Indian Organization that 
                created the records or for which the records were 
                created. If that officer, employee, or contractor has a 
                need for such record or testimony to perform official 
                duties.
                    ``(F) To a criminal or civil law enforcement agency 
                or instrumentality charged under applicable law with 
                the protection of the public health or safety, if a 
                qualified representative of such agency or 
                instrumentality makes a written request that such 
                record or testimony be provided for a purpose 
                authorized by law.
                    ``(G) In an administrative or judicial proceeding 
                commenced by a criminal or civil law enforcement agency 
                or instrumentality referred to in subparagraph (F), but 
                only with respect to the subject of such proceeding.
            ``(2) Identity of participants.--With the exception of the 
        subject of a quality assurance action, the identity of any 
        person receiving health care services from any Indian Health 
        Program or Urban Indian Organization or the identity of any 
        other person associated with such program or organization for 
        purposes of a medical quality assurance program that is 
        disclosed in a medical quality assurance record described in 
        subsection (a) shall be deleted from that record or document 
        before any disclosure of such record is made outside such 
        program or organization.
    ``(d) Disclosure for Certain Purposes.--
            ``(1) In general.--Nothing in this section shall be 
        construed as authorizing or requiring the withholding from any 
        person or entity aggregate statistical information regarding 
        the results of any Indian Health Program or Urban Indian 
        Organizations's medical quality assurance programs.
            ``(2) Withholding from congress.--Nothing in this section 
        shall be construed as authority to withhold any medical quality 
        assurance record from a committee of either House of Congress, 
        any joint committee of Congress, or the Government 
        Accountability Office if such record pertains to any matter 
        within their respective jurisdictions.
    ``(e) Prohibition on Disclosure of Record or Testimony.--A person 
or entity having possession of or access to a record or testimony 
described by this section may not disclose the contents of such record 
or testimony in any manner or for any purpose except as provided in 
this section.
    ``(f) Exemption From Freedom of Information Act.--Medical quality 
assurance records described in subsection (a) may not be made available 
to any person under section 552 of title 5, United States Code.
    ``(g) Limitation on Civil Liability.--A person who participates in 
or provides information to a person or body that reviews or creates 
medical quality assurance records described in subsection (a) shall not 
be civilly liable for such participation or for providing such 
information if the participation or provision of information was in 
good faith based on prevailing professional standards at the time the 
medical quality assurance program activity took place.
    ``(h) Application to Information in Certain Other Records.--Nothing 
in this section shall be construed as limiting access to the 
information in a record created and maintained outside a medical 
quality assurance program, including a patient's medical records, on 
the grounds that the information was presented during meetings of a 
review body that are part of a medical quality assurance program.
    ``(i) Regulations.--The Secretary, acting through the Service, 
shall promulgate regulations pursuant to section 802.
    ``(j) Definitions.--In this section:
            ``(1) The term `health care provider' means any health care 
        professional, including community health aides and 
        practitioners certified under section 121, who are granted 
        clinical practice privileges or employed to provide health care 
        services in an Indian Health Program or health program of an 
        Urban Indian Organization, who is licensed or certified to 
        perform health care services by a governmental board or agency 
        or professional health care society or organization.
            ``(2) The term `medical quality assurance program' means 
        any activity carried out before, on, or after the date of 
        enactment of this Act by or for any Indian Health Program or 
        Urban Indian Organization to assess the quality of medical 
        care, including activities conducted by or on behalf of 
        individuals, Indian Health Program or Urban Indian Organization 
        medical or dental treatment review committees, or other review 
        bodies responsible for quality assurance, credentials, 
        infection control, patient safety, patient care assessment 
        (including treatment procedures, blood, drugs, and 
        therapeutics), medical records, health resources management 
        review and identification and prevention of medical or dental 
        incidents and risks.
            ``(3) The term `medical quality assurance record' means the 
        proceedings, records, minutes, and reports that emanate from 
        quality assurance program activities described in paragraph (2) 
        and are produced or compiled by or for an Indian Health Program 
        or Urban Indian Organization as part of a medical quality 
        assurance program.
    ``(k) Continued Protection.--Disclosure under subsection (c) does 
not permit redisclosure except to the extent such further disclosure is 
authorized under subsection (c) or is otherwise authorized to be 
disclosed under this section.
    ``(l) Inconsistencies.--To the extent that the protections under 
the Patient Safety and Quality Improvement Act of 2005 and this section 
are inconsistent, the provisions of whichever is more protective shall 
control.
    ``(m) Relationship to Other Law.--This section shall continue in 
force and effect, except as otherwise specifically provided in any 
Federal law enacted after the date of enactment of the Indian Health 
Care Improvement Act Amendments of 2009.

``SEC. 814. CLAREMORE INDIAN HOSPITAL.

    ``The Claremore Indian Hospital shall be deemed to be a dependant 
Indian community for the purposes of section 1151 of title 18, United 
States Code.

``SEC. 815. SENSE OF CONGRESS REGARDING LAW ENFORCEMENT AND 
              METHAMPHETAMINE ISSUES IN INDIAN COUNTRY.

    ``It is the sense of Congress that Congress encourages State, 
local, and Indian tribal law enforcement agencies to enter into 
memoranda of agreement between and among those agencies for purposes of 
streamlining law enforcement activities and maximizing the use of 
limited resources--
            ``(1) to improve law enforcement services provided to 
        Indian tribal communities; and
            ``(2) to increase the effectiveness of measures to address 
        problems relating to methamphetamine use in Indian country (as 
        defined in section 1151 of title 18, United States Code).

``SEC. 816. PERMITTING IMPLEMENTATION THROUGH CONTRACTS WITH TRIBAL 
              HEALTH PROGRAMS.

    ``Nothing in this Act shall be construed as preventing the 
Secretary from--
            ``(1) carrying out any section of this Act through 
        contracts with Tribal Health Programs; and
            ``(2) carrying out sections through 214, 701(a)(1), 
        701(b)(1), 701(c), 707(g), and 712(b), through contracts with 
        urban Indian organizations.
The previous sentence shall not affect the authority the Secretary may 
otherwise have to carry out other provisions of this Act through such 
contracts.

``SEC. 817. AUTHORIZATION OF APPROPRIATIONS; AVAILABILITY.

    ``(a) Authorization of Appropriations.--There are authorized to be 
appropriated such sums as may be necessary to carry out this title.
    ``(b) Limitation on New Spending Authority.--Any new spending 
authority (described in subparagraph (A) or (B) of section 401(c)(2) of 
the Congressional Budget Act of 1974 (Public Law 93-344; 88 Stat. 317)) 
which is provided under this Act shall be effective for any fiscal year 
only to such extent or in such amounts as are provided in appropriation 
Acts.
    ``(c) Availability.--The funds appropriated pursuant to this Act 
shall remain available until expended.''.
    (b) Rate of Pay.--
            (1) Positions at level iv.--Section 5315 of title 5, United 
        States Code, is amended by striking ``Assistant Secretaries of 
        Health and Human Services (6).'' and inserting ``Assistant 
        Secretaries of Health and Human Services (7)''.
            (2) Positions at level v.--Section 5316 of title 5, United 
        States Code, is amended by striking ``Director, Indian Health 
        Service, Department of Health and Human Services''.
    (c) Amendments to Other Provisions of Law.--
            (1) Section 3307(b)(1)(C) of the Children's Health Act of 
        2000 (25 U.S.C. 1671 note; Public Law 106-310) is amended by 
        striking ``Director of the Indian Health Service'' and 
        inserting ``Assistant Secretary for Indian Health''.
            (2) The Indian Lands Open Dump Cleanup Act of 1994 is 
        amended--
                    (A) in section 3 (25 U.S.C. 3902)--
                            (i) by striking paragraph (2);
                            (ii) by redesignating paragraphs (1), (3), 
                        (4), (5), and (6) as paragraphs (4), (5), (2), 
                        (6), and (1), respectively, and moving those 
                        paragraphs so as to appear in numerical order; 
                        and
                            (iii) by inserting before paragraph (4) (as 
                        redesignated by subclause (II)) the following:
            ``(3) Assistant secretary.--The term `Assistant Secretary' 
        means the Assistant Secretary for Indian Health.'';
                    (B) in section 5 (25 U.S.C. 3904), by striking the 
                section designation and heading and inserting the 
                following:

``SEC. 5. AUTHORITY OF ASSISTANT SECRETARY FOR INDIAN HEALTH.'';

                    (C) in section 6(a) (25 U.S.C. 3905(a)), in the 
                subsection heading, by striking ``Director'' and 
                inserting ``Assistant Secretary'';
                    (D) in section 9(a) (25 U.S.C. 3908(a)), in the 
                subsection heading, by striking ``Director'' and 
                inserting ``Assistant Secretary''; and
                    (E) by striking ``Director'' each place it appears 
                and inserting ``Assistant Secretary''.
            (3) Section 5504(d)(2) of the Augustus F. Hawkins-Robert T. 
        Stafford Elementary and Secondary School Improvement Amendments 
        of 1988 (25 U.S.C. 2001 note; Public Law 100-297) is amended by 
        striking ``Director of the Indian Health Service'' and 
        inserting ``Assistant Secretary for Indian Health''.
            (4) Section 203(a)(1) of the Rehabilitation Act of 1973 (29 
        U.S.C. 763(a)(1)) is amended by striking ``Director of the 
        Indian Health Service'' and inserting ``Assistant Secretary for 
        Indian Health''.
            (5) Subsections (b) and (e) of section 518 of the Federal 
        Water Pollution Control Act (33 U.S.C. 1377) are amended by 
        striking ``Director of the Indian Health Service'' each place 
        it appears and inserting ``Assistant Secretary for Indian 
        Health''.
            (6) Section 317M(b) of the Public Health Service Act (42 
        U.S.C. 247b-14(b)) is amended--
                    (A) by striking ``Director of the Indian Health 
                Service'' each place it appears and inserting 
                ``Assistant Secretary for Indian Health''; and
                    (B) in paragraph (2)(A), by striking ``the 
                Directors referred to in such paragraph'' and inserting 
                ``the Director of the Centers for Disease Control and 
                Prevention and the Assistant Secretary for Indian 
                Health''.
            (7) Section 417C(b) of the Public Health Service Act (42 
        U.S.C. 285-9(b)) is amended by striking ``Director of the 
        Indian Health Service'' and inserting ``Assistant Secretary for 
        Indian Health''.
            (8) Section 1452(i) of the Safe Drinking Water Act (42 
        U.S.C. 300j-12(i)) is amended by striking ``Director of the 
        Indian Health Service'' each place it appears and inserting 
        ``Assistant Secretary for Indian Health''.
            (9) Section 803B(d)(1) of the Native American Programs Act 
        of 1974 (42 U.S.C. 2991b-2(d)(1)) is amended in the last 
        sentence by striking ``Director of the Indian Health Service'' 
        and inserting ``Assistant Secretary for Indian Health''.
            (10) Section 203(b) of the Michigan Indian Land Claims 
        Settlement Act (Public Law 105-143; 111 Stat. 2666) is amended 
        by striking ``Director of the Indian Health Service'' and 
        inserting ``Assistant Secretary for Indian Health''.

SEC. 3102. SOBOBA SANITATION FACILITIES.

    The Act of December 17, 1970 (84 Stat. 1465), is amended by adding 
at the end the following:
    ``Sec. 9.  Nothing in this Act shall preclude the Soboba Band of 
Mission Indians and the Soboba Indian Reservation from being provided 
with sanitation facilities and services under the authority of section 
7 of the Act of August 5, 1954 (68 Stat. 674), as amended by the Act of 
July 31, 1959 (73 Stat. 267).''.

SEC. 3103. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

    (a) In General.--The Indian Self-Determination and Education 
Assistance Act (25 U.S.C. 450 et seq.) is amended by adding at the end 
the following:

      ``TITLE VIII--NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION

``SEC. 801. DEFINITIONS.

    ``In this title:
            ``(1) Board.--The term `Board' means the Board of Directors 
        of the Foundation.
            ``(2) Committee.--The term `Committee' means the Committee 
        for the Establishment of Native American Health and Wellness 
        Foundation established under section 802(f).
            ``(3) Foundation.--The term `Foundation' means the Native 
        American Health and Wellness Foundation established under 
        section 802.
            ``(4) Secretary.--The term `Secretary' means the Secretary 
        of Health and Human Services.
            ``(5) Service.--The term `Service' means the Indian Health 
        Service of the Department of Health and Human Services.

``SEC. 802. NATIVE AMERICAN HEALTH AND WELLNESS FOUNDATION.

    ``(a) Establishment.--
            ``(1) In general.--As soon as practicable after the date of 
        enactment of this title, the Secretary shall establish, under 
        the laws of the District of Columbia and in accordance with 
        this title, the Native American Health and Wellness Foundation.
            ``(2) Funding determinations.--No funds, gift, property, or 
        other item of value (including any interest accrued on such an 
        item) acquired by the Foundation shall--
                    ``(A) be taken into consideration for purposes of 
                determining Federal appropriations relating to the 
                provision of health care and services to Indians; or
                    ``(B) otherwise limit, diminish, or affect the 
                Federal responsibility for the provision of health care 
                and services to Indians.
    ``(b) Perpetual Existence.--The Foundation shall have perpetual 
existence.
    ``(c) Nature of Corporation.--The Foundation--
            ``(1) shall be a charitable and nonprofit federally 
        chartered corporation; and
            ``(2) shall not be an agency or instrumentality of the 
        United States.
    ``(d) Place of Incorporation and Domicile.--The Foundation shall be 
incorporated and domiciled in the District of Columbia.
    ``(e) Duties.--The Foundation shall--
            ``(1) encourage, accept, and administer private gifts of 
        real and personal property, and any income from or interest in 
        such gifts, for the benefit of, or in support of, the mission 
        of the Service;
            ``(2) undertake and conduct such other activities as will 
        further the health and wellness activities and opportunities of 
        Native Americans; and
            ``(3) participate with and assist Federal, State, and 
        tribal governments, agencies, entities, and individuals in 
        undertaking and conducting activities that will further the 
        health and wellness activities and opportunities of Native 
        Americans.
    ``(f) Committee for the Establishment of Native American Health and 
Wellness Foundation.--
            ``(1) In general.--The Secretary shall establish the 
        Committee for the Establishment of Native American Health and 
        Wellness Foundation to assist the Secretary in establishing the 
        Foundation.
            ``(2) Duties.--Not later than 180 days after the date of 
        enactment of this section, the Committee shall--
                    ``(A) carry out such activities as are necessary to 
                incorporate the Foundation under the laws of the 
                District of Columbia, including acting as incorporators 
                of the Foundation;
                    ``(B) ensure that the Foundation qualifies for and 
                maintains the status required to carry out this 
                section, until the Board is established;
                    ``(C) establish the constitution and initial bylaws 
                of the Foundation;
                    ``(D) provide for the initial operation of the 
                Foundation, including providing for temporary or 
                interim quarters, equipment, and staff; and
                    ``(E) appoint the initial members of the Board in 
                accordance with the constitution and initial bylaws of 
                the Foundation.
    ``(g) Board of Directors.--
            ``(1) In general.--The Board of Directors shall be the 
        governing body of the Foundation.
            ``(2) Powers.--The Board may exercise, or provide for the 
        exercise of, the powers of the Foundation.
            ``(3) Selection.--
                    ``(A) In general.--Subject to subparagraph (B), the 
                number of members of the Board, the manner of selection 
                of the members (including the filling of vacancies), 
                and the terms of office of the members shall be as 
                provided in the constitution and bylaws of the 
                Foundation.
                    ``(B) Requirements.--
                            ``(i) Number of members.--The Board shall 
                        have at least 11 members, who shall have 
                        staggered terms.
                            ``(ii) Initial voting members.--The initial 
                        voting members of the Board--
                                    ``(I) shall be appointed by the 
                                Committee not later than 180 days after 
                                the date on which the Foundation is 
                                established; and
                                    ``(II) shall have staggered terms.
                            ``(iii) Qualification.--The members of the 
                        Board shall be United States citizens who are 
                        knowledgeable or experienced in Native American 
                        health care and related matters.
                    ``(C) Compensation.--A member of the Board shall 
                not receive compensation for service as a member, but 
                shall be reimbursed for actual and necessary travel and 
                subsistence expenses incurred in the performance of the 
                duties of the Foundation.
    ``(h) Officers.--
            ``(1) In general.--The officers of the Foundation shall 
        be--
                    ``(A) a secretary, elected from among the members 
                of the Board; and
                    ``(B) any other officers provided for in the 
                constitution and bylaws of the Foundation.
            ``(2) Chief operating officer.--The secretary of the 
        Foundation may serve, at the direction of the Board, as the 
        chief operating officer of the Foundation, or the Board may 
        appoint a chief operating officer, who shall serve at the 
        direction of the Board.
            ``(3) Election.--The manner of election, term of office, 
        and duties of the officers of the Foundation shall be as 
        provided in the constitution and bylaws of the Foundation.
    ``(i) Powers.--The Foundation--
            ``(1) shall adopt a constitution and bylaws for the 
        management of the property of the Foundation and the regulation 
        of the affairs of the Foundation;
            ``(2) may adopt and alter a corporate seal;
            ``(3) may enter into contracts;
            ``(4) may acquire (through a gift or otherwise), own, 
        lease, encumber, and transfer real or personal property as 
        necessary or convenient to carry out the purposes of the 
        Foundation;
            ``(5) may sue and be sued; and
            ``(6) may perform any other act necessary and proper to 
        carry out the purposes of the Foundation.
    ``(j) Principal Office.--
            ``(1) In general.--The principal office of the Foundation 
        shall be in the District of Columbia.
            ``(2) Activities; offices.--The activities of the 
        Foundation may be conducted, and offices may be maintained, 
        throughout the United States in accordance with the 
        constitution and bylaws of the Foundation.
    ``(k) Service of Process.--The Foundation shall comply with the law 
on service of process of each State in which the Foundation is 
incorporated and of each State in which the Foundation carries on 
activities.
    ``(l) Liability of Officers, Employees, and Agents.--
            ``(1) In general.--The Foundation shall be liable for the 
        acts of the officers, employees, and agents of the Foundation 
        acting within the scope of their authority.
            ``(2) Personal liability.--A member of the Board shall be 
        personally liable only for gross negligence in the performance 
        of the duties of the member.
    ``(m) Restrictions.--
            ``(1) Limitation on spending.--Beginning with the fiscal 
        year following the first full fiscal year during which the 
        Foundation is in operation, the administrative costs of the 
        Foundation shall not exceed the percentage described in 
        paragraph (2) of the sum of--
                    ``(A) the amounts transferred to the Foundation 
                under subsection (o) during the preceding fiscal year; 
                and
                    ``(B) donations received from private sources 
                during the preceding fiscal year.
            ``(2) Percentages.--The percentages referred to in 
        paragraph (1) are--
                    ``(A) for the first fiscal year described in that 
                paragraph, 20 percent;
                    ``(B) for the following fiscal year, 15 percent; 
                and
                    ``(C) for each fiscal year thereafter, 10 percent.
            ``(3) Appointment and hiring.--The appointment of officers 
        and employees of the Foundation shall be subject to the 
        availability of funds.
            ``(4) Status.--A member of the Board or officer, employee, 
        or agent of the Foundation shall not by reason of association 
        with the Foundation be considered to be an officer, employee, 
        or agent of the United States.
    ``(n) Audits.--The Foundation shall comply with section 10101 of 
title 36, United States Code, as if the Foundation were a corporation 
under part B of subtitle II of that title.
    ``(o) Funding.--
            ``(1) Authorization of appropriations.--There is authorized 
        to be appropriated to carry out subsection (e)(1) $500,000 for 
        each fiscal year, as adjusted to reflect changes in the 
        Consumer Price Index for all-urban consumers published by the 
        Department of Labor.
            ``(2) Transfer of donated funds.--The Secretary shall 
        transfer to the Foundation funds held by the Department of 
        Health and Human Services under the Act of August 5, 1954 (42 
        U.S.C. 2001 et seq.), if the transfer or use of the funds is 
        not prohibited by any term under which the funds were donated.

``SEC. 803. ADMINISTRATIVE SERVICES AND SUPPORT.

    ``(a) Provision of Support by Secretary.--Subject to subsection 
(b), during the 5-year period beginning on the date on which the 
Foundation is established, the Secretary--
            ``(1) may provide personnel, facilities, and other 
        administrative support services to the Foundation;
            ``(2) may provide funds for initial operating costs and to 
        reimburse the travel expenses of the members of the Board; and
            ``(3) shall require and accept reimbursements from the 
        Foundation for--
                    ``(A) services provided under paragraph (1); and
                    ``(B) funds provided under paragraph (2).
    ``(b) Reimbursement.--Reimbursements accepted under subsection 
(a)(3)--
            ``(1) shall be deposited in the Treasury of the United 
        States to the credit of the applicable appropriations account; 
        and
            ``(2) shall be chargeable for the cost of providing 
        services described in subsection (a)(1) and travel expenses 
        described in subsection (a)(2).
    ``(c) Continuation of Certain Services.--The Secretary may continue 
to provide facilities and necessary support services to the Foundation 
after the termination of the 5-year period specified in subsection (a) 
if the facilities and services--
            ``(1) are available; and
            ``(2) are provided on reimbursable cost basis.''.
    (b) Technical Amendments.--The Indian Self-Determination and 
Education Assistance Act is amended--
            (1) by redesignating title V (25 U.S.C. 458bbb et seq.) as 
        title VII;
            (2) by redesignating sections 501, 502, and 503 (25 U.S.C. 
        458bbb, 458bbb-1, 458bbb-2) as sections 701, 702, and 703, 
        respectively; and
            (3) in subsection (a)(2) of section 702 and paragraph (2) 
        of section 703 (as redesignated by paragraph (2)), by striking 
        ``section 501'' and inserting ``section 701''.

SEC. 3104. GAO STUDY AND REPORT ON PAYMENTS FOR CONTRACT HEALTH 
              SERVICES.

    (a) Study.--
            (1) In general.--The Comptroller General of the United 
        States (in this section referred to as the ``Comptroller 
        General'') shall conduct a study on the utilization of health 
        care furnished by health care providers under the contract 
        health services program funded by the Indian Health Service and 
        operated by the Indian Health Service, an Indian Tribe, or a 
        Tribal Organization (as those terms are defined in section 4 of 
        the Indian Health Care Improvement Act).
            (2) Analysis.--The study conducted under paragraph (1) 
        shall include an analysis of--
                    (A) the amounts reimbursed under the contract 
                health services program described in paragraph (1) for 
                health care furnished by entities, individual 
                providers, and suppliers, including a comparison of 
                reimbursement for such health care through other public 
                programs and in the private sector;
                    (B) barriers to accessing care under such contract 
                health services program, including, but not limited to, 
                barriers relating to travel distances, cultural 
                differences, and public and private sector reluctance 
                to furnish care to patients under such program;
                    (C) the adequacy of existing Federal funding for 
                health care under such contract health services 
                program; and
                    (D) any other items determined appropriate by the 
                Comptroller General.
    (b) Report.--Not later than 18 months after the date of enactment 
of this Act, the Comptroller General shall submit to Congress a report 
on the study conducted under subsection (a), together with 
recommendations regarding--
            (1) the appropriate level of Federal funding that should be 
        established for health care under the contract health services 
        program described in subsection (a)(1); and
            (2) how to most efficiently utilize such funding.
    (c) Consultation.--In conducting the study under subsection (a) and 
preparing the report under subsection (b), the Comptroller General 
shall consult with the Indian Health Service, Indian Tribes, and Tribal 
Organizations.

 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.

    (a) Medicaid.--
            (1) Expansion to all covered services.--Section 1911 of the 
        Social Security Act (42 U.S.C. 1396j) is amended--
                    (A) by amending the heading to read as follows:

``SEC. 1911. INDIAN HEALTH PROGRAMS.'';

                and
                    (B) by amending subsection (a) to read as follows:
    ``(a) Eligibility for Payment for Medical Assistance.--An Indian 
Health Program shall be eligible for payment for medical assistance 
provided under a State plan or under waiver authority with respect to 
items and services furnished by the Program if the furnishing of such 
services meets all the conditions and requirements which are applicable 
generally to the furnishing of items and services under this title and 
under such plan or waiver authority.''.
            (2) Repeal of obsolete provision.--Subsection (b) of such 
        section is repealed.
            (3) Revision of authority to enter into agreements.--
        Subsection (c) of such section is amended to read as follows:
    ``(c) Authority To Enter Into Agreements.--The Secretary may enter 
into an agreement with a State for the purpose of reimbursing the State 
for medical assistance provided by the Indian Health Service, an Indian 
Tribe, Tribal Organization, or an Urban Indian Organization (as so 
defined), directly, through referral, or under contracts or other 
arrangements between the Indian Health Service, an Indian Tribe, Tribal 
Organization, or an Urban Indian Organization and another health care 
provider to Indians who are eligible for medical assistance under the 
State plan or under waiver authority. This subsection shall not be 
construed to impair the entitlement of a State to reimbursement for 
such medical assistance under this title.''.
            (4) Cross-references to special fund for improvement of ihs 
        facilities; direct billing option; definitions.--Such section 
        is further amended by striking subsection (d) and adding at the 
        end the following new subsections:
    ``(c) Special Fund for Improvement of IHS Facilities.--For 
provisions relating to the authority of the Secretary to place payments 
to which a facility of the Indian Health Service is eligible for 
payment under this title into a special fund established under section 
401(c)(1) of the Indian Health Care Improvement Act, see subparagraphs 
(A) and (B) of section 401(c)(1) of such Act.
    ``(d) Direct Billing.--For provisions relating to the authority of 
an Tribal Health Program to elect to directly bill for, and receive 
payment for, health care items and services provided by such Program 
for which payment is made under this title, see section 401(d) of the 
Indian Health Care Improvement Act.''.
            (5) Definitions.--Section 1101(a) of such Act (42 U.S.C. 
        1301(a)) is amended by adding at the end the following new 
        paragraph:
            ``(11) For purposes of this title and titles XVIII, XIX, 
        and XXI, the terms `Indian Health Program', `Indian Tribe' (and 
        `Indian tribe'), `Tribal Health Program', `Tribal Organization' 
        (and `tribal organization'), and `urban Indian organization' 
        (and `urban Indian organization') have the meanings given those 
        terms in section 4 of the Indian Health Care Improvement 
        Act.''.
    (b) Medicare.--
            (1) Expansion to all covered services.--Section 1880 of 
        such Act (42 U.S.C. 1395qq) is amended--
                    (A) by amending the heading to read as follows:

``SEC. 1880. INDIAN HEALTH PROGRAMS.'';

                and
                    (B) by amending subsection (a) to read as follows:
    ``(a) Eligibility for Payments.--Subject to subsection (e), an 
Indian Health Program shall be eligible for payments under this title 
with respect to items and services furnished by the Program if the 
furnishing of such services meets all the conditions and requirements 
which are applicable generally to the furnishing of items and services 
under this title.''.
            (2) Repeal of obsolete provision.--Subsection (b) of such 
        section is repealed.
            (3) Cross-references to special fund for improvement of ihs 
        facilities; direct billing option; definitions.--
                    (A) In general.--Such section is further amended by 
                striking subsections (c) and (d) and inserting the 
                following new subsections:
    ``(b) Special Fund for Improvement of IHS Facilities.--For 
provisions relating to the authority of the Secretary to place payments 
to which a facility of the Indian Health Service is eligible for 
payment under this title into a special fund established under section 
401(c)(1) of the Indian Health Care Improvement Act, and the 
requirement to use amounts paid from such fund for making improvements 
in accordance with subsection (b), see subparagraphs (A) and (B) of 
section 401(c)(1) of such Act.
    ``(c) Direct Billing.--For provisions relating to the authority of 
a Tribal Health Program to elect to directly bill for, and receive 
payment for, health care items and services provided by such Program 
for which payment is made under this title, see section 401(d) of the 
Indian Health Care Improvement Act.''.
                    (B) Conforming amendments.--Such section is further 
                amended--
                            (i) in subsection (e)(3), by striking 
                        ``Subsection (c)'' and inserting ``Subsection 
                        (b) and section 401(b)(1) of the Indian Health 
                        Care Improvement Act'';
                            (ii) by redesignating subsection (e) as 
                        subsection (d); and
                            (iii) by striking subsection (f).
            (4) Definitions.--Such section is further amended by 
        amending adding at the end the following new subsection:
    ``(e) Definitions.--In this section, the terms `Indian Health 
Program', `Indian Tribe', `Service Unit', `Tribal Health Program', 
`Tribal Organization', and `Urban Indian Organization' have the 
meanings given those terms in section 4 of the Indian Health Care 
Improvement Act.''.
    (c) Application to SCHIP.--Section 2107(e)(1) of the Social 
Security Act (42 U.S.C. 1397gg(e)(1)) is amended--
            (1) by redesignating subparagraphs (K) through (M) as 
        subparagraphs (L) through (N), respectively; and
            (2) by inserting after subparagraph (J), the following new 
        subparagraph:
                    ``(K) Section 1911 (relating to Indian Health 
                Programs, other than subsection (c) of such 
                section).''.

SEC. 3202. ADDITIONAL PROVISIONS TO INCREASE OUTREACH TO, AND 
              ENROLLMENT OF, INDIANS IN SCHIP AND MEDICAID.

    (a) Assurance of Payments to Indian Health Care Providers for Child 
Health Assistance.--Section 2102(b)(3)(D) of the Social Security Act 
(42 U.S.C. 1397bb(b)(3)(D)) is amended by striking ``(as defined in 
section 4(c) of the Indian Health Care Improvement Act, 25 U.S.C. 
1603(c))'' and inserting ``, including how the State will ensure that 
payments are made to Indian Health Programs and urban Indian 
organizations operating in the State for the provision of such 
assistance''.
    (b) Inclusion of Other Indian Financed Health Care Programs in 
Exemption From Prohibition on Certain Payments.--Section 2105(c)(6)(B) 
of such Act (42 U.S.C. 1397ee(c)(6)(B)) is amended by striking 
``insurance program, other than an insurance program operated or 
financed by the Indian Health Service'' and inserting ``program, other 
than a health care program operated or financed by the Indian Health 
Service or by an Indian Tribe, Tribal Organization, or urban Indian 
organization''.
    (c) Definitions.--Section 2110(c) of such Act (42 U.S.C. 1397jj(c)) 
is amended by adding at the end the following new paragraph:
            ``(9) Indian; indian health program; indian tribe; etc.--
        The terms `Indian', `Indian Health Program', `Indian Tribe', 
        `Tribal Organization', and `Urban Indian Organization' have the 
        meanings given those terms in section 4 of the Indian Health 
        Care Improvement Act.''.

SEC. 3203. SOLICITATION OF PROPOSALS FOR SAFE HARBORS UNDER THE SOCIAL 
              SECURITY ACT FOR FACILITIES OF INDIAN HEALTH PROGRAMS AND 
              URBAN INDIAN ORGANIZATIONS.

    The Secretary of Health and Human Services, acting through the 
Office of the Inspector General of the Department of Health and Human 
Services, shall publish a notice, described in section 1128D(a)(1)(A) 
of the Social Security Act (42 U.S.C. 1320a-7d(a)(1)(A)), soliciting a 
proposal, not later than July 1, 2010, on the development of safe 
harbors described in such section relating to health care items and 
services provided by facilities of Indian Health Programs or an urban 
Indian organization (as such terms are defined in section 4 of the 
Indian Health Care Improvement Act). Such a safe harbor may relate to 
areas such as transportation, housing, or cost-sharing, assistance 
provided through such facilities or contract health services for 
Indians.

SEC. 3204. ANNUAL REPORT ON INDIANS SERVED BY SOCIAL SECURITY ACT 
              HEALTH BENEFIT PROGRAMS.

    Section 1139 of the Social Security Act (42 U.S.C. 1320b-9), as 
amended by the sections 3203 and 3204, is amended by redesignating 
subsection (e) as subsection (f), and inserting after subsection (d) 
the following new subsection:
    ``(e) Annual Report on Indians Served by Health Benefit Programs 
Funded Under This Act.--Beginning January 1, 2011, and annually 
thereafter, the Secretary, acting through the Administrator of the 
Centers for Medicare & Medicaid Services and the Director of the Indian 
Health Service, shall submit a report to Congress regarding the 
enrollment and health status of Indians receiving items or services 
under health benefit programs funded under this Act during the 
preceding year. Each such report shall include the following:
            ``(1) The total number of Indians enrolled in, or receiving 
        items or services under, such programs, disaggregated with 
        respect to each such program.
            ``(2) The number of Indians described in paragraph (1) that 
        also received health benefits under programs funded by the 
        Indian Health Service.
            ``(3) General information regarding the health status of 
        the Indians described in paragraph (1), disaggregated with 
        respect to specific diseases or conditions and presented in a 
        manner that is consistent with protections for privacy of 
        individually identifiable health information under section 
        264(c) of the Health Insurance Portability and Accountability 
        Act of 1996.
            ``(4) A detailed statement of the status of facilities of 
        the Indian Health Service or an Indian Tribe, Tribal 
        Organization, or an Urban Indian Organization with respect to 
        such facilities' compliance with the applicable conditions and 
        requirements of titles XVIII, XIX, and XXI, and, in the case of 
        title XIX or XXI, under a State plan under such title or under 
        waiver authority, and of the progress being made by such 
        facilities (under plans submitted under 1911(b) or otherwise) 
        toward the achievement and maintenance of such compliance.
            ``(5) Such other information as the Secretary determines is 
        appropriate.''.

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.

    (a) Study.--The Secretary shall conduct a study to identify 
barriers to interstate coordination of enrollment and coverage under 
the Medicaid program under title XIX of the Social Security Act and the 
State Children's Health Insurance Program under title XXI of such Act 
of children who are eligible for medical assistance or child health 
assistance under such programs and who, because of educational needs, 
migration of families, emergency evacuations, or otherwise, frequently 
change their State of residency or otherwise are temporarily present 
outside of the State of their residency. Such study shall include an 
examination of the enrollment and coverage coordination issues faced by 
Indian children who are eligible for medical assistance or child health 
assistance under such programs in their State of residence and who 
temporarily reside in an out-of-State boarding school or peripheral 
dormitory funded by the Bureau of Indian Affairs.
    (b) Report.--Not later than 18 months after the date of enactment 
of this Act, the Secretary, in consultation with directors of State 
Medicaid programs under title XIX of the Social Security Act and 
directors of State Children's Health Insurance Programs under title XXI 
of such Act, shall submit a report to Congress that contains 
recommendations for such legislative and administrative actions as the 
Secretary determines appropriate to address the enrollment and coverage 
coordination barriers identified through the study required under 
subsection (a).
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